For Parents and Schools: 13 Reasons Why, Season 2

Netflix launched Season 2 of its smash hit series 13 Reasons Why on May 18. With the “gravity” of issues featured in the series that debuted in 2017—suicide, bullying, sexual assault, substance abuse, and school shootings—a coalition of mental health organizations issued a statement of concern to parents, educators, and professionals “in an effort to help reduce the risk of a tragedy.”

13-reasons-why-netflix-00

Suicide Voices of Education (SAVE), which issued the statement, also announced the launch of a website containing information, resources, and toolkits for youth/peers, parents, educators and clinicians/professionals to address the specific topics raised in the episodes. Click here to access the website.

Netflix itself, following the intense criticism it received from mental health experts after the launch of Season 1 in March 2017, has created a website including a warning video, discussion guide, and other resources. The page includes the warning: “This show is rated MA for mature audiences, it covers many issues including depression, sexual assault and suicide. If you are struggling, this series may not be right for you or you may want to watch it with a trusted adult.” Click here to access the Netflix 13 Reasons Why information website.

The Sophie Fund created a web page with links to information and resources about 13 Reasons Why. The page contains expert studies and commentaries discussing how the series creates risks for suicide ideation and contagion among young people by romanticizing suicide, downplaying the reality of mental health struggles, and undermining the roles of parents and school counselors in supporting young people in distress. Click here to access The Sophie Fund web page for 13 Reasons Why resources.

Here are the recommendations released by the coalition of mental health organizations in its statement of concern:

1. For vulnerable and at-risk youth (for example those living with depression or an anxiety disorder) we encourage families to make a thoughtful decision about whether or not to watch 13 Reasons Why because of the triggering impact it might have on them. We recommend using the show’s TV rating as a source of guidance about the intensity of the content. Some of the story lines could be quite upsetting and result in them needing additional monitoring, support and/or treatment.

2. If your teens do watch the series, make an effort to watch with them. This will allow you the opportunity to monitor the impact the show has on your child. It also affords you the chance to talk after each episode and ensure that they are comfortable enough to continue watching.

3. If you are not able to watch together, talk with your teens about their thoughts, reactions and their feelings about the content. Check in with them multiple times as it can take a few days to process the content and they will likely continue to talk about the show with their peers. Let them know that they can come to you with questions or worries about themselves or their friends and that you will be there to listen and help guide them.

4. Reassure youth that fiction and reality are not the same thing. Even though some might believe that what they have seen on television is or feels like reality, it is critical that you help them understand it is not and that the outcomes from the series do not have to be their outcomes.

5. Learn what resources are available in your local community where you can find help if needed. These might include: a local public health agency, a mental health professional, the counselors in your child’s school, or a crisis phone service in your area. Knowing who you can reach out to for support is a good prevention strategy.

The release of 13 Reasons Why Season 2 coincided with another deadly school shooting on May 18, this time in Sante Fe, Texas, where 10 people—eight students and two teachers—were killed by a 17-year-old student who reportedly confessed to the violent rampage. (Early reports indicated that the suspect had been bullied in school and was suicidal.)

The Jed Foundation, a national mental health and suicide prevention organization, added this statement to its concerns about 13 Reasons Why Season 2:

In light of the gun violence depicted in 13 Reasons Why and the devastating school shootings on Friday, we want to remind you how to be safe if you are involved in an active shooting, urge media to follow guidelines for safe reporting on these incidents, and provide tips for discussing and coping with these terrible events.
What to do if you find yourself in an active shooting:
—RUN and escape, if possible. Call 911 once you’re in a safe place.

—HIDE, if escape is not possible. Once you feel safe, try to reach out for help silently (i.e. text, social media, email, put a sign up in the window).

—FIGHT as an absolute last resort. The first response is never to confront an active shooter.

