Your Screens Are a Public Health Problem

Anthony Bourdain. (Source: Wikimedia.)

Based on the title, you might imagine this column will be a tired diatribe about violent movies and video games or sex on the internet. Or perhaps it will be another admonishment about spending too much time on your screens and the perils of distracted drivers. That’s not where this column is going.

If you have been paying attention for the past couple of years, you are aware of two unfortunate trends. First, mass shootings have increased dramatically (Berkowitz, Lu, and Alcantara 2018). Mass shootings are a small fraction of overall homicide deaths, and homicides overall have been generally on the decline. But mass shootings are not. As a result, children have new fears about going to school, and throughout the United States, students are required to practice active shooter drills. Second, suicide rates are rising. We have been reminded of this last trend most recently by the deaths of fashion designer Kate Spade and celebrity chef Anthony Bourdain, both in a single week of June 2018.

Figure 1. U.S. suicide and homicide rates per 100,000 population from 1981–2016. Homicides experienced a slight increase in 2016 but have otherwise declined since the 1990s. In contrast, suicides have been on the rise and are currently at their highest rate during this period. (Source: Centers for Disease Control and Prevention.)

The deaths of Spade and Bourdain brought an outpouring of concern on the internet. There were calls for compassion and expressions of caring, as well as renewed requests for increases in mental health funding and gun control. Many of the reports of these deaths also displayed the phone number of the National Suicide Prevention Lifeline (800-273-8255). But in the midst of all of this emotion, one relatively easy and evidence-based strategy received almost no attention. Why? Because this strategy impugns the very avenue by which we learn about celebrity suicides and mass shootings—the news media.

If this week has kicked your ass because you've faced suicidal ideation or lost someone you loved to it, please take extra care of yourself. This is all devastating. https://t.co/ECUEjetMGB

— MaryElizabeth Williams (@embeedub) June 8, 2018

The other half of these stories is just as important: when that someone sincerely asked, "Are you ok?," the person in pain answered honestly. Everyone can be that person that asks--you can also be that person that answers. We need you both in this world.

— ana marie cox (@anamariecox) June 8, 2018

As the figure above suggests there are thousands of suicides and homicides each year—44,965 suicides and 19,362 homicides in 2016 to be exact. These figures represent 123 suicides and 53 homicides per day. Tragically, the young are particularly vulnerable to both suicide and homicide. According to the National Center for Health Statistics (2017), in 2015, suicide and homicide were the second- and third-ranked causes of death in people aged 15–24, after unintentional injuries.

The overwhelming number of these unnatural deaths happen in the shadows, entirely out of our sight. They are not news. The deaths that do come to our attention are likely to come via television. According to a 2016 Pew survey, 57 percent of respondents said they got their news from television, and the next most popular method was online sources at 38 percent (Mitchell, Gottfried, Barthel, and Shearer 2016). Radio and print bring up the rear. And so, when it bleeds, the lede comes to us very quickly and very vividly on a screen, and mass shootings and celebrity suicides command our attention. We stare, and, in many cases, we feel real emotions: fear, loss, and sadness. But the very compelling nature of these stories creates an important ethical dilemma.

The Media and Suicide

When it comes to preventing suicide and mass shootings, the elephant in the living room is the news media. A study by Columbia University researchers published earlier this year in the journal PLOS One (Fink, Santaella-Tenorio, and Keyes 2018) found that suicides in the United States increased by 9.9 percent in the months following the death of beloved actor and comedian Robin Williams. This represented an excess of 1,841 deaths in the four months following his death, with males between the ages of 30 and 44 particularly affected. Although the researchers were quick to say that it was impossible to be certain the observed increase was caused by reports of Williams’s death, they point out that the effect was timed to his death in August of 2014 and that suffocation, the method Williams used, showed the greatest increase during that period.

