When Dese'Rae Stage interviews survivors of suicide attempts for a website she created, she asks herself a question news reporters may not always consider: How much did it hurt?
A survivor herself, she wants to be sure that readers of her website "Live Through This" come away with a real picture of suicide — no romance, no facile explanations and no inducements for others to kill themselves. Stage, 33, is encouraging people to survive.
"Because what we see on TV is, 'Oh I'm just going to take a nap forever and it's going to be peaceful,' and that's not the reality," she said. "And I'm like, 'Tell me what the reality looks like.'"
Mental health professionals have for decades warned that media can drive suicides, with studies pinpointing what kind of coverage can be deadly and journalists urged to follow reporting guidelines. But the influence that newspapers and television newscasts had in the past is being eclipsed by Facebook, YouTube and other popular sites. The enormous reach of social media has left mental health professionals even more worried about copycat suicides — or contagion, as it is called — and determined to confront the online world.
Most troubling today: young people live streaming their suicides.
The phenomenon of imitating well publicized suicides is sometimes called the "Werther effect," named for Goethe's 1774 novel, "The Sorrows of Young Werther," which was banned in some European cities after it was published over fears it triggered an increase in deaths. "My friends….thought that they must transform poetry into reality, imitate a novel like this in real life and, in any case, shoot themselves," Goethe himself wrote about the cases.
"They were found dead with the book," said Madelyn Gould, a psychiatry professor at Columbia University College of Physicians and Surgeons and a research scientist at the New York State Psychiatric Institute.
More than 50 studies worldwide have shown that some types of news coverage can increase the likelihood of suicide for vulnerable people. That coverage includes explicit descriptions of the method, graphic headlines or images and repeated reports that glamorize a death, the American Foundation for Suicide Prevention says.
Young people appear to be particularly susceptible, according to some studies, with one finding that 15- to 19-year-olds exposed to a suicide had a relative risk two to four times higher than others. And celebrity suicides can be especially deadly. Marilyn Monroe's reportedly caused the suicide rate in the United States to jump 12 percent.
A Netflix series, "13 Reasons Why," is the most recent show to be criticized by mental health professionals who worry that it glorifies the suicide of a teenager who had been sexually assaulted and bullied. It tells her story through audio tapes in which she blames specific people for her death.
The National Association of School Psychologists warned in a statement: "Its powerful storytelling may lead impressionable viewers to romanticize the choices made by the characters and/or develop revenge fantasies."
Netflix added another "viewer warning card" to the show.
Suicide is the second leading cause of death for those 10 to 35, a toll that has been rising each year since 2007. Gould and others cannot be certain that social media is contributing to the increase. New studies must first measure any effect. But Gould noted social media's influence, its large audience for sensational content and the danger that it could change norms about what is acceptable.
"Is there a possibility given the characteristics of some of the social media reports?" she asked. "Yes, it's certainly consistent that it might."
Researchers who have begun looking at the links between social media and suicide have already found that among middle school children, victims of cyber-bullying were almost two times as likely to attempt suicide than those who have not.
Guidelines for reporting on suicides were drawn up after prevention specialists and public health officials held a national workshop in 1989 to help news reporters and others avoid sparking additional deaths. Now revised, they come with a list of do's and don'ts and suggestions for what information to avoid and what to include. Some studies show a decrease in suicides after guidelines are implemented.
The website reportingonsuicide.org recommends against sensational headlines, prominent placement, photographs or videos of the place or manner of death or grieving friends and memorials. Do not describe a suicide as inexplicable or without warning. Do not refer to epidemics of suicides or skyrocketing numbers. Do not disclose what is in a suicide note. And do not refer to a suicide as "successful" or "unsuccessful."
Journalists are urged instead to present information about the death in a non-sensational way and to report on suicide as a public health issue. According to the American Foundation for Suicide Prevention, 90 percent of people who died by suicide had shown signs of mental disorders or engaged in substance abuse. Most people exhibit early warning signs. Include those signs and information about what to do.
Most suicide cases involve a fairly short window of decision-making and action, so you want to "avoid giving people an easy and impulsive answer," said Bruce Shapiro, the executive director of the Dart Center for Journalism and Trauma at the Columbia University Graduate School of Journalism.
"If you are establishing barriers, whether physical or informational, you're going to save lives," he said.
New research by Thomas Niederkrotenthaler of the Medical University of Vienna and others suggests that the opposite effect could be true as well: that articles about survival and treatment can reduce the number of suicides. It too has a name drawn from the arts, the Papageno effect, for the character in Mozart's opera "The Magic Flute," who after losing his love, plans to kill himself but is dissuaded by three boys.
"The possible role of media reports in preventing suicide may make it worthwhile for journalists of both traditional and online news platforms to follow media guidelines on the reporting of suicide," Niederkrotenthaler wrote in a 2010 study.
The guidelines sometimes are not heeded. Stage, an advocate, speaker and photographer whose website features profiles of suicide survivors, says she has been interviewed multiple times, and in all cases reporters wanted to know how she had tried to kill herself. Her efforts to dissuade them from including what she thought were too many details failed, she said.
