What Can We Learn about Suicide from S-Town?

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It’s been over five months since S-Town, the Serial podcast series, was first released. It captivated so many listeners with its compelling story about a bright, unique, complicated man named John McLemore. Even though the major media hype about the show has kind of passed, I chose to write about S-Town in honor of World Suicide Prevention Day. My goals are to highlight some of the main risk factors featured in S-Town, to place them in the context of related empirical research, and to increase awareness about suicide prevention resources. If you want to avoid spoilers for S-Town, please stop here, go listen to it in rapid succession, and then come back in 7+ hours to read the rest.

As a bit of background information, I listened to all of S-Town in two or three days. The first time I listened to it was all about being absorbed in John’s story – experiencing all of the painful aspects, struggling with mixed feelings as complexities were revealed, and fitting puzzle pieces together. I walked away from it for a few days to process my raw emotions and thoughts about it all. Then, I listened to it a second time through the lens of a suicide prevention researcher and identified risk factors that I think may have contributed to John’s tragic death. My understanding of John is limited by what the folks at S-Town chose to include in their framing of his story in their seven episodes. In addition, I am attempting to extract general suicide risk factors from one person’s story (as best as I can I know it) and that necessarily involves speculation. With those limitations in mind, I have listed some of the risk factors below:

Demographic variables. John’s age (49), race (White), and sex (male) placed him in the highest risk group for suicide in 2015, the year that he died. Alabama has a suicide rate that is somewhat higher (15.1/100,000) than the national average (13.8/100,000). John also told Brian Reed that his sexual orientation was “semi-homosexual” and suggested that he was secretive about it to avoid discrimination. Research with lesbian, gay, and bisexual youth suggests that they have higher suicide attempt rates than their heterosexual peers, and that this is linked to more frequent exposure to stressful experiences (e.g., stigma, being threatened with violence, institutional discrimination). These stressors may have been particularly prevalent where John lived. As a reflection of the local attitudes, S-Town points out that the county that John lived in refused to issue same-sex marriage licenses following the Supreme Court decision to legalize same-sex marriage nationwide. Importantly, there is evidence that less discriminatory state law is associated with fewer suicide attempts.

Mood disturbance. John told Brian, “I guess if I sound like I’m disinterested today, it’s firstly because I’m tired and wore-ass out. And secondly because, you know, I just—I’m not the most cheerful person. You know, I spend most spare time now either studying energy or climate change, and it’s not looking good. So yes, sometimes it’s hard for me to get focused back on something when the whole goddamned Arctic summer sea ice is going to be gone by 2017. And we’re fixing to have heat waves in Siberia this year, and sometimes I feel like a total idiot because I’m worried about a goddamn crackhead out here in fucking Shittown, Alabama. So yeah, that’s just a personality disorder of mine. You know, sometimes when you call me, I’m kind of in an upbeat mood. And sometimes, like today, you caught me in one of these tired, somber, you know, reflective moods, where I’ve been, you know, sitting there mulling over climate change for about the past 10 damned hours.”  That quote is characteristic of many of John’s quotes with similar themes throughout the series. Relatedly, Brian makes an observation about John in the first episode, “No positive comment, no matter how innocuous, survives his virtuosic negativity.” However, John’s long-time friends later tell Brian that John used to be “idealistic” and joyously participated in community events (e.g., the Christmas parade). Per their report, he had not become consistently irritable and dysphoric until closer to his death.

While it appeared that John had long struggled with untreated mood problems (with the exception of brief treatment for depression in college), the series posited that his condition deteriorated markedly over time due to mercury exposure. Brian presents compelling evidence that John may have been experiencing “mad hatter syndrome” and it is presented as a primary factor in his suicide. John knew the dangers of mercury exposure, but chose to continue working with it without safety precautions. It is unclear if this choice was due to a devotion for utilizing what he viewed as the best approach to fix antique clocks, if it was some kind of neglectful, self-destructive behavior related to his mood problems, or both.

While mercury exposure in itself is rare in modern times, mood disturbances and mood disorders (regardless of cause) generally increase the risk for suicidal thoughts and behaviors. Therefore, it’s of the utmost importance to seek evidence-based treatments to effectively combat mental health problems, prevent suicide, and to improve quality of life.