 

Suicide on the Campus: A Task Force, a Death, and a Lawsuit

Legal counsel, risk managers, counseling centers, and student mental health advocates at colleges in Ithaca and across the nation will be monitoring a new lawsuit that asserts that the University of Pennsylvania’s failure to provide “any meaningful help, support and safety net” led to the suicide of 21-year-old business school student Ao “Olivia” Kong. The lawsuit seeks to hold Penn’s trustees accountable for “reckless disregard” in failing to follow best practices for suicide prevention, contending that the university “had a duty to ensure her safety and wellbeing and protect her from harm.” In asserting the university’s negligence, the lawsuit says “Penn didn’t just fail her, it killed her.”

oliviakong

Ao “Olivia” Kong (Source: Feldman Shepherd)

In the spring of 2016, according to the lawsuit filed on April 10 in Philadelphia County’s Court of Common Pleas, Kong became despondent while struggling with an academic overload and symptoms of anxiety, depression, insomnia, and anorexia during the second semester of her junior year. The 3.3 GPA student feared that she might fail a course, and jeopardize her financial aid as well as an upcoming paid summer internship with Bank of America, the lawsuit says.

Born in China, Kong had immigrated to the United States at age 9 with her parents and became one of the top students in the Philadelphia public school system. She placed first in national math contests and city science fairs; played violin in the school orchestra; was a member of the drama club, varsity tennis squad, and newspaper editorial board; and volunteered in community service organizations. She won early admission to Penn’s prestigious Wharton School, Class of 2017; Wharton is ranked as the No. 1 undergraduate business school in the United States, with annual tuition and fees of $53,534.

Kong was struck and killed by a SEPTA train in West Philadelphia in the early morning of Monday April 11, 2016. The lawsuit brought by her parents contends that in seeking help amidst a mental health crisis from the university’s Counseling and Psychological Services (CAPS), Student Health Center, and the Wharton School, Kong communicated that she was suicidal to Penn professionals on at least nine occasions between April 7 and April 9.

According to the lawsuit, Kong’s suicidal thoughts were expressed directly or indirectly to a CAPS psychiatrist on four occasions; a CAPS clinician; a CAPS social worker; a Wharton academic advisor; and on a CAPS intake form and a school petition for a course withdrawal.

The four-count lawsuit, which alleges negligence, wanton and willful misconduct, reckless disregard, and includes a wrongful death claim and a survival action, reads as a scathing indictment of Penn’s academic pressures and mental health policies and practices as well as of its institutional mindset. It labels the suicides at Penn a “worsening epidemic,” stating that Kong had been the tenth Penn student to die by suicide in three years, and another four have taken their own lives in the two years since then.

“So long as Penn refuses to adequately address the academic and personal stresses underlying these suicides, and take appropriate measures to protect its students from the harms associated with those stresses, it willfully and recklessly exposes its students to an extraordinarily high risk of suicide,” the lawsuit says.

It goes on: “Similarly, Penn’s abject failure to hire competent and qualified professionals to assist its students in managing their stress and/or enact and implement policies designed to ensure the safety, physical and mental wellbeing of its students, constitutes a reckless disregard and callous indifference to the safety, health and wellbeing of its students.”

The lawsuit alleges Penn’s repeated failures to follow best practices related to suicide prevention, including:

— Failure to provide outreach and support programs and to formulate, implement, and enforce policies, practices, and guidelines that comply with current professional standards and nationally established criteria and/or best practices “to reduce academic stress and the risk of suicide”;

—Failure to formulate, implement, and enforce policies, practices, and guidelines to address the warning signs of suicide in students-in-crisis, including those suffering from academic stress; and to assess and treat students with suicide ideation;

—Failure to hire, retain, and ensure that the persons overseeing, supervising, administering, and providing psychological services are aware of and/or comply with best practices for suicide prevention;

—Failure to waive patient confidentiality to inform parents when a student was in imminent danger of suicide;

—Failure to dedicate sufficient resources to reduce the risk of, and prevent, suicides.

The lawsuit slates Penn for other failures, including:

——Failure to formulate, implement, and enforce policies, practices, and guidelines to assess and treat students-in-crisis, including those suffering from academic stress;

—Failure to ensure that information about Penn’s mental health resources is easily accessible to people providing the services and to its students;

—Failure to hire, retain, and ensure that the persons overseeing, supervising, administering, and providing psychological services are aware of Penn’s programs and resources for students-in-crisis;

—Failure to provide adequate procedures for late withdrawal from courses; taking leaves of absence; reducing unmanageable course loads; managing student distress caused by unmanageable course loads; and receiving tutoring services.

