Spring 2019 Issue
Volume 11 | Number 2
Michelle Garber-Talamo, OMS III
Touro University California College of Osteopathic Medicine
The Netflix original TV series “13 Reasons Why” was released in the spring of 2017 and immediately sparked a world-wide controversy around its explicit depiction of suicide. The series depicts the life and graphic death by suicide of the adolescent protagonist Hannah Baker. The series became immensely popular and quickly achieved the status of the most watched Netflix series ever. Season two was released in the spring of 2018 and season three is currently being filmed. “13 Reasons Why” remains an influential piece of popular culture. Parents, clinicians and educators who work with adolescents should understand both the risks associated with the show and how it can be used to initiate important discussions.
This paper summarizes the plot and controversy surrounding the series, describes research conducted about the effect of the series, and organizes the resources published in response to it. It is my hope that this paper will serve as a guide to those interested in this topic and a useful resource for professionals on the frontline of adolescent suicide prevention. The paper is divided into four sections: plot summary, an overview of criticism of the series, research and resources. Additional appendices provide a list of resources organized by intended audience (parents, clinicians, youth, educators).
A basic understanding of the plot of both seasons of “13 Reasons Why” is imperative to understand the controversy, research, and suicide prevention resources related to the series. The narrative is structured around 13 audiocassette tapes left by Hannah Baker as an elaborate form of a suicide note. Each tape names one person as a “reason” for her death. The tapes cover her experiences of bullying, social isolation, sexual harassment, rape, and her final attempt to seek help from a school counselor. The show alternates between the storyline of her life and the story of the experiences of her friends as they listen to the tapes. The final episode includes a graphic three-minute scene of Hannah slitting her wrist and bleeding to death in her bathtub. This scene is one of the most controversial aspects of the series.
The final episodes of season one also explicitly depict the rape of Hannah and one of her friends. Season two is centered around a lawsuit against Hannah’s high school for its alleged failure to address bullying. Sexual assault and school violence are also prominent themes in season two. Throughout season two, Hannah returns in the form of hallucinations of her friend Clay as he attempts to come to terms with her death and seek justice for her rape. Akin to the graphic suicide scene in episode one, the final episode of season two depicts the brutal sexual assault of a teenage male in a school bathroom. The explicit depiction of sexual violence has been criticized as sensationalizing a serious crime and as potentially triggering for viewers with similar experiences. Hannah’s persisting influence in season two has been criticized as a failure to portray the permanence of suicide.
13 Reasons Why Criticism
The popularity, controversy, and sheer magnitude of publications about "13 Reasons Why" could rightly be characterized as a cultural phenomenon. Over 600,000 articles were published in the popular press in the wake of the debut of season one.1 Prominent suicide experts published statements cautioning parents, educators, and clinicians about the potential harm. Many professional and advocacy organizations including the National Society of School Psychologists, the American Academy of Child and Adolescent Psychiatry, the National Alliance for Mental Illness, American School Counselor Association, American Association of Suicidology, the International Association for Suicide Prevention and other respected groups published cautionary statements. In the realm of academia, multiple studies attempted to capture the effects of the show on suicide rates. Several articles criticizing the series have been published by field experts in prominent academic journals,2, 3,4 and other online platforms.5, 6, 7, 8, 9, 10 Their criticisms share many general themes.
The most prominent concern for most authors is the potential for suicide contagion. The Werther Effect is a term that refers to an increase in suicide risk following exposure to a portrayal of suicide in the fictional or news media. The term is derived from Goethe’s 1776 novel The Death of Young Werther, in which a young man dies by suicide because of unrequited love. Following the publication of the novel, multiple young men in Europe died by suicide in the same manner as Werther in the novel.11 In the more recent era, the World Health Organization has published guidelines for the news media regarding responsible reporting on suicides. The guidelines advise reporters to avoid sensationalizing suicide, avoid explicit description of the method used, exercise caution with video footage and avoid presenting suicide as a rational response to a problem.12 Many critics argue that the graphic depiction of Hannah’s suicide violates all of these guidelines.2,4,5,6,8 However, an important caveat often overlooked by critics of the show is that these guidelines were primarily developed for news media. Although the term “Werther Effect” is derived from a fictional novel, the contemporary research that supports its existence is mostly based on suicide contagion in relation to the news media.