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Loneliness. John also told Brian, “But I think the thing that’s happened is I’ve gotten myself in an almost prison of my own making, where all my friends have died off. Because I only had contact with people much older than me. Even when I was a kid in school, I didn’t want to hang around other kids. Because kids are talking about getting girls, or deer hunting, or football. Whereas I was interested in the astrolabe, sundials, projective geometry, new age music, climate change, and how to solve Rubik’s cube.” This quote and others like it (including John discussing his romantic hardships) suggest that John felt he was alone, which is a major risk factor for suicide. One of many surprising turns in S-Town occurs when Brian learned that John actually had a number of people that cared about him. He also had a solid group of friends that he spoke to on a fairly regular basis. John was arguably closest to Tyler at the end of his life and apparently begged him to not leave him alone on the night that he ended his life. This happened right after they had spent the whole day together affirming how much they meant to one another. This speaks to a key, painful point about suicide – feeling disconnected from others leads people to want to end their life EVEN if they actually are loved by many people.

Hopelessness. John blames himself for his misery and attributes it to never leaving Woodstock, Alabama (i.e., S-Town). He expressed insight when he told Brian, “I need to get out of my depression. I need to get over this attitude problem I’ve got, that nothing can be done.” In the last decade of John’s life, he faced multiple stressors that could have contributed to his sense of hopelessness: his dad died, he had a falling out with a close friend, he was heartbroken when the man he loved stopped returning his calls, and he was caring for his aging mother. He also seemed to suffer from a broader sense of hopelessness about the injustices of the world related to climate change, the legal system, and a variety of other issues. He expressed a particular pain in feeling like he was the only one so upset about it all. The combination of pain and hopelessness are particularly linked to suicidal desire. Finding ways to build real hope (e.g., through connecting a person to a mental health professional) can be important for decreasing suicide risk.

Plans and preparations for suicide. Most of John’s friends knew that he planned on killing himself at some point. He spoke of his suicide plans matter-of-factly, kept a lengthy suicide note on his computer, left a list of people to contact after his death, and had access to lethal means for suicide. John’s resolved plans and preparation were particularly dangerous in light of his apparent fearlessness about suicide. Many more people consider suicide than ever attempt or die by suicide, in part, because of a survival instinct that protects people from acting on suicidal thoughts. Under these circumstances, one powerful suicide prevention action is to remove their access to lethal means (e.g., store their gun, pills, or other possible means safely).

Nonsuicidal self-injury.  Toward the end of S-Town, we discover that John went from despising tattoos and piercings to asking Tyler to regularly tattoo and pierce him. Eventually, John was covered in tattoos and would ask Tyler to pierce and re-pierce him and even use the tattoo needle on him without any ink. Tyler told Brian that he thought it was John’s version of cutting, with the purpose of distracting from emotional pain with physical pain. In my opinion, based on the information available, it sounded like a form of nonsuicidal self-injury. Tattoos and piercings are not typically considered nonsuicidal self-injury because they are culturally sanctioned, but the way that John experienced them was atypical and extreme. Nonsuicidal self-injury is associated with higher suicide risk, and this connection is thought to be, at least in part, due to the experience of nonsuicidal self-injury increasing an individual’s pain tolerance while reducing fear about self-inflicted harm.

In the interest of keeping this post relatively brief, I focused on what I view as some of the major risk factors for suicide present in S-Town. There is so much more to John’s story. One of the most moving and painful components of S-Town was hearing John’s loved ones struggle with his death. Many of them experienced self-blame, regret, and wondered if they could have done anything else to prevent it – all feelings that are common for people who have lost someone to suicide.

I thank you for taking the time to read this post. Below are some suicide prevention resources that I hope you find useful:

-The American Association of Suicidology website has a list of warning signs.

-The National Suicide Prevention lifeline has contact information for people in crisis.

-The American Foundation for Suicide Prevention has tips for helping someone who is at risk for suicide.

