S1E5 / The Role of TV & Film / Victor Schwartz, Erahm Christopher, Jenny Jaffe, Michael Lehman

How can movies and shows tell stories responsibly about mental health & suicide?

Note: This season of American Diagnosis was originally published under the title In Sickness & In Health. 

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: This is “In Sickness and in Health.” I’m Dr. Celine Gounder.

In this episode, we’re going to talk about topics that some parents may find unsuitable for young children. Parental discretion is advised.

In March, Netflix released a new series.

[Clip from 13RY trailer] Hey, it’s Hannah. Hannah Baker.

Celine Gounder: In a matter of days, the show was all over the news and social media.

Settle in, because I’m about to tell you the story of my life. More specifically, why my life ended.

Celine Gounder: A high school student commits suicide… and her downward spiral is doled out in cassette tapes.

And if you’re listening to this tape… you’re one of the reasons why.

Celine Gounder: Thirteen Reasons Why is a no-holds-barred version of the after-school special. It’s based on a book that came out ten years ago, but the show is what’s stirred real controversy. Hannah Baker commits suicide in a scene that makes a very graphic appearance in the show itself, but not before preparing a detailed narrative describing the sequence of traumatic events leading her to that point and distributing tapes of that story to the people she blames for her choice.

On this episode of In Sickness and In Health, we’re going to dig into a very public dimension to the mental health conversation: the world of youth pop culture.

Young adult depression, social stress, suicidality — it’s been fodder for writers and directors for a long time. Teen dramas are chock full of struggling kids acting out, breaking down, stewing in teen angst. Teens may see a lot of themselves in these storie and that often makes for high ratings.

But is this kind of art responsible? And does it have any obligation to be?

Thirteen Reasons Why takes on some of the toughest teen issues: bullying, sexual-shaming, rape, alcohol, drugs and mental health. It’s polarized the conversation around suicide and raised questions about whether the show’s place in that conversation is a healthy one.

Victor Schwartz: This show was meant as a tale to portray the worst things that could possibly happen under almost every circumstance. And they succeeded in doing that, they really believed that the whole thing was and intended the whole thing to be a cautionary tale.

Celine Gounder: Victor Schwartz is the Chief Medical Officer for the JED Foundation. It’s an organization we’ve talked about on the show before, one whose mission is to protect the emotional and mental well-being of young people and to prevent suicide.

Victor Schwartz: And I think for a lot of the viewers of it, that may very well work. But unfortunately there are some vulnerable young people who may or may not get that message. And if they don’t get the message, it leaves them with a feeling that the world is pretty bleak.

Celine Gounder: Victor has been playing a major role in the media conversation about this show because he knows messaging can have a major impact on the way young people think and act.

Victor Schwartz: That’s part of the concern is that there are many young kids out there who I think will see themselves in Hannah’s experience and the experience of many other characters — this is part of the concern around contagion — where the extent to which a kid will kind of read themselves, will identify with a character like Hannah who is very appealing in a lot of ways as a character, actually raises some risk of potential contagion.

Celine Gounder: The loudest backlash against Thirteen Reasons Why has been just this: that the show might cause a kid on the edge to take a step too far. The series is engrossing, it’s entertaining and the main character is sympathetic. But the show is also a virtual memorial to Hannah Baker’s fictional death and a revenge fantasy in which she finally receives everything she wanted — understanding, remorse, friendship and love — after her death. There are so many instances in the show where she misses an opportunity to get help, even when she asks for it.

So there is some concern, Victor says, that a minority of viewers might conclude all adults are useless in a desperate situation even though that doesn’t reflect the real world.

Victor Schwartz: Do things like this happen sometimes? Sure. But, you know, we have good data out there that people who seek help lower their risk of bad outcomes and of suicide, that the vast majority of interactions with school counselors and clinicians in clinic and private settings are actually helpful to people. And lower their risk of self-harm and suicide.

Celine Gounder: In the 3 weeks following the release of 13RY, Google searches about suicide spiked, with between a million and a million and a half more such searches than usual. While some were looking for suicide hotlines and prevention resources, there were also a lot more searches about “how to commit suicide” and “how to kill yourself.” Like many other mental health experts, Victor has heard of suicide attempts among kids emulating what they saw in the show.