Some critics of the series also argue that the show presents Hannah’s suicide as a rational decision based on “13 reasons” to commit suicide.5,6,7
They argue it is dangerous to suggest that there is ever a single reason for suicide, especially not 13 reasons. Although bullying and sexual assault are risk factors for suicide, they are not reasons for suicide. No direct causal link between an act of bullying and suicide has been established.13
Furthermore, the series depicts the torment of the characters named by the tapes suggesting that suicide can be an effective means of revenge. Critics argue that these aspects of the series may place youth who have been victims of bullying or assault at greater risk for suicide.3,5
A concern voiced by many is the failure to depict school faculty and parents as trustworthy and reliable resources for getting help.5,6,14
This may dissuade troubled youth from reaching out for help. The series also fails to include any overt discussion of depression, mental illness, mental healthcare or suicide intervention strategies.5,6,9
This has been described as a missed opportunity to educate youth and a false portrayal of depression. The school’s handling of Hannah’s suicide drew sharp criticism by professional organizations of school psychologists and social workers.14 The final episode contains a controversial scene in which the school counselor dismisses Hannah’s suicidal statement and her accusation of rape. Additionally, the school allows her locker to be turned into a memorial and the suicide prevention actions of the school are inappropriate for a post-vention situation.5,6,14 The overall failure of all potential sources for help may dissuade viewers from seeking help from adults when faced with depression, bullying, sexual assault, and suicidal ideation.
The producers of “13 Reasons Why” dismissed these concerns and defended the show as an honest portrayal of uncomfortable issues.15
The producers of the show argue that it successfully initiates important conversations about suicide, bullying, and sexual assault. They contend that by opening dialogues about difficult issues, the show is beneficial to viewers. These arguments are directly at odds with the opinions of suicide experts and mental health professionals.
A modest body of research conducted in the aftermath of the debut of season one has attempted to describe and measure the effect of the show on viewers. One widely cited study published in JAMA Internal Medicine examined how internet searches before and after the release of the show changed in both content and volume.1 The authors utilized Google trends to track the trends of searches for words or phrases relating to suicide from March 31, 2017 to April 18, 2017. The study found that queries indicative of suicidal ideation (e.g. “how to kill yourself” and “commit suicide”) were significantly elevated in this window of time as compared to baseline. However, queries indicative of suicide awareness (e.g. “suicide prevention”) were also elevated, as were searches for “suicide hotlines.” The authors concluded that the data suggest both an increase suicide awareness and suicidal ideation following the release of “13 Reasons Why.”1
In a meta-analysis of fictional media and suicide contagion published soon after the release of “13 Reasons Why”, Christopher Ferguson examined the contention that fictional media containing suicidal themes causes the Werther Effect.16 The analysis found little evidence for the causal relationship of fictional media and suicide contagion. Although none of the studies include in the meta-analysis examined “13 Reasons Why”, the author used the results to argue that the criticisms of the series had little basis in factual evidence. This article is notable in that it is the only paper published in response to “13 Reasons Why” that suggests there is no basis for the contention that fictional media may cause suicide contagion.16
In an attempt to describe the influence of the show on the thoughts and behavior of adolescents, researchers in Brazil turned to social media.17 They used advertising on Facebook to distribute surveys to Brazilian and American adolescents. Eighty percent of the respondents included in the study were Brazilian. They measured self-reported changes in suicidal ideation, depressive symptoms and attitudes toward bulling in adolescents who watched the entire first series of “13 Reasons Why.” The study differentiated between adolescents with and without prior depressive or suicidal symptoms. In respondents with previous suicidal ideation the majority (59.3%) reported a decrease in suicidal ideation. However, in adolescents with baseline depressive symptoms and a history of suicidal ideation, 21.6% expressed an increase in suicidal ideation. A small but notable minority (6.4%) of adolescents with no history reported new suicidal ideation. Respondents also reported reduced shame about being bullied and engaging in less bullying behavior after watching the series. The authors concluded that while it appears the show may have a positive effect on many teens, the increase in suicidal ideation in the most vulnerable group (baseline depression and previous suicidal ideation) is very concerning. Limitations to this study include limited generalizability to the adolescents in the United States, a self-selected sample and the reliance on retrospective reports of change.17