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Logic Performs a Suicide Prevention Song at the VMAs

I’m quite certain that I’m no longer in the target audience for the MTV Video Music Awards (VMAs). Fortunately, I found out about an incredibly moving VMA performance through the American Association of Suicidology listserv. I have never seen any other live performance like it. Logic, Alessia Cara, and Khalid performed a song named after the National Suicide Prevention Lifeline: “1-800-273-8255”. It has raw lyrics from the perspective of someone experiencing suicidal ideation. In my work, I have heard people express sentiments just like those in the song. It feels real to me – the painful and hopeful aspects don’t feel sugar-coated or contrived.

That, in and of itself, likely reduces some of the stigma associated with suicidal thoughts. But, Logic went even further for the VMAs. He contacted a mental health organization and asked suicide attempt survivors to be part of the performance. During the song, the cameras show a diverse group of people who have survived suicide attempts standing with shirts that have the Lifeline phone number on the front and “You are not alone,” on the back. “You are not alone,” is a powerful message that specifically speaks to a major risk factor for suicide: loneliness. While there are demographic differences in the overall rates of suicidal behavior, people of all backgrounds can be affected by suicide. It was a powerful visual display of many individuals, each with their own journeys, standing together as survivors.

In addition to however many people saw the performance live, the youtube video has been viewed over 3 million times in 3 days (only 2 million were my views). All of those people probably have the National Suicide Prevention Lifeline memorized.

I am curious whether more people reached out to the Lifeline following the VMAs. This is a question that could be partially addressed through their call center data (update: it appears the call volume did increase) or perhaps via Google search trends (which was one useful tool in examining how 13 Reasons Why impacted its audience). It seems likely that this type of widely-viewed content impacts people and their perceptions of mental health. I am grateful that Logic chose to use his platform in a responsible, compassionate way.

Teaching About Mental Health through Music

Clinical psychology graduate student, Samantha Myhre, and I bonded a few years ago over our love of music. We both like to see live shows and get super-close to the stage. For example, here are some pictures Samantha has taken:

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Eddie Vedder on the left; Chris Cornell on the right

And a few I have taken:

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Aesop Rock on the left; Against Me! on the right

 

 

The connections we each have personally with music (discussed in more detail in this podcast episode) carried over to our Abnormal Psychology classes. We both found that adding class activities with music components engaged undergraduate students. Anecdotally, they enjoyed looking more deeply into lyrics than they had in the past. Some also said they experienced increased compassion and comprehension for mental disorder symptoms through the connection to music.

I posted our combined list of mental health-related songs below in case it’s helpful for people teaching these topics. If you have any that you think should be added, please let us know!

Anxiety:

  • 19th Nervous Breakdown (by The Rolling Stones)
  • If I Ever Feel Better (by Phoenix)
  • Breathe (by U2)
  • Flagpole Sitta (by Harvey Danger)
  • Intro to Anxiety (by Hoodie Allen)

Attention-Deficit/Hyperactivity Disorder:

  • Wrong (by Depeche Mode)
  • A.D.H.D. (by Kendrick Lamar)
  • Epiphany (by Staind)
  • Bouncing Around the Room (by Phish)

Autism Spectrum:

  • We’ll Get By (The Autism Song) (by Johnny Orr Band)
  • So It Goes (by various artists and parents)
  • Missing Pieces (by Mark Leland/Tim Calhoun)
  • I’m In Here (the anthem for autism – written from perspective of child with autism

Bipolar Disorder:

  • Manic (by Plumb)
  • Bi-Polar Bear (by Stone Temple Pilots)
  • Manic Depression (by Jimi Hendrix)
  • Lithium (by Nirvana)
  • Secrets (by Mary Lambert)
  • Down In It (by Nine Inch Nails)
  • Given to Fly (by Pearl Jam)
  • Everybody Cares, Everybody Understands (by Elliot Smith)
  • I Go To Extremes (by Billy Joel)
  • One Step Up (by Bruce Springsteen)

Depression:

  • Fell on Black Days (by Soundgarden)
  • Cleaning my Gun (by Chris Cornell)
  • Hurt (by Nine Inch Nails)
  • Lithium (by Nirvana)
  • Save Me (by Ryan Adams)
  • Today (by The Smashing Pumpkins)
  • Sway (by The Rolling Stones)
  • Turn Blue (by The Black Keys)
  • Twilight (by Vanessa Carlton)
  • Come Around (by Counting Crows)
  • Lost Cause (by Beck)
  • You Know You’re Right (by Nirvana)
  • Oh My Sweet Carolina (by Ryan Adams & Emmylou Harris)
  • Philadelphia (by Bruce Springsteen)
  • Someone Saved My Life Tonight (by Elton John)
  • Spaceman (by The Killers)
  • Go Tell Everybody (by The Horrible Crowes)
  • Danko/Manuel (by Drive-By Truckers/Jason Isbell)
  • Fade to Black (by Metallica)
  • Nutshell (by Alice in Chains)
  • Keep Steppin’ (by Atmosphere)
  • Adam’s Song (by Blink 182)
  • Whiskey Lullaby (by Brad Paisley & Allison Krauss)
  • Screaming Infidelities (by Dashboard Confessional)
  • Rhyme & Reason (by Dave Matthews Band)
  • Gotta Find Peace of Mind (by Lauryn Hill)
  • Creep (by Radiohead)
  • Everybody Hurts (by R.E.M.)
  • So Many Tears (by Tupac Shakur)
  • Dark Times (by The Weeknd)
  • Electro-Shock Blues (by Eels)
  • Quiet Times (by Dido)
  • Comfortably Numb (by Pink Floyd)
  • Hate Me (by Blue October)
  • Girl With Broken Wings (by Manchester Orchestra)
  • Jumper (by Third Eye Blind)
  • Miss Misery (by Elliott Smith)
  • Best I Ever Had (by Gary Allan)
  • A Picture of Me (Without You) (by George Jones)
  • Behind Blue Eyes (by The Who)
  • One of Four (hidden track, end of Maintenance by Aesop Rock)
  • Down in a Hole (by Alice in Chains)
  • Keep Steppin’ (by Atmosphere)
  • Picket Fence (by Brother Ali)
  • Rain Water (by Brother Ali)
  • Sullen Girl (by Fiona Apple)
  • That Hump (by Erykah Badu)
  • Rock Bottom (by Eminem)
  • Boulevard of Broken Dreams (by Green Day)
  • Moonshine (by the Gift of Gab)
  • Mad World (by Tears for Fears)
  • Black Clouds (by Papa Roach)
  • Trouble in Mind (by Nina Simone)
  • Much Finer (by Le Tigre)

Eating Disorders:

  • Ana’s Song (Open Fire; by Silverchair)
  • Demons (by Imagine Dragons)

Intellectual Disabilities:

  • This Isn’t Disneyland (by The Sisters of Intervention)
  • I Am (by Liz Longley)
  • We’re Just the Same (by Terry Vital)

Obsessive-Compulsive Disorder:

  • Monster (by Paul Walters) is a song by Paul Walters who was on A&Es Obsessed. This song was created after his decade long battle with OCD
  • Ana’s Song (by Silverchair) does a nice job of highlighting compulsions)
  • Obsessions (by Marina and the Diamonds)

Panic Disorder/Panic:

  • Be Calm (by fun.)
  • If the Brakeman Turns My Way (by Bright Eyes)
  • Circus Galop (by Marc-André Hamelin)

Positive Body Image:

  • Nobody’s Perfect (by Hannah Montana – nice Disney Channel throwback)
  • Stay Beautiful (by Taylor Swift)
  • All About That Bass (by Meghan Trainor)
  • Dumb Blonde (by Dolly Parton)
  • Just the Way You Are (by Bruno Mars)
  • What Makes You Beautiful (by One Direction)
  • Try (by Colbie Caillat)
  • Fat Bottomed Girls (by Queen)
  • Born This Way (by Lady Gaga)
  • Beautiful (by Christina Aguilera)
  • Flawless (by Beyonce)
  • You’re Beautiful (by James Blunt)
  • F**kin’ Perfect (by P!nk)
  • Beautiful (by John Mayer)
  • Hips Don’t Lie (by Shakira)
  • Fight Song (by Rachel Platten)
  • Love Me (by Katy Perry)
  • On My Own (by Miley Cyrus)
  • Unpretty (by TLC)
  • Feelin’ Myself (by Nicki Minaj ft. Beyonce)
  • My Kind of Woman (by Justin Moore)
  • I’d Want It to Be Yours (by Justin Moore)
  • The Perfect Woman (by Bo Burnham)

Here‘s a playlist my class made with positive body image songs.