Evidence that suicide can be spread through media contagion has a very long history. The response to Goethe’s wildly popular novel Die Leiden des jungen Werther (The Sorrows of Young Werther), published in 1774, is one of the most famous cases. The novel’s main character shoots himself in the head after being spurned by the woman he loves, and when it was published, many men began to dress like the main character and take their own lives in the same manner. This copycat phenomenon was labeled the “Werther effect” and prompted the banning of the book in parts of Europe (Pirkis and Nordentoft 2011). Beginning in the 1970s, a series of empirical studies documented clusters of suicides at specific times and locations, and in the 1990s, research uncovered media contagion effects in the United States, western Europe, and Japan (Gould, Jamieson, and Romer 2003; Romer, Jamieson, and Jamieson 2006). Furthermore, a kind of dose-response effect has been identified, with the number of suicides being greater when more television networks cover a story than when fewer do (Phillips and Cartensen 1986). Finally, although most of the empirical research has been on the effects of news reports of actual suicides, there is some evidence that, as in the Werther case, fictional stories can encourage contagion. For example, a 2017 study published in the Journal of the American Medical Association showed an increase in internet searches for “suicide” and “how to commit suicide” following the release of the Netflix series Thirteen Reasons Why, a show that closely examined a teen suicide and, in the final episode, depicted a suicide in great detail (Ayers, Althouse, Leas, Dredze, and Allem 2017).

The Media and Mass Shootings

There have been fewer empirical studies of media effects on mass shootings, and the evidence of a short-term contagion effect, similar to that observed with suicide, has been more mixed. A 2014 study using two different datasets found that shootings of four or more people were more likely to occur in the fourteen days following a mass shooting (Towers, Gomez-Lievano, Khan, Mubayi, and Castillo-Chavez 2015), but other studies have found no short-term contagion effect (e.g., Lankford and Tomek 2017). However, although unequivocal proof of short-term contagion is lacking, there is much stronger evidence that many mass shooters are motivated, at least in part, by a quest for fame, and that the United States produces a disproportional share of the fame-seeking rampage shooters. A recent estimate suggested that the United States accounted for 31 percent of rampage shooters worldwide but that we produced 75 percent of the world’s shooters who were driven by fame (Lankford 2016). The most chilling recent evidence of this motive was a video produced by the Parkland, Florida, shooter prior to his attack. In the brief recording, he referred to himself as the “next school shooter,” predicted the total number of people he would shoot, and talked about being seen on television after the attack.

What’s Really Going On?

The word contagion is, of course, merely a metaphor for what might actually be happening in these suicides and mass shootings. Unlike a disease, these killings do not require actual contact or transmission of a physical germ. The process is presumed to be a kind of mental priming effect that stimulates suicidal or homicidal ideation in people who are prone to these activities (Jo and Berkowitz 1994) or a process of generalized imitation in which vulnerable individuals learn by observing a model (Gould, Jamieson, and Romer 2003). The imitation theory is supported by cases that involve the use of similar methods. It is presumed that the publicity surrounding prior cases serves as a kind of vicarious reinforcement that encourages future behavior.

Which brings us back to the role of the media. Neither priming nor imitation would be possible without the effect of media reports that bring these episodes to our attention, and as a result, the media represents a potential point of intervention. Furthermore, although it may not have come to your attention, this is very old news.

For years a number of respected researchers and non-governmental organizations (NGOs) have offered guidelines for media reports of suicides and mass shootings (Meindl and Ivy 2017). For example, Lankford and Madfis (2017) have proposed four easy guidelines for the reporting of mass shootings:

• Don’t name the perpetrator.
• Don’t use photos or likenesses of the perpetrator.
• Stop using the names, photos, or likenesses of past perpetrators.
• Report everything else about these crimes in as much detail as desired.

Given the more extensive research history and the much more frequent occurrence of suicide contagion, there have long been recommendations from a variety of NGOs for the reporting of suicides in the media (e.g., World Health Organization 2000; Guardians New and Media 2000). For example, the World Health Organization (2000) recommends the following principles:

• Sensational coverage of suicides should be assiduously avoided, particularly when a celebrity is involved.
• Detailed descriptions of the method used and how the method was procured should be avoided.
• Suicide should not be reported as unexplainable or in a simplistic way. Suicide is never the result of a single factor or event.
• Suicide should not be depicted as a method of coping with personal problems.
• Reports should take account of the impact of suicide on families and other survivors.
• Glorifying suicide victims as martyrs and objects of public adulation may suggest to susceptible persons that their society honors suicidal behavior.
• Describing the physical consequences of non-fatal suicide attempts (brain damage, paralysis, etc.) can act as a deterrent.