Academic Stress and Anxiety

The lawsuit says that Kong was afraid of failing a course, and was frustrated by hurdles in the way of dropping it and by her inability to get academic tutoring. She first reported academic stress, anxiety, lack of sleep, and inability to concentrate during a visit to the Student Health Center on March 30, according to the lawsuit. The attending physician attributed Kong’s signs and symptoms to an upper respiratory infection and fever, and failed to address her academic stress and anxiety or refer her to any university resources for students experiencing such conditions, the lawsuit says.

A week later, after her physical and mental health deteriorated, the lawsuit goes on, Kong placed a call in a state of distress to the after-hours CAPS number at around 1:30 a.m. on April 7. She reportedly told the on-call psychiatrist that she was anxious and afraid of failing a class, unable to sleep, and had experienced a panic attack, feelings of self-hatred, and suicidal thoughts. The lawsuit alleges that the psychiatrist dismissed Kong’s academic fears as “run of the mill” for undergraduates and discussed how CAPS could assist her in dropping the course during regular business hours.

According to the lawsuit, later that day she went to CAPS and conveyed her academic anxiety and current suicidal thoughts on the intake form as well as to a social worker—with whom she also shared her feelings of depression and shame and idea of taking an overdose of sleeping pills as the method of killing herself. The social worker concluded that Kong had no actual intention or means of taking her own life, the lawsuit says. It adds that the social worker scheduled Kong for a follow-up CAPS appointment four days later at 3 p.m. on April 11—by then, Kong had died as the result of blunt force trauma.

Still later on April 7, Kong met with a Wharton advisor, mentioned her past suicide ideation, and filed a petition for late withdrawal from an upper-level course. She explained that she was “struggling with the class and it is causing me to become depressed. I have not been able to sleep for the past week.” She concluded the petition by stating she has “thoughts of suicide.”

According to the lawsuit, after the Wharton advisor alerted CAPS about her meeting with Kong, the CAPS social worker sent Kong an email reminding her of her CAPS appointment the following Monday afternoon April 11; she also said that in the meantime Kong had the options of visiting or calling CAPS during regular business hours, contacting the CAPS after-hours clinician, or calling a national suicide hotline 24/7.

On Saturday evening April 9, after a Penn graduate assistant alerted CAPS of his concern about Kong, the CAPS psychiatrist reportedly spoke with her again by phone for about an hour. She had gone to spend part of the weekend at home with her parents, who were concerned about her welfare but were unaware of her expressed intention to kill herself.

According to the lawsuit, Kong told the psychiatrist of her frustration and hopelessness with Wharton’s “roadblocks” to dropping a class and exploring a leave of absence. “After telling him that ‘people aren’t listening to me,’” the lawsuit alleges, “Olivia said that she planned to return to campus the next day and kill herself.”

Kong and the psychiatrist also discussed the possibility of an inpatient psychiatric admission, which Kong was told was an option “if no other plan can work,” the lawsuit says. When Kong inquired about the expense of an emergency room visit, the lawsuit alleges, the psychiatrist remarked that “the cost of [an emergency room] is likely less than [the] cost of funeral arrangements.”

According to the lawsuit, the psychiatrist advised Kong to speak with her parents and said he would contact Wharton about her academic situation; and said if she could not make it emotionally until her Monday appointment with CAPS, she had the options of calling CAPS, dialing 911, or to “get herself to the ER.”

The lawsuit faults Penn professionals for failing due to ignorance or incompetence to refer Kong to multiple available mental health services and programs; failing to develop a treatment plan for Kong’s suicide ideation, provide psychotherapy and medication, or refer her to a local hospital or emergency room; failing to notify Kong’s parents that she was at imminent risk of self-harm, or to arrange for somebody to stay with Kong until she obtained medical help; failing to alert the police of her intention to take her own life; failing to relieve Kong of severe academic stress; failing to ensure that she was capable of handling a heavy course load.

“The failure of these multiple professionals,” the lawsuit argues, “to take adequate and proper precautions or preventative measures to adequately treat Olivia and protect her from harm during a period when they knew her articulated suicidal thoughts and plans or in the exercise of due care should have known that she was suicidal and that she was incapable of maintaining proper perspective and making sound decisions regarding her health, safety and wellbeing was the proximate cause of her suicide.”