Post-Traumatic Stress Disorder/Trauma:

  • Wrong Side of Heaven (by Five Finger Death Punch)
  • Hidden Wounds (by dEUS)
  • Drum + Fife (by Smashing Pumpkins)

Schizophrenia/Psychotic Symptoms:

  • Jump They Say (by the late and great David Bowie) was a song written about Bowie’s brother who had schizophrenia and died by suicide while experiencing auditory hallucinations
  • Basket Case (by Green Day)
  • Is There a Ghost (by Band of Horses) is about Band of Horses member Ben Bridwell’s experiences with paranoia
  • Annabelle (by Dessa)
  • Shine On You Crazy Diamond (by Pink Floyd)
  • Going Crazy (by Jean Grae)

Social Anxiety:

  • Social Anxiety (by Nicola Elias)
  • The Quiet One (by The Who)
  • Things the Grandchildren Should Know (by Eels)

Substance Use:

  • Everyone’s At It (by Lily Allen)
  • Never Did (by Perfume Genius)
  • Sober (by P!nk)
  • Not If You Were The Last Junkie On Earth (by The Dandy Warhols):
  • Needle and the Damage Done (by Neil Young)
  • Under the Bridge (by Red Hot Chili Peppers)
  • Rehab (by the late Amy Winehouse)
  • Detox Mansion (by Warren Zevon)
  • Cover Me Up (by Jason Isbell)
  • Super 8 (by Jason Isbell)
  • Choices (by George Jones)
  • Stockholm (by Jason Isbell)
  • Starting Over (by Macklemore & Ryan Lewis)
  • Amazing (by Aerosmith)
  • That Smell (by Lynyrd Skynyrd)
  • Gravity (by A Perfect Circle)
  • Numb (by Alanis Morissette)
  • Save You (by Pearl Jam)
  • You’re Gone (by Diamond Rio)
  • Sunloathe (by Wilco)
  • Unforgiven (by Hal Ketchum)
  • Uncle Johnny (by The Killers)
  • Drug Ballad (by Eminem)
  • The Man I Knew (by Dessa)
  • Habits (Stay High, by Tove Lo)

Suicide/Self-Harm

  • Asleep (by The Smiths)
  • The Ledge (by The Replacements)
  • Vincent (by Don McClean)
  • King’s Crossing (by Elliott Smith)
  • Suicidal Thoughts (by Notorious B.I.G.)
  • Last Resort (by Papa Roach)
  • Like Suicide (by Soundgarden)
  • The Great Escape (by P!nk)
  • Hold On (by Good Charlotte)
  • Don’t Try Suicide (by Queen)
  • 1-800-273-8255 (by Logic)
  • Out of Here (by Brother Ali)
  • Moment of Truth (by Gang Starr)
  • Jeremy (by Pearl Jam)
  • Coming Apart (by Friends of Emmet)
  • The Pretender (by Jackson Browne)
  • Keep Livin’ (by Jean Grae)
  • Keep on Livin’ (by Le Tigre)

Here‘s a playlist my class made with songs that give them hope when they’re feeling down.

While I have you here thinking about mental health and music, I recommend checking out Dessa:

 

Congratulations to Dr. Kwan & Dr. Minnich!

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Congratulations to Dr. Mun Yee Kwan & Dr. Allison Minnich for completing their doctorates in clinical psychology! After their internships, Dr. Kwan will be an Assistant Professor at West Texas A & M University, while Dr. Minnich will be a clinician at the Chicago Cognitive Behavioral Treatment Center! It was an honor to serve as their advisor, and I couldn’t be prouder of them on their graduation day! The world gained two fantastic clinical psychologists!

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A Note to Chris Cornell Fans from a Chris Cornell Fan

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Chris Cornell in Minneapolis, October 2015 (photo credit: Samantha Myhre)

When I learned about Chris Cornell’s death this morning, I was filled with disbelief and sadness. Chris was a remarkable musician

and a humanitarian.

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When I learned that he died by suicide, I couldn’t help but think back to how painful it was to learn of Kurt Cobain’s death by suicide years ago.