Researchers have also turned to emergency departments for more information about the effects of the show. A study published in the Annals of Emergency Medicine compared pediatric psychiatric presentations to the emergency department for 41 days before and after the release of the series. They found an increase in psychiatric presentations, but not in diagnoses of suicide attempts or of suicidal ideation.18 The authors concluded that further studies are needed to determine the effect of the series. Feuer et al. described the results of a survey of pediatric presentations to 14 emergency departments which was notable for 40% of sites reporting copycat suicide attempts within 30 days of the release of the series.2 Feuer et al. also reported that numerous copycat attempts or gestures have been reported by clinicians on listservs operated by the American Academy of Child and Adolescent Psychiatry.2
Northwestern University’s Center for Media and Human Development conducted a multinational internet-based survey of viewers who liked the series on Facebook.19 The study received funding from Netflix and its results have been publicly cited by Netflix to support the series and its mission. A report released by Northwestern described only the positive results of the survey. According to the report, a majority of viewers felt the show was beneficial for them to watch, it accurately depicted issues they face in their lives, make it easier to discuss issues and increased their understanding of suicide. The survey also found that 70% of viewers would like more access to mental health and suicide prevention resources.19
While these results may superficially appear very positive, there are important limitations to consider. The study did not distinguish between mentally healthy viewers and those at high risk for suicide. The effect of the show may vary greatly based on the baseline mental health of the viewer and thus the risks of the series to vulnerable individuals may not be accurately captured by the opinions of the majority of viewers. A self-report of “improved my understanding” by an adolescent may represent “misunderstanding.” The fact that the report cited only positive results and that the study was funded by Netflix raises significant concerns for bias. The concern for bias is amplified by the stark contrast between the conclusions of this industry-funded study and studies conducted by researchers without conflicts of interest.
A recent study conducted at the University of Michigan explored the viewing patterns of a group of youth presenting to a psychiatric emergency department. The study is similar to the aforementioned research out of Northwestern in that it attempts to capture the behaviors and perceptions of youth and parents concerning “13 Reasons Why” using surveys. An important difference is that the sample in the Michigan study is focused on a high-risk group of youth. Researchers at the University of Michigan administered a survey to 87 parent-youth dyads who presented to the psychiatric emergency department with a complaint related to suicide.20 About half of the youth surveyed had watched at least one episode of “13 Reasons Why” and the majority (84%) of them watched it alone. Only a third reported they were likely to discuss the show with their parents. Half of the youth reported they felt their risk for suicide increased after watching the show. Youth who identified with Hannah were more likely to report increased perception of suicide risk due to viewing the series, have higher rates of suicidal ideation and more depressive symptoms. About one third of adolescents reported they were less likely to discuss their mental health with others and another third reported they were more likely to discuss their mental health after viewing the show. The authors highlighted the contrast between their results and those of the Netflix-sponsored Northwestern study in which 71% of youth reported talking about the show with a parent. This difference may be attributable to the fact that the sample in Northwestern’s study is of a self-selected community-level sample compared to a targeted group of high risk youth. Overall, the authors concluded that the study demonstrated increased self-reported suicidal risk after viewing the series in at-risk adolescents.