Standards and Practices

The lawsuit does not specifically identify a source for its reference to professional standards and nationally established best practices. However, one prominent example is the 2012 National Strategy for Suicide Prevention, released by the U.S. Surgeon General, which describes goals to “promote suicide prevention as a core component of healthcare services” and to “promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.” The strategy is meant to guide suicide prevention actions in the United States throughout the decade.

In February 2016, The Joint Commission, a body that accredits healthcare programs in the United States, issued recommendations to improve the treatment of individuals with suicide ideation. The commission urged all healthcare organizations “to develop clinical environment readiness by identifying, developing and integrating comprehensive behavioral health, primary care and community resources to assure continuity of care for individuals at risk for suicide.”

Furthermore, the commission said, “it’s imperative for healthcare providers in all settings to better detect suicide ideation in patients, and to take appropriate steps for their safety and/or refer these patients to an appropriate provider for screening, risk assessment, and treatment.”

Many experts point to the Zero Suicide Model of the Suicide Prevention Resource Center (SPRC) as a prime example of best practices; it holds that “suicide deaths for individuals under care within health and behavioral health systems are preventable.”

The question of whether universities and college counseling centers have a legal “duty of care” to prevent suicide is currently evolving. A strong legal precedent has yet to be established, due in part to the fact that many lawsuits alleging university negligence in suicide cases are settled before they reach court.

Guidance issued by SPRC notes that in successful medical malpractice lawsuits, the plaintiff proves a breach of duty of care by showing that the defendant’s act or omission fell below the standard of care and increased the risk of harm to the plaintiff. The core of a suicide case, SPRC says, is whether the suicide was “foreseeable”—that there was a reasonable anticipation that some harm or injury is likely to result from certain acts or omissions.

The Jed Foundation, with which Penn maintains a mental health review partnership, argues that “ultimately, litigation risk can be substantially reduced by following some simple advice—use good professional judgment; develop a comprehensive suicide/violence prevention program; follow written and/or unwritten policies and protocols; ensure that available mental health services are in keeping with professional codes of ethics and standards of practice.”

The Kong lawsuit also takes Penn administrators to task for the way in which they announced Kong’s death. Initially, the lawsuit says, President Amy Gutmann informed the campus community of a student death without identifying the student or the manner of death. The same day, Penn representatives allegedly told Kong’s parents as well as Wharton undergraduates that her death was an “accident.”

“Responsibility for Their Own Wellbeing”

Kong’s death occurred just a year after a high-profile Penn task force issued a report praising Penn for its “impressive” and “wide array” of mental health resources, peer-education and support groups, and singling out CAPS for providing “excellent services to a wide range of students.” The report said that the “unwavering commitment” of staff and faculty to ensuring mental health support for students was “very impressive” and “clearly evident.”

Rather, the report said, the problem was the pressures engendered by the perception among Penn students that “one has to be perfect” in every academic, co-curricular, and social endeavor. That perception can lead to stress and distress, compounded in some cases by the endemic use or misuse of alcohol or other drugs, lack of sleep, and improper nutrition, the report said.

The report emphasized that “stress is a normal part of life,” that “campuses across the country” face mental health challenges, and that college students are not statistically at a higher risk for suicide. At Penn, the report stated, “students (undergraduate, graduate, and professional) are expected to take responsibility for their own wellbeing.”

The report recognized that “during times of stress or distress, it is challenging to maintain one’s perspective and to make sound decisions about whether and to whom to turn for help.” Therefore, the report explained, “Penn has a strong and committed network of individuals and of offices that can either provide direct assistance or ensure that students are appropriately referred.”

Gutmann and Provost Vincent Price convened the task force in February 2014 shortly after two student suicides, and charged it with examining student mental health challenges; reviewing Penn’s programs, policies, and practices for addressing the challenges; and making recommendations for improvement.

The task force said there were “opportunities to further strengthen the university’s efforts” and made recommendations in four main areas: 1) communicating to students about the importance of mental health and wellbeing to their academic success; 2) making information about Penn’s mental health and wellness resources more accessible; 3) educating and training faculty, staff, students, and parents about mental health and in responding to students who need help; and 4) “optimizing” the resources the university devotes to psychological counseling.

The report cited “the limits” on the resources Penn provides to CAPS and made no recommendation to increase funding; instead, the report said that CAPS should communicate to students—as well as to staff, faculty, and students who refer students to CAPS—that CAPS is only designed to provide short-term care and make referrals to other care providers.