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a bench turned memorial outside of Kurt Cobain’s former house

If someone you don’t know can have such an impact on your life, it’s hard to fathom how much pain Chris’ loved ones are experiencing right now. My heart goes out to them. I hope they receive all of the support, respect, and privacy they need in the face of their tragic loss.

There will be (and already are) amazing pieces dedicated to Chris’ legacy as a musician, as a humanitarian, and his personal impact in his roles as a friend, father, and husband.

What I want to focus on here is something that came to mind as I recalled MTV’s interviews with people about their reactions to Kurt’s death. In particular, I was thinking about people who had suffered from their own mental health problems and looked to Kurt as a symbol of hope. I know there were people who looked at Chris, who had been open about past mental health struggles, in the same way. When you see someone you look up to survive and thrive in the face of mental health struggles – it’s inspiring. When you lose that person, it can dampen your own hope.

To the Chris Cornell fans out there:

First, I am so very sorry for your loss and all of the hurt that goes with it.

Secondly, I want you to know that mental health problems are treatable and that suicide is preventable. Please take care of yourself – reach out for help and support. There is strength in seeking help, and mental health struggles are nothing to be ashamed of. You matter – please stay.*

For information about suicide warning signs and suicide prevention, please go to the American Association of Suicidology website.

A useful resource for finding mental health help can be found here.

If you are having thoughts about suicide, please contact the National Suicide Prevention Lifeline.

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*#STAY is a t-shirt campaign for suicide prevention started by Live Through This. You can find out more about it here.

13 Thoughts on 13 Reasons Why

**WARNING: SPOILERS APPEAR IN THIS POST.**

I watched the new Netflix series 13 Reasons Why (based on a book with the same title). This post sums up my reactions, and I am also in the process of recording detailed Jedi Counsel podcast episodes on the series with my co-host. Some people say this is art and entertainment, and therefore, exempt from social responsibility. Nonetheless, many people will watch this series, and that makes it important to view it critically and to consider its implications. My thoughts aren’t fully formed yet, but I wanted to post something as the series came out without waiting until I had it all sorted out. My feelings and opinions may develop more as I process the material for a longer period of time. I’m open and curious about other perspectives.

