(Warning: This article contains show spoilers, graphic details of a suicide scene and descriptions of self-harm which may be triggering for some readers.)
In the final episode of Netflix's controversial teen hit 13 Reasons Why, we see a flashback of the show's dead protagonist Hannah Baker (Katherine Langford) slitting her wrists in wrenching detail. The much talked about suicide scene is startlingly graphic, and while its creators call the explicit violence necessary, critics say it glamorizes suicide and can trigger those who struggle with suicidal thoughts.
But there's a barely talked about scene in the series that also shows a character who cuts her wrists, and in this case experts emphatically agree that it gets something very right about the behavior it depicts. The show's living protagonist, Clay Jensen (Dylan Minnette), is arguing about Hannah's suicide with former friend Skye Miller (Sosie Bacon) when he sees what look like relatively fresh wounds at the edge of her sleeve.
"It's what you do instead of killing yourself," she explains.
Cutting is a form of nonsuicidal self-injury (NSSI), defined as the deliberate, self-inflicted destruction of body tissue, which experts say people often do to discharge painful emotions. The behavior has been around for nearly all of recorded history, though it remained a poorly understood phenomenon until a few decades ago. Other types of self-injury include burning, carving, picking at the skin, hitting and bone-breaking. Since self-harm is largely a hidden behavior, it's hard to gauge how prevalent it is, though Cornell University's Program on Self-Injury and Recovery says U.S. studies find self-injury ranges from 12% to 37% in adolescents and 12% to 20% in young adult populations, with cutting as the most common form. Skye's comments are accurate, experts say, because while cutting can look like a suicidal gesture, it's actually an anti-suicidal move.
"Suicide is what you do to end your life," said Lori Hilt, a psychology professor at Lawrence University in Wisconsin and an expert on nonsuicidal self-injury. "This is something you do to cope with it."
Why hurt yourself?
There are a variety of reasons why people say they self-injure. Many report sadness, anxiety or emotional numbness as triggers. Experts say the behavior can release a rush of endorphins — the "feel-good" hormones. It makes the self-injurer feel better.
Stacey Freedenthal, a professor at the University of Denver who has worked extensively in crisis settings, says while self-harm used to be something people thought was connected to a mental health disorder, it is now understood as a method people use to help regulate anxiety, tension or unbearable pain.
"It's a way to stay alive," she said.
While research is not definitive, the International Society for the Study of Self-Injury says evidence suggests self-injury is only slightly more common in females than males, though Patricia Adler, co-author of the The Tender Cut: Inside the Hidden World of Self-Injury, says self-harm is still a gendered issue.
"Boys are taught to take their frustration out externally. Punch a tree. Punch a wall. Fight. Girls aren't socially conditioned to be aggressive like that, so they turn it in more," she says. "The culture of masculinity is much more geared toward ... outward behavior. Girls' social status is much more heavily tied to their appearance. ... A lot of times girls think if they can control their bodies, they can control themselves."
The pop-culture effect
Experts say cutting has likely crested as an epidemic, though the behavior is still common. In the past several centuries, Adler writes in The Tender Cut, self-injury was practiced largely among young, white, middle class women, but in the 1990s the behavior began to increase and expand to new populations as public awareness began to rise. Johnny Depp and Angelina Jolie talked about doing it. So did Princess Diana. The New York Times Magazine ran a cover story on self-injury in 1997 called The Thin Red Line.
Adler said the more people knew about it, the more people tried it.
The National Association of School Psychologists said in a statement, "We do not recommend that vulnerable youth, especially those who have any degree of suicidal ideation, watch this series. Its powerful storytelling may lead impressionable viewers to romanticize the choices made by the characters and/or develop revenge fantasies."
In response to the backlash, Netflix said it will add more trigger warnings, expected to go into effect as soon as this week.
Experts say depictions of these topics in the media — in TV shows, movies, on the