The Kong lawsuit, arguing that Penn failed to provide and/or dedicate sufficient resources to implement and enforce current professional standards and nationally established best practices for reducing academic stress and the risk of suicide, challenges the task force’s claim of funding limitations. “Given Penn’s $12 billion endowment, there were (and are) sufficient resources to address its continued failure to ensure the safety of its students, but for inexplicable reasons, it has failed (and continues) to do so,” the lawsuit says.

The lawsuit takes issue with the task force for “shockingly” placing “the responsibility for its students’ health and wellbeing not on the professionals associated with those offices and programs but on the students themselves” and for concluding “that the problem did not lie with those programs and resources but in persuading students to use them.” The lawsuit says “the ultimate irony” is that Kong “not only sought help from all of the resources available to her, but she also specifically communicated her suicidal thoughts and plans, all to no avail.”

Nevertheless, the lawsuit adds, the task force report established that “Penn was clearly aware that the highly competitive academic stresses it placed upon its students not only increased their risk of developing depression and anxiety but decreased their ability to maintain proper perspective and make sounds decisions about their safety, health and wellbeing thereby increasing their risk of committing suicide.”

The lawsuit blames Penn for failing to ensure that the members of the task force were “qualified” or that its findings and conclusions complied with current professional standards and nationally established best practices to reduce academic stress and the risk of suicide. The lawsuit accuses Penn of failing to ensure that “the entire Penn community” was aware of and complied with the findings, recommendations, and conclusions of the task force.

The lawsuit criticizes Penn for excluding students from the task force reviewing the university’s mental health policies and practices; the 10 task force members were all Penn senior administrators and academic officers, including five vice presidents and vice provosts, and a number of current and former deans and department chairs.

In response to the Kong lawsuit, a university spokesperson told local media that Penn does not comment on pending litigation.

After Kong’s suicide, Penn reconvened the mental health task force in 2016 but did not release a new report. According to the Daily Pennsylvanian, “the University’s task force concluded after Kong’s 2016 death that Penn’s wide array of ongoing mental health initiatives are sufficient to address the issue.” Penn’s student newspaper quoted task force co-chair Rebecca Bushnell, a former dean of arts and sciences, saying: “The task force completed its work at the end of the summer of 2016, so we have nothing new to say.”

[If you or someone you know feels the need to speak with a mental health professional, you can contact the Crisisline (National Suicide Prevention Lifeline) at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.]

Saying “The S Word” at Cornell

The uncomfortable topic of suicide was the main theme of a four-day-long “Mental Health Weekend” organized by the student mental health advocacy group Cornell Minds Matter. As part of its effort to encourage open discussion about suicide and to destigmatize mental disorders, the group hosted a screening for the Ithaca community Sunday evening of The S Word, a new award-winning documentary by director Lisa Klein. The event was sponsored by The Sophie Fund.

swordpix

Reba McCutcheon, Cornell University associate dean of students; Garra Lloyd-Lester, director, New York State Suicide Prevention Community Initiatives; Lisa Klein, director of The S Word; Kelechi Ubozoh, mental health activist; and Cooper Walter, president of Cornell Minds Matter

The film follows the remarkable journey of suicide attempt survivor Dese’Rae L. Stage as she “documents the stories of courage, insight, and humor of fellow survivors.” Klein was on hand to personally present the film on the Cornell University campus, and, along with one of those survivors, Kelechi Ubozoh, took part in a panel discussion immediately following the screening. They were joined by Garra Lloyd-Lester, director of the New York State Suicide Prevention Community Initiatives.

Klein is a survivor of both her father’s and brother’s suicides. She has struggled with the “whys” for years, along with the guilt, shame, and confusion that lingers in suicide’s wake. She made The S Word to spur more open conversations about suicide.

TheSWord@Cornell

Watching The S Word at the Biotechnology Building conference room Sunday evening

“Tragically, 1,100 college students die each year by suicide, making suicide one of the leading causes of death among college students and young people generally,” said Cornell Minds Matter President Cooper Walter. “We hosted The S Word to increase the awareness and understanding of suicide. By expanding the conversation, we hope to contribute to the growing Zero Suicide initiative in Tompkins County.”