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  1. The series is set up as a mystery that quickly pulled me into the story. I finished the whole series within a few days. The framework for the series is that an adolescent, Hannah Baker, has died by suicide and left behind audio tapes detailing every component that she believes led up to her death. In addition, she has a methodical plan for the specific people who should listen to the tapes, how they should be listened to, and the order in which people hear them. While this is a compelling way to reveal a mystery, I believe that it contributes to stigma by painting the picture of a woman who ended her life for the purposes of getting attention from the individuals she believed ruined her life. The tone of her delivery is blaming and feels vengeful. I worry this perpetuates the myth that suicide is typically driven by desire for attention, selfishness, or revenge…which it most certainly is not.
  2. There is a scene that is explicitly blaming of one of the few kind (though not perfect) people in the series (Hannah’s friend and love interest, Clay). Hannah’s friend, Tony, tells Clay that Hannah would have been alive if he had acted differently. He later softens his tone, saying it is not Clay’s fault and Hannah is responsible for the choice that she made. Still, the blame message is there in a scene where Hannah tells Clay repeatedly to leave her alone. He reluctantly leaves the room. The show then depicts a parallel universe where the “right” things happened: Clay insists on staying despite Hannah clearly asking him to leave her alone, he turns the conversation around through persistence, Hannah feels loved, and suicide is prevented. In light of the violations of consent elsewhere in the series (including two rape scenes), I was bothered by Clay being painted as having done the wrong thing when he honored Hannah’s wishes to leave her alone.
  3.  Hannah decides, as her last attempt at help-seeking, to reach out to her school counselor about her suicidal thoughts and being the victim of rape. The counselor, insensitively and against best practice guidelines, implies she may be partially to blame (e.g., asking if she verbally said no to the perpetrator, asking if she had been drinking) and jumps right into telling her that her only choices are to: 1) report the assault or 2) to move on. She leaves the office, and he doesn’t follow-up with her in any way. He doesn’t ask for more details or conduct a suicide risk assessment, and he does not try to reach out to her parents to prevent her from harming herself. Of course, there are some counselors out there who might act in this irresponsible way. However, the vast majority would not. In a show that is viewed by a lot of young people, the depiction of the counselor matters a lot. People are already reluctant to reach out to mental health professionals. I worry people would feel even more discouraged from seeking help after seeing this terrible, judgmental, unethical interaction.
  4. The series accurately portrays some of the risk factors for suicide: social isolation, loneliness, and disconnection from others (including in the painful forms of bullying), perceiving herself as a burden (e.g., she describes herself as a “problem” for her parents and especially feels burdensome after accidentally losing some of their money), family conflict (her parents argue about issues including finances), witnessing and then being a victim of sexual assault, and hopelessness about her future (e.g., with regard to college and other plans).
  5. I appreciated the series emphasizing how crucial social connections are for health and talking about different types of loneliness – including individuals truly isolated and those who feel “lonely in a crowd.” It seemed to make the point that even apparently popular people (like Zack) can feel lonely. I believe this sends the message that anyone is vulnerable to loneliness, and we shouldn’t assume people are doing well just because they appear that way on the outside.
  6. One of the themes of the series is that – at any point – one person listening, reaching out, or doing something differently could have prevented Hannah’s suicide. Ultimately, this is a positive message. Unfortunately, I think it’s lost and distorted because it is used to blame people for their failures to save Hannah rather than demonstrating that one person could have made a difference and changed the story to a hopeful one. If the counselor or one of her parents had connected with Hannah and supported her in seeking help for her struggles, this point would have been much more persuasive. Instead, the story feels more demoralizing than inspiring to me.
  7. Hannah’s death scene is a graphic depiction of her cutting her wrists with razorblades in a bathtub. In a documentary-type episode made about the series, they said that it was to show the painful and hard-to-look-at nature of suicide. To me, it feels like a choice to make a dramatic, visually startling conclusion to the story rather than to deliver a lesson. It makes sense – this is a series meant to be watched and to get people glued to their screens- not a PSA. It’s possible that an individual who feels suicidal might see that and be afraid; however, it’s also quite plausible that an individual feeling suicidal might mistakenly view it as an end to all of Hannah’s emotional pain and problems. Anecdotally, there are cases of suicidal individuals watching scenes of suicide building up to taking their own life.
  8. There are warnings in the beginnings of episodes where there are graphic scenes (e.g., sexual assault, suicidal behavior). It would have been helpful if the episodes had information about resources, such as the National Suicide Prevention Lifeline and the American Foundation for Suicide Prevention, embedded in them too. It would be a simple way to reach a lot of people. Again, the series created a separate short documentary-like episode with mental health professionals and resources in it. However, it appears completely separately from the series (rather than as the 14th episode, for example). It would reach more people if it was connected to the full series.
  9. The pain Hannah’s parents experience after her death is excruciating. I feel this is one of the most realistic aspects of the series. It shows their horror, their confusion, their regret, and their desire to prevent other suicides from occurring. In the documentary afterwards, they suggest that this might show individuals who feel suicidal about the pain that others would experience if they died. I think this may be the case for some, but for certain individuals, tragically, they might imagine that people wouldn’t feel the same way about their death. That’s the cruelty of perceiving oneself as a burden – people struggling with mental health problems may not see how the world is better with them in it.
  10. Related to the second point, several characters clearly violate Hannah. Marcus and Bruce grab her, Tyler and Justin take and share revealing pictures without permission, and Bryce rapes her. When Hannah and Clay are starting to kiss, Clay asks, “Is this okay?” I really liked this scene because it shows how asking about consent is natural and enhances, rather than ruins, the moment. It also shows a welcome contrast in that Clay genuinely respects and cares about her feelings and perspective. Sadly, this positive point gets diminished when the scene turns into Hannah yelling for him to “get the hell out” and the suggestion that if he had only ignored her wishes, he would have saved her life (as described above).
  11. From one perspective, it seems like a point of the series is to teach bullies that their actions can lead to someone dying by suicide. However, most people who are bullied do not die by suicide – people are often remarkably resilent in the face of great adversity. It’s important that people who are on the receiving end of bullying know that. Secondly, most of the people on Hannah’s tapes are more concerned about protecting their own secrets (e.g., that Courtney is attracted to women, that Justin allowed Bryce to rape Jessica, that Ryan published Hannah’s poem without her permission) than how they hurt Hannah. If the message is supposed to be an anti-bullying one, I don’t think it really connects with bullying people in the audience. I guess that it would resonate more with people on the receiving end of bullying who feel a sense of hopelessness about the bullies having any potential for empathy and a sense that there is no help available to them.
  12. On two occasions, two adults (the counselor and the communications teacher) state that the warning signs for suicide include withdrawing from friends and family, changes in appearance, and trouble in group projects. This was a great opportunity to share the real warning signs for suicide, but unfortunately, only the first one really maps onto the list.
  13. A lighthearted, sweet aspect of the series is that Clay is different from his peers in that he cares relatively less about what other people think of him. He still cares what people, including Hannah, think of him to some extent, but he doesn’t try as hard as his peers to be something he’s not. He feels nervous around Hannah, but doesn’t ever really pretend to be someone else. He doesn’t let other people’s opinions make him feel bad about himself. Again, Clay’s not perfect (he says some mean things to Hannah and looks at a revealing picture that Tyler took without consent). But, overall, he’s smart, sensitive, caring, a good student, interested in the world beyond the walls of his school, helps others, takes reasonable caution in his decision-making, and likes geek stuff like Lord of the Rings and Star Wars. During one exchange, Hannah says to Clay, “Wow. You’re an actual nerd. There’s courage in that.” Most of the other characters in the series view themselves and their worth in terms of what their peers think of them. This generally rings true with regard to this developmental period in adolescence. It’s refreshing to see someone who has some self-acceptance and a sense of what’s right in the midst of all of the tragedy.