In the case of Anthony Bourdain’s suicide, which has been the most widely covered recent death, by happenstance there are examples of both good and bad media reports. On the positive side, Asia Argento (Bourdain’s girlfriend) posted a message on Instagram that emphasized how devastating his death was for her. It is tragic to think of Argento’s expression of despair as positive thing, but by posting this widely circulated message, she reminded us of suicide’s effects on family members and close friends.

Instagram post by Asia Argento, who was Anthony Bourdain’s partner at the time of his death.

In contrast, a number of outlets quickly reported the method Bourdain used to take this life (e.g., Bios 2018). The reporting of methods is thought to encourage imitation of suicidal behavior.

What Can We Do?

The media are not responsible for all—or even most—of the homicides and suicides that occur each year, but there is strong evidence that a substantial number of these deaths are encouraged by the messages displayed on our television and computer screens. So why do we hear so little about this research? Why are the recommendations of the World Health Organization, Samaritans, and many crime and violence researchers largely ignored by the major news media? If we give it a moment of thought, the reasons are obvious. First, the news media have a clear conflict of interest. The old journalistic adage still holds: if it bleeds it leads. The sensational nature of mass killings and celebrity suicides produces very high ratings. Implementing some of the restrictions that could curtail copycat suicides or homicides might require a ratings sacrifice. Second, the United States places a high value on freedom of the press. There is little motivation for regulating the media. Finally, we, as viewers, are complicit. When mass shootings break out or celebrities take their own lives, we stare, and we want to know why. But we should begin to recognize that our prurient curiosity has very real public health consequences.

Dolores O’Riordan, lead singer of The Cranberries. (Source: Wikimedia.)

Often when we hear about a great tragedy, we are overcome by a feeling of powerlessness. The school shooting at Stoneman Douglas High School in Parkland, Florida, was a devastating blow, and many of us searched in vain for things that might have prevented the massacre. That episode was followed by the now familiar calls for gun control, better policing, and better mental health treatment, and so far—as in the past—very few of these things have happened. But there is something we could do that would help. Something that would not be as difficult as gun control or increased mental health funding. Something that, in fact, is being done in other places.

Following tragedies in their countries, the news media in both Canada and Finland adopted major aspects of the recommended “Don’t Name Them, Don’t Show Them, But Report Everything Else” policy with respect to mass shootings in their countries (Lankford and Madfis 2018). Similarly, in January of this year, Dolores O’Riordan, the lead singer of The Cranberries, was found dead in her hotel room in London. In the following days and weeks there was an outpouring of sadness and affection for the beloved Irish singer, but the cause of death was not publicly released. Indeed, an inquest into her death was cancelled and not rescheduled (“Dolores O’Riordan Death” 2018). As a result, in the months since her death, the focus has remained on her life and accomplishments.

There are evidence-based responses to these tragedies that we are not implementing. Of course, a free news media is an essential feature of our democracy, but the classic example of shouting “Fire!” in a crowded theater is an apt comparison to what is going on now. Each time the news media panders to our curiosity about the details of these needless and premature deaths, they ensure that others will follow. When lives are at stake, it is reasonable to adopt modest limitations on freedom of expression and our need to know. The voluntary adoption of the reporting standards long promoted by researchers and advocacy organizations could make a substantial difference and would be a fitting way to honor those who are no longer with us. All we have to do is act.

• Ayers, John W., Benjamin M. Althouse, Eric C. Leas, Mark Dredze, and Jon-Patrick Allem. 2017. “Internet searches for suicide following the release of 13 Reasons Why.” JAMA internal medicine 177, no. 10: 1527–1529.
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