Other Mental Health Weekend events included a Speak Your Mind student panel in partnership with Active Minds at Ithaca College, where students could share their personal stories about suicide. On Saturday evening, the Suicide Prevention & Crisis Service of Ithaca hosted Dancing for Life, its 6th annual fundraiser for the local crisisline that provides 24/7 support for people in crisis.

The Sophie Fund is a nonprofit organization advocating for improved mental health policies and practices in Tompkins County. It was established by the family of Sophie Hack MacLeod, a Cornell senior who took her own life in Ithaca in March 2016 while on a health leave of absence.

sophiejones

Sophie Jones, a Cornell University student and volunteer with The Sophie Fund, at The S Word screening

(Photography by Sarah Horbacewicz/The Sophie Fund)

IMG_2299

Click here to read the Cornell Daily Sun‘s story on the screening of The S Word

[If you or someone you know feels the need to speak with a mental health professional, you can contact the Crisisline (National Suicide Prevention Lifeline) at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.]

 

“Nobody Talks About This”

“I need to talk about it so other people can talk about it.” — Padriac Lillis on writing and performing in a play about suicide.

Episode 6

Episode 6 of Michayla Savitt’s The Scoop on Mental Health features Brooklyn-based artistic director Padriac Lillis, who discusses Hope You Get To Eleven, his play inspired by a former student’s suicide and his own struggle with depression. In “Nobody Talks About This,” Padriac explores the emotional process of bringing the difficult subject matter to the stage. “I have a story to tell, not because it’s my story, because I need to talk about it so other people can talk about it,” he says.

6pod“Nobody Talks About This”  [Episode 6] Listen

Padriac Lillis wrote and performed a play about his struggle with depression and suicidal thoughts, prompting conversations about mental illness from audience members and people in his life.

Save a Life: Learn the Suicide Risk Factors and Warning Signs

Consider sharing this post. It’s National Suicide Prevention Week— please take a moment to review the Risk Factors and the Warning Signs as they may apply to loved ones, friends, colleagues, or even yourself. Click here for the Risk Factors/Warning Signs page of the American Foundation for Suicide Prevention. People with Risk Factors or exhibiting Warning Signs are strongly encouraged to seek treatment—suicide is preventable. If you or someone you know feels the need to speak with a mental health professional, please consider contacting the National Suicide Prevention Lifeline at 1-800-273-8255.

AFSP_SPW_socialgraphics_150ppi17

From AFSP:

“There’s no single cause for suicide. Suicide most often occurs when stressors exceed current coping abilities of someone suffering from a mental health condition. Depression is the most common condition associated with suicide, and it is often undiagnosed or untreated. Conditions like depression, anxiety and substance problems, especially when unaddressed, increase risk for suicide. Yet it’s important to note that most people who actively manage their mental health conditions lead fulfilling lives.”

Risk Factors are characteristics or conditions that increase the chance that a person may try to take their life:

Health Risk Factors—such as mental health conditions, substance abuse disorders, or serious/chronic health conditions and/or pain.

Environmental Risk Factors—such as stressful life events, prolonged stress conditions, access to lethal means, and exposure to suicide.

Historical Risk Factors—such as previous suicide attempts.

Be aware of Warning Signs.

According to AFSP, most people who take their lives exhibit one or more warning signs, either through what they say or what they do.

Warning Signs relate to a person’s Talk— about “being a burden to others,” or “feeling trapped,” or “experiencing unbearable pain,” or “having no reason to live,” or “killing themselves.”

Warning Signs relate to a person’s Mood—displaying one or more moods such as depression, loss of interest, rage, irritability, humiliation, anxiety.

Warning Signs relate to a person’s Behavior—such as increased use of alcohol or drugs, aggression, acting recklessly, withdrawing from activities, isolating from family and friends, sleeping too much or too little, visiting or calling people to say goodbye, giving away prized possessions, and looking for a way to kill themselves.

“Something to look out for when concerned that a person may be suicidal is a change in behavior or the presence of entirely new behaviors. This is of sharpest concern if the new or changed behavior is related to a painful event, loss, or change.”

How to help someone who may be struggling: click here for guidance from the American Foundation for Suicide Prevention.

Click on the infographic below to download a Warning Signs checklist.