"I don't think the perspective on method is going to change," she said. "I think we're just reporting on this and that is a piece of the story. I think it becomes about how it's reported on."
If someone Stage is interviewing for her website tells her that he or she overdosed on pills, for example, she will include that information, but ask about the pain.
"Letting people know how painful it is is just going to change perspectives and that could maybe help," she said.
Stage remains convinced guidelines can save lives, and recently worked with Ohio's Department of Mental Health and Addiction Services to develop a set for its website. Journalists can change perspectives, she said.
"Social media makes it more difficult because obviously we're all rubberneckers, and we want the clicks, and so we look for the clicks in those headlines and in the details and the methods," she said. "And that's what people share, so how do we neutralize it?"
'PEOPLE WANT TO TALK ABOUT IT'
The guidelines can present a dilemma to journalists, used to ferreting out information and presenting it in as dramatic way as possible. Deciding how to cover suicides is an ethically challenging issue that vexes every newsroom, from the smallest local newspaper to national news organizations, said Shapiro with Columbia's Graduate School of Journalism.
"We don't like it when well intentioned health specialists tell us what we should do," he said. "We want to make our own choices as a profession."
Daniel J. Reidenberg, who wrote the guidelines on reportingonsuicide.org, said that a drawback of earlier versions was the source: exclusively mental health, suicide prevention experts, scientists and researchers. He turned to reporters, editors and news directors for the current version.
Today, social media can easily circumvent traditional media reporting. A news article that might have remained local can now quickly go viral and be seen worldwide. Message boards and forums can spread information about how to die by suicide. Unregulated online pharmacies outside of the United States can provide the means.
In recognition of social media's new role, Reidenberg has added a separate website for bloggers, bloggingonsuicide.org, that recommends checking comments regularly, taking action against rude or derogatory comments, avoiding arguments in the comments section and paying attention to suicide threats.
WHAT SOCIAL MEDIA CAN DO TO HELP
For mental health professionals such as Gould, the focus now is as much on sites like Facebook and YouTube.
When a 12-year-old from Georgia livestreamed her suicide on an app called Live.me, it was shared on YouTube and Facebook. YouTube took the video down but it remained on Facebook for nearly two weeks, even after police officials asked it be removed, according to The Washington Post.
Then in January, a 14-year-old South Florida girl in foster care killed herself on Facebook Live.
In a statement, Facebook, which has more than 1.8 billion users, said that it was saddened by such deaths and that it was working with organizations around the world to provide help for people in distress.
"Our teams work around the clock to review content that is being reported by users and we have systems in place to ensure that time sensitive content is dealt with quickly," it said.
If someone violates its standards, it wants to interrupt streams as quickly as possible and it will notify law enforcement of a threat that requires an emergency response, it said.
Facebook promoted new suicide prevention tools in March, including making it easier to get help during a Facebook Live video and also via Messenger. Anyone who wants will be able to connect on Messenger with such organizations as the Crisis Text Line and the National Suicide Prevention Lifeline. Facebook also plans to use artificial intelligence to identify suicidal posts.
And it announced it would hire 3,000 more people to help police harmful posts, among them livestreamed suicides.
"These reviewers will also help us get better at removing things we don't allow on Facebook like hate speech and child exploitation," Facebook chief executive officer Mark Zuckerberg wrote in a Facebook post.
For all the potential dangers on social media, Reidenberg and others argue its advantages outweigh its risks. Google has changed its algorithm so that the first site brought up by a search for "suicide" is one offering help, he noted. Young people looking for help can find it online — on Facebook and other sites, in chat rooms and on the Crisis Text Line by typing 741741.
Liz Mitchell, a 39-year-old teacher's aide in Illinois, said the Crisis Text Line allowed her to reach out for help without alerting her family, whom she did not confide in. She found the counselors to be open and willing to listen, understanding, she said.
"That was super helpful," said Mitchell, who said she had tried to kill herself five times, the last in 2014.
Her first hospitalization occurred when she was 11. When she was last hospitalized, she started taking antidepressants. Now after years of struggling-she is doing well and has gotten the help she needed, she said.
"That was the turning point," she said.
"Social media is a wonderful thing," Reidenberg said. "The advancements have helped save people's lives. It doesn't mean that it's not without its challenges but it is where people are interacting and it's where they're spending their lives today."
That was true for Ashley Shoemaker, a 29-year-old who works overnight in the freight department of a grocery store in Portland, Oregon.
She said an online friend became worried after she signed off with a sad post one night and persisted until he was able to reach her at 2 a.m.
"He kept me on the phone for eight hours," she said.
Shoemaker had called a suicide hotline once before. But for Shoemaker and her contemporaries, social media has become the place to seek help, where anonymity can better allow them to admit to feeling suicidal.
"When you're that far down, and you feel that hopeless and sad that you want to die, the last you want to do is hurt the people around you," said Shoemaker, who said she has depression. "You already feel like a big enough burden. To have to look a parent in the eye and say 'I want to die,' no good parent is going to react well to that. They're going to freak."
On social media, she said, "You feel safer reaching out."