Recent research out of The Nationwide Children’s Hospital Center for Suicide Prevention and Research provides significant evidence supporting an association between the release of the first series “13 Reasons Why” and an increase in adolescent suicide.21 The study used monthly suicide rates in the United States from 2013 to 2017 to predict the expected monthly suicide rates for the months after the release of “13 Reasons Why.” They divided the data by both gender and by three development age groups: children and adolescents (ages 10-17), young adults (18-29) and adults (29-64). They found that the actual suicide rate for males ages 10-17 was significantly higher than predicted in the two months following the release of the series. In fact, the month following the release of the show had the highest monthly suicide rate of all months included in the study. Interestingly, the study did not find a significant elevation in suicide rates of adolescent females as might be expected. No significant increase in suicide rates was demonstrated in the older age groups. It is somewhat puzzling that the significant increase in suicide rates was restricted to males given the series centers around the suicide of an adolescent female. The authors of the study hypothesized that the lack of statistical significance in the female adolescent category may be attributable to the smaller overall number of female suicides compared to males. It is generally thought that although males are more likely to complete suicide, females make more attempts.21 This study did not include rates of suicide attempts and thus may not have entirely captured the suicidal behavior of adolescents during this period.21 Overall, this study provides some of the most conclusive evidence to date supporting the concern for suicide contagion related to “13 Reasons Why.”
Mitigating the Risk and Opening Dialogue
In response to this widespread criticism, Netflix has taken some important steps to mitigate the risks associated with the series. Season 2 added trigger warnings to the beginning of each series warning that the show might not be right for every viewer. Netflix also added a series of short videos in which the actors come out of character to discuss mental illness, substance abuse, suicide, bullying, sexual assault and how adults can talk to youth about difficult topics. Season 2 also includes explicit discussions about mental illness and mental healthcare within its plot. It includes depictions of positive interactions between youth and parents, counselors and teachers. In “Beyond the Reasons,” the actors and a panel of experts discuss the controversial topics addressed in the series.
Netflix partnered with suicide prevention and mental health experts to create 13reasonswhy.info, a website containing many useful resources for viewers concerning suicide prevention. The website also contains a discussion guide addressing issues in seasons 1 and 2.22 The discussion guide includes a statement about the purpose of the show, tips for viewing the show, questions to start discussions and facts about difficult topics depicted in the series. Tips for watching the show include pausing an episode to talk about an issue, comparing issues in real life to how they are portrayed in the series with attention the fictional nature of the series and continuing the conversation using “I was watching 13 Reasons Why” as a conversation starter. The themes of the questions to initiate conversations include differentiating fiction from reality, considering how characters could have responded better to situations and asking if teens have ever experienced anything similar. The guide provides basic facts about depression, signs of suicide, bullying, sexual assault and consent, substance abuse and violence. Although the website provides useful resources, it also serves as a promotion of the series and neglects to address the criticisms of the show. The discussion guide encourages detailed and repeat viewings of the series, which may not be in the best interest of vulnerable viewers.
The most robust collection of resources is available on 13reasonswhytoolkit.org. The website was created by a panel of 75 mental health and suicide prevention experts working in collaboration with SAVE (Suicide Awareness Voices of Education). It serves a similar purpose as 13reasonswhy.info, but has no affiliation with Netflix. Unlike 13reasonswhy.info, it is an unbiased site and includes critical statements about the series. The website includes a “toolkit” of information organized by intended audience: parents, youth, clinician, educators and media professionals. In addition to the toolkit, its resources section lists crisis hotlines for multiple countries worldwide. The website includes an extensive list of research articles supporting the stance that irresponsible depictions of violence and self-harm poses a risk for adolescents.