You can check out our first podcast episode on this series here and our second episode here.

If you or someone you know needs help, please reach out. There is hope and help is available here.

10 Hamilton Quotes for Therapists

Hamilton

Like many people, I am enamored with the music from Hamilton. There are so many things to like – all the hip-hop (e.g., Cabinet Battle #1!), the psychologically complex and nuanced development of the characters, the diversity of the creators, cast, and crew, and the powerful storytelling of US history. Because I like to explore mental health in fictional characters, I was tempted to with Hamilton as well (i.e., why did Burr and Hamilton end up on such different trajectories?). However, they are based on real people and real lives, so I don’t want to speculate about them (at least not in a blog post). So, similar to what I did with Star Wars, I decided to make a list of 10 quotes from Hamilton, that in my opinion, may be useful for therapists working with Hamilton fans (who are numerous these days).

1)  On mindfulness and gratitude:

Look around, look around at how/Lucky we are to be alive right now!

2) On taking healthy risks and decreasing unhealthy avoidance:

Rise up! Time to take a shot!

3) On acceptance, patience, resilience, and meaning-making:

Love doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep loving anyway
We laugh and we cry
And we break
And we make our mistakes

Death doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep living anyway
We rise and we fall
And we break
And we make our mistakes
And if there’s a reason I’m still alive
When everyone who loves me has died
I’m willing to wait for it
I’m willing to wait for it

4) On self-empowerment/accepting that one cannot change other peoples’ behavior:

I am the one thing in life I can control

5-6) On understanding historical context for clients who may belong to marginalized groups:

You want a revolution? I want a revelation
So listen to my declaration:

“We hold these truths to be self-evident
That all men are created equal”

And when I meet Thomas Jefferson

I’m ‘a compel him to include women in the sequel!

A civics lesson from a slaver. Hey neighbor
Your debts are paid cuz you don’t pay for labor

7) On not equating self-worth with work achievements

I don’t pretend to know
The challenges you’re facing
The worlds you keep erasing and creating in your mind

So long as you come home at the end of the day
That would be enough

We don’t need a legacy

8) On self-compassion:

Look at where you are
Look at where you started
The fact that you’re alive is a miracle

9) On not letting perfectionism interfere with productivity:

Burr (on the U.S. Constitution): And if it fails?
Hamilton: Burr, that’s why we need it
Burr: The constitution’s a mess
Hamilton: So it needs amendments
Burr: It’s full of contradictions
Hamilton: So is independence
/We have to start somewhere

10)  On prioritizing health and balance:

Take a break