Could 13RY’s creators have done more to mitigate the risk? Did they need to be so graphic in their depiction of Hannah’s suicide? Could they have done more to emphasize the need to seek help? and tell young people how and where to get it?

In Hollywood, sequels and copycats are all too common. If films and shows about superheroes or zombies sell, we’ll see more of them. And if suicide, eating disorders and school shootings sell, we’ll see more such productions too. But at what cost?

Victor says he has heard of suicide attempts among kids who’ve watched the show, about crisis hotlines getting more calls and texts from kids who bring up Thirteen Reasons Why as they discuss thoughts of suicide. But is Thirteen Reasons Why to blame here?

Victor says that might be the wrong question to ask.

Victor Schwartz: In some of the press interviews I think there hasn’t necessarily been a kind of balance, because they’re focusing on the controversy. So they haven’t always included the fact that I think there’s potential for this show to actually be quite helpful on a number of fronts.

Celine Gounder: Victor and I talked did talk a lot about the controversy surrounding the show. For emotionally vulnerable people, for younger viewers, Victor says Thirteen Reasons Why could have a negative impact. But he thinks that if watched in the right context with the right support, for him, the right response to the show is taking Thirteen Reasons Why the way it was intended, as a cautionary tale and what could be an effective learning tool.

Victor Schwartz: It is almost, you can tell the stories, but then the stories have to be unpacked. So this is why we’ve consistently been telling parents and young people, if you’re making the choice to watch it, watch it with an adult, watch it with a parent, and you know, really talk about what you’re seeing.

Celine Gounder: Of course that conversation with adults, with parents, it isn’t necessarily a given.

But this show in particular has drawn intense scrutiny and conversation. People are talking about it. Parents, teachers, school administrators and health care professionals are concerned about its messaging.

Victor sees this as an opportunity.

Victor Schwartz: So I think we all learn about feelings, by, you know, reading stories, watching TV shows, but to make it really stick it’s great if you have an opportunity to discuss and understand what you’ve seen.

Celine Gounder: When Thirteen Reasons Why first came out, Victor wrote a blog post explaining what viewers should consider when watching the series, and the JED Foundation and SAVE (short for Suicide Awareness Voices of America) responded quickly, distributing their talking points on the show.Netflix released a companion video, in which the actors and healthcare professionals discuss depression, bullying and sexual assault. Schools across the country sent letters home, alerting parents to the show, and teens spoke out on social media about its usefulness.

This kind of response, Victor says, is key, and it’s something built into the way we consume other kinds of art, where scenarios on the page or the stage can be analyzed and debated in the classroom or around the dinner table, with others, in a healthy, constructive way.

Victor Schwartz: The wonderful thing about art and drama, and things like that, we’re doing it, typically, at a safe distance. You know, we’re doing it one step removed from ourselves. I think that’s why art and drama and things like that are such wonderful ways to teach kids to, you know, unpacking that stuff, reading Shakespeare and understanding what’s motivating the characters, and how they’re resolving the situations and decisions that they’re making are great ways to learn about mental health.

Celine Gounder: Of course a show on Netflix isn’t part of the typical lesson plan unless you’re working with a foundation that specializes in preventing teen suicide. Chances are, you don’t have a place in the curriculum to address depictions of suicide in film or television.

And Thirteen Reasons Why is different from other portrayals of depression, bullying and suicide in teen-targeted shows because the entire series it is explicitly about teen suicide and the events that can lead up to it or be blamed for it.

Because the show depicts extremes… and because so many young people watch the show on their own, online, without a parent or other adult there to talk through those extremes with them, it has the capacity to trigger young people at risk.

Now if that triggering means that a young person reaches out and seeks help because something seems clearer to them after they’ve watched the show, that’s ultimately positive, right? But what about the kids who don’t look for the safe space after they watch something traumatic?

I spoke with someone who anticipated that need. Someone who’s made a film — also very much about bullying, depression and suicide — but the intentions of his project are a lot clearer.

Erahm Christopher: We wanted this film to be experienced in a community. We didn’t want someone to just watch it on their iPad.

Celine Gounder: This is Erahm Christopher. His film is called Listen, but you can’t find it on Netflix or Amazon. Actually, for now, you can’t watch it online at all.

Erahm Christopher: The way I grew up is, when you watched a piece of content, you had the ability to discuss it because you were watching it with your family. Usually only one TV in the house, so everyone was watching at the same time. And that’s where people were asking questions: why did he do this? What does this mean? And my parents would explain it to me, and I would explain it to my sister. And nowadays, you can come home and everybody can go in a separate room and watch a different show on a different channel on a different device, and there is no discussion.

Celine Gounder:  Erahm’s been making teen-centric movies for most of his career as a director, aiming to understand young people and to make them feel they’re understood, that somebody is paying attention. So when he released his latest film, Listen, he wanted to build a listening exercise into the experience of watching the movie. So he decided to keep Listen out of theaters for a full year.

Erahm Christopher: I had this idea. Instead of going the traditional route, let’s make this film accessible, because we believe it has the ability to have a tremendous impact, and we wanted to find out if it could.

Celine Gounder: Erahm and his team made Listen available, for free. The only catch? Every venue had to facilitate a half-hour discussion after the screening and they had to collect survey data.

Erahm Christopher: We wanted to connect the entire community on these issues and get them to talk about it afterwards.

It’s in that conversation that you understand where the person’s mental health is and how they’re really doing, and that’s where we can actually get the support that the person needs.

We wanted that conversation to be more important than the film itself, we wanted to bring back why we watch movies in the first place.

I think that is one of the most magical parts of a movie experience, when you’re watching it with people.

Celine Gounder: The film Listen follows the intersecting lives of high school teens after a school shooting in a nearby district.

Erahm Christopher: From the beginning of the film, we see a snapshot of all of these characters. And at its core, in every one of these scenes, you see how individuals are not being listened to.

It’s not about them feeling heard, it’s about them feeling “paid attention to.”

Celine Gounder: Erahm based the characters on the kids he’s met over a decade-plus of making educational films about teen issues: from bullying and school violence to body image and self-harm.

Erahm Christopher: It highlights what happens when a youth joins a gang, it highlights what happens when a youth gets pressured by a coach to be perfect and by their parents to be perfect … and what happens when this counselor tries to hold it all together.

Celine Gounder: It’s important to note here, Listen isn’t so different from Thirteen Reasons Why in terms of entertainment value or drama. It, too, is full of emotionally-charged scenes and good-looking young actors, And it, too, suffers from some of the same pitfalls: oversimplifying and stereotyping, demonizing adults, and the potential for re-traumatizing the most vulnerable:

Erahm Christopher: The reaction to the film was extremely positive and powerful… and then during the active listening training, I had a student that wanted to talk to me, and I thought that she was participating in the training… but it turns out that she didn’t want to stay for the training, and she just wanted to tell me how she felt about the film. And, this was a young girl who had actually dealt with some of the issues the film had focused on, and she had a very strong reaction to the film. She actually told me that she hated the film… because it got her to think about some of these issues again that she was trying to avoid… specifically depression and suicide.

Celine Gounder: But while many of same criticisms of Thirteen Reasons Why could be leveled at Listen — concerns about contagion, romanticizing, laying blame, sending the message that adults are incompetent, that suicide is on the table as an option. The big difference is in the way Listen is being shown: as an educational tool complete with a curriculum and training workbook to help guide discussion and learning, screened at high schools, universities, health organizations and community centers across the country before it’s release later this year.

Erahm Christopher: We need to exhaust all avenues of reaching these youth. And for people to be afraid of one manner of sparking this conversation, it really baffles me.

Celine Gounder: Erahm acknowledges he’s gotten pushback. Often, this comes after administrators or parents watch the film themselves and decide it isn’t appropriate for young viewers. After one of the first pre-pre-screenings of the film for school staff, a colleague of Erahm’s asked for feedback:

Erahm Christopher: The administrator told her that he was deeply offended by the way the educators and administrators were portrayed in the film. He said that he would never show this in his school district.

It’s ironic that parents are afraid to have a conversation about something that already has unfolded at the very school. And I honestly believe that that is the problem today.

Celine Gounder: But cinéma vérité –direct, dramatic and authentic — isn’t the only way to tell stories and spur conversations.

[Heathers clip 1] Heather Chandler’s not your everyday suicide. She was very popular.

C’mon, Paul, if I let these kids out before lunch, the switchboard’d light up like a Christmas tree.

I must say, I was impressed to see that she made proper use of the word “myriad,” in her suicide note.

Celine Gounder: Heathers came out in 1989. It’s a cult favorite — a dark, tongue-in-cheek movie complete with a cruel high school clique, multiple homicides and a sharp commentary on how high schools and students think about suicide. It’s the kind of movie that director Michael Lehman says couldn’t be made today without getting a lot of people angry because Heathers isn’t sensitive, it’s a satire.

Michael Lehman: We were satirizing the fact that the institutional perception of what happened was actually completely different than what happened and that in a certain way, what ended up happening was the suicide was being glorified. Or the alleged suicide was being glorified and that the person who died was suddenly transformed into a completely different person than the person she was.

Celine Gounder: In Heathers, the main character is disgusted by the school’s response to multiple suicides, but she’s also a self-obsessed teenager, blaming herself for the deaths while scribbling in her diary, a bottle of vodka at her side.

[Heathers clip 2] The most popular people in school are dead, everybody’s sad… but it’s a weird kind of sad. Suicide gave Heather depth… Kurt, a soul, Ram a brain. I don’t know what it’s given me, but I’ve got no control over myself when I’m with J.D. Are we going to prom or to hell?

Celine Gounder:  The school counselor seizes student suicide as her kumbaya moment — an opportunity to have vague conversations about feelings, in particular, disingenuous feelings about those who died. And Michael says he wanted to highlight that kind of sensationalizing and how useless it was in the face of real trauma.

Michael Lehman: There was no actual insight into what this person may have been going through. It was simply an exercise. Let’s talk about how it makes us feel. So, we were saying that it was basically empty on the part of the teacher even though the teacher’s intentions were perfectly good.

Celine Gounder: In case you haven’t picked up on it yet, Heathers is meant to be funny. You can’t help but laugh at the absurdity of the situations, which means that this is a comedy about teen suicide. Which might seem totally counter-intuitive, if not totally inappropriate. But that’s not how Michael Lehman sees it. For him, that’s one of the best ways to broach really difficult topics.

Michael Lehman: Partly because humor is therapeutic, and partly because humor allows us to look at things that would otherwise make us way too uncomfortable to discuss and also because humor tends to break down problems and turn them into — it unveils the irony in problems and allows us to get a different perspective on them.

Celine Gounder: When Heathers came out, Michael says, teenage suicide was already part of the collective conscious. It was all over the news, being talked about with labels and explanations, Michael says, that just didn’t seem appropriate. And there were dramas about teen suicide at the time, too, and Michael says some were good, but satire, he says, can broaden discussion of uncomfortable, off-limits topics. Those absurd situations and characters in Heathers? Michael says they’re doing the work of exposing underlying problems, inconsistencies, fundamental ironies.

Michael Lehman: And you can open people’s eyes to aspects of situations that otherwise a serious approach wouldn’t allow them to see because the ironies would be too hard to process somehow. People, when they do something more directly dramatic or a documentary, they want to try to explain everything. And a satire doesn’t have the obligation to explain. It simply has the explanation to show where things don’t fit in a way that’s just happily uncomfortable.

Celine Gounder: Michael says he’s shown Heathers to modern-day high school students, and the harsh but funny scenes of bullying and high school bureaucracy and death, he says that kids get it and connect to it. They see behavior that’s consistent with what’s happening in their schools every day, which, Michael says, can help them process their worlds in a clearer way.

A really important part of satire, Michael says, especially satire about a subject like suicide, is that you don’t make fun of the victim, you don’t laugh at a kid in trouble. The point is to depict that trouble without having it hit too close to home in such a way that a young person, especially a victim, can gain some perspective on their own situation.

Michael Lehman: You don’t want to make fun of the victims because the victims are really victims in these cases. But you might be able to allow the people who would otherwise be depressed or victimized or singled out and suffer from the way that people perceive them, you might be able to help them get some insight into their own situation and get detachment enough to not become a complete victim.

Celine Gounder: Michael feels that film and television are great places to tackle serious issues because that’s where many people get a piece of their moral compass these days.

Michael Lehman: …and also get a sense of how people should be treated who are going through things that may different than what each of us is experiencing.

Celine Gounder: But Michael acknowledges that his approach to these tough issues, satire, is harder and harder to make happen. Part of that, he says, is that the real world is growing increasingly absurd in a way that’s difficult to make fun of, but, he says that he still falls back on satire as the best way to expose taboo subjects — the best way to start honest, open conversations — but the other barrier to making that happen, well, that’s Hollywood.

Michael Lehman: Hollywood loves to talk a game about responsibility and moral responsibility and I think most of that is complete bullshit, because when you go into the meetings involved in trying to get a project made, it’s pretty much commerce. In Hollywood, it’s a classic struggle. Artists are struggling to get their voices through and get a point made and have that fit into the world of commerce.

Celine Gounder: So you’ve got to collaborate with the mercenary side of the business to get a project made. But that does end up raising questions about moral responsibility. Thirteen Reasons Why may start a conversation, but it takes some effort, nd in the meantime, it’s a glossy, addictive TV show. And Listen has it’s intended impact in the confines of Erahm’s educational screenings, but what happens to that movie after it’s released and hits the big and small screen, when the viewing experience can’t be controlled?

There’s another form of entertainment that might be a way to skirt these questions of moral responsibility. It’s a lot lighter and definitely shies away from the heavy dramatics.

[UROK fake commercial] Are you ready for lip color that really lasts? Tired of lipsticks that smear and fade away? Introducing Trauma… a new line of lip color from project UROK. Trauma is built to last. For days, weeks, even years! You think it’s gone? No way! Ridiculously long last coverage. Like really. This is ridiculous. Seriously, who would even want this? So live your life, do your thing! Trauma will be there.

Celine Gounder: This is a commercial. A fake one, obviously, in the style of Saturday Night Live ad parodies. It’s by an organization that calls itself Project UROK. This is the founder, Jenny Jaffe.

Jenny Jaffe: So, Project UROK creates digital content for teens and young adults who are struggling with mental illness by adults or slightly older peers who have been there before.

Celine Gounder: UROK isn’t all fake ads and it doesn’t tie itself to comedy either, although sarcasm does play a big role in a lot of the content. The point of UROK is to normalize mental health and social issues for young people, to be blunt about really hard things, to say, yes, this sucks and it’s okay to admit that.

Jenny Jaffe: There’s a pressure to have things appear all good. Nobody is really talking about things that are wrong, with themselves or their families, and I think that the kids sort of key into that and they thing, okay, so we’re pretending nothing’s wrong. So, I’m not gonna tell anybody if anything’s wrong with me. And then they don’t end up seeking help.

Celine Gounder: Jenny is a writer, actress and comedienne, and she taps into her connections to others in the biz — actors and directors and other comedians — to shed some light on just how common mental health struggles can be… and how possible it is to survive them.

[UROK clip 2] JJ: My first real sort of battle with mental health issues was when I was probably around ten years old and that was the first time I can remember being suicidal…

[UROK clip 3] My name is Mara Wilson … I wish somebody had told me it’s okay to be anxious. That you don’t have to fight it. That, in fact, fighting it is this thing that makes it worse. And that it’s okay to be depressed… and also, it’s not a romantic thing.

[UROK clip 4] My name is Wil Wheaton, I am an actor, writer and producer … I wasn’t aware of how my mental illness was affecting me until I’d been suffering from it for easily 15 or 20 years…

Celine Gounder: Jenny decided to found UROK when she realized that a platform like this — where people share their struggles with mental health for teens and do it in a direct, light-hearted, informative way — didn’t really exist. She wanted to create a place where a young person could find someone who represented their story, and she felt that she had the responsibility — as someone who grew up with mental health issues and a really good support system — to create a support system for people who didn’t have one because there’s no one type of person who struggles with mental health issues, and no one reason, either.

Jenny Jaffe: All I know is that I was basically… I was born anxious. The OCD stuff, there’s no external place I got that from. You know, I have a case of OCD so textbook, I’m literally going to be featured in a textbook about OCD that’s coming out.

Celine Gounder: Jenny brings voices in and provides lots of resources on the site, but she also leaves space for Project UROK users to post their own videos, to contribute to the unique community that they’re a part of.

[UROK clip 5] Parker Molloy: I have panic attacks on more than a weekly basis … but at the same time, I know that I’m not alone in that. And I know that I’m not broken. And I know that I’m doing the best I can. And in that sense, I’m okay. And in that sense, you are okay.

Celine Gounder: Jaffe grew up in a California suburb that was so troubled by teen suicide the Centers for Disease Control and Prevention actually conducted an investigation into the area. But, she says, sometimes a study can’t tell you exactly what’s going on… because Jenny? She didn’t experience common pressures that might lead to suicidality, but she still had the feelings, the thoughts.

Jenny Jaffe: I think the community response is to be like, well, the reason that there’s so much suicide is because there’s so much academic pressure and there’s so much stress and I think that’s a factor… but I was deeply suicidal growing up in that part of the country and I don’t remember the academic pressure at all. I don’t remember that. I never felt stressed about school stuff, I had a mental illness. And I think that’s scarier for parents to think about than the idea that there is some external factor causing these feelings.

Celine Gounder: The Project UROK videos combine a little of the seriousness — the blunt-talk about depression, anxiety, fear, bullying, suicidal ideation that you see in shows like Thirteen Reasons Why and movies like Listen — with the one-step-removed approach of movies like Heathers. It acknowledges that mental health problems are absurd in a way. They’re so difficult to pin down, to define, to treat, to prevent. But that doesn’t mean that having them makes you or your mental health absurd.

Jenny, like the others I spoke to for this episode, is creating content that sparks conversation. She just cut out the middleman. Her content is the conversation.

Jenny Jaffe: The thing about Project UROK is that the only thing any of us ever have to go on is our own experience, which is why all we can do is tell our stories and help other people do the same.

Celine Gounder: So many of the conversations in this miniseries have had to do with responsibility — the right or wrong way to talk about mental health with young people — and it’s important to recognize that we’re having that conversation because we’re at a turning point in the way that we discuss and address mental health in teens and young adults. Our youth are in the midst of a crisis, but it isn’t going unnoticed. We’re responding from every angle — parents, teachers, doctors, nonprofits, academics, artists, even teens themselves — are looking for ways to talk about depression and anxiety, about identity, about academic and social pressure, about suicide to help those at risk.

As we continue to troubleshoot to look for the best way to keep adolescence safe for our youth, we’ve got to keep the conversation going.

I’m Dr. Celine Gounder. This is “In Sickness and In Health.”

You can learn more about Thirteen Reasons Why and some useful ways to watch it by going to www.jedfoundation.org, information about Erahm Christopher’s film, Listen, and his outreach work by going to www.listenthemovie.com. Jenny Jaffe’s Project UROK can be found at www.projectUROK.org — that’s the word “project” followed by the letters “U” “R” “O” and “K” dot org.

If someone you know is in crisis or thinking of hurting themself:

• Do not leave them alone.

• Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt.

• Take them to an emergency room or seek help from a medical or mental health professional.

• Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255).

• Or text the Crisis Text Line at 741-741.

• Another resource for LGBTQ youth is the Trevor Project’s Lifeline at 866-488-7386.

• Thank you for listening.

Credits: Today’s episode of “In Sickness and in Health” was produced by Hannah McCarthy and me. Our theme music is by Allan Vest.