The toolkit’s guide for parents emphasizes the need to monitor children watching the show, preventing at-risk youth from watching it and checking in with youth for several weeks after viewing.23 The guide provides several discussion topics for parents and it provides an outline of actions parents can take if they are concerned their child is suicidal. The toolkit’s guide for youth touches on many of themes discussed in the guide for parents and it describes the steps youth can take if they are concerned about themselves or their peers.24 It recommends that youth reach out to a trustworthy adult, create a safety plan for a crisis (the MY3app is an excellent resource) and a contact crisis line. It lists suicide warning signs and recommends #bethe1to as a guide for helping a friend.24
The guide for clinicians recommends clinicians take the following actions: urge at-risk patients not watch the series, cautioning against binge watching and watching in isolation, advocate for responsible media, encourage help-seeking behaviors, integrate evidence-based screening into their practice and develop safety plans with patients.25 The “Pediatric Integrated Care Resource Center: Instruments”, accessible here , is an excellent source for screening tools. The toolkit for media includes recommendations for responsible reporting on suicide, mass shootings, sexual violence, bullying and substance abuse. The toolkit for educators includes the same content as the guide for parents, but it also includes a model for suicide prevention in schools.26
Many of the experts and organizations involved with the creation of the toolkit have also published resources independently. The National Association of School Psychologists produced “13 Reasons Why Netflix Series: Considerations for Educators” as a guide for educators, parents, and students.14 This guide provides steps educators can take to inform and support parents and students. It emphasizes teachers or parents should never promise confidentiality and never leave a suicidal student alone. The American School Counselor Association (ASCA) published “13 Reasons Why Netflix Series: How School Counselors Can Help” and hosted a webinar for school counselors, parents, and educators.27 The ASCA includes criticism of the portrayal of the school counselor in "13 Reasons Why" and provides information for school counselors on educating parents, students, and school staff on suicide, sexual assault and bullying.
“13 Reasons Why Talking Points” released by The JED Foundation and SAVE (2017), are succinct lists of 14 talking points dispelling various suicide myths promoted by the series. The language is clear, compelling, and at level appropriate for youth.28 Suicide expert DeQuincy Lezine published an entire book titled 13 Answers for 13 Reasons Why: An Episode- by-Episode Mental Health Resource Guide for Parents.29 Each chapter of the book addresses one issue that is prominent in each episode. These are: 1. Suicide (support, prevention, and risks), 2. substance abuse, 3. sexual assault, 4. safe driving, 5. mental health screening and treatments and 6. seeking help. Each chapter provides a concise discussion of the topic and provides relevant resources for parents. This book is an excellent example of how the popularity of "13 Reasons Why" can be harnessed to create a lasting source of information that will endure after the popularity of “13 Reasons Why” fades.
The many risks of “13 Reasons Why” as elaborated upon by suicide and mental health experts should not be ignored or dismissed. Both primary research and the opinions of experts illustrate the significance of the risks of the series to vulnerable youth and the pressing need to mitigate them. Although the potential for harm should not be overlooked, “13 Reasons Why” resonates with many adolescents and thus opens a door for important conversation. The producers of “13 Reasons Why” wanted to open a dialogue about many sensitive issues faced by adolescents and they have succeeded at a societal level, as evidenced by the tremendous amount of literature generated in response to the series. The series should have been much more responsible in its portrayal of suicide, but perseverating on the negative aspects of the series is not the most constructive response. The series cannot be “unwatched” at either a societal or an individual level. Parents, clinicians, and educators should be aware of “13 Reasons Why”, attempt to mitigate the risks it poses to vulnerable viewers, and capitalize on the opportunity to educate and connect with the adolescents in their lives.
Appendix 1: Resources for Parents, Clinicians, Youth, and Educators
Resources for Parents
Resources for Clinicians
Resources for Youth
Resources for Educators
Appendix 2: Suicide Prevention Resources Not Specific to 13 Reasons Why
The mission of the ACOP eJournal is to serve as a mentor. The journal
will strive to act as a teaching
portal for those students, fellows
and attending physicians who
strive for, and have a thirst for,
a scholarly existence.
ACOP Pediatric Track at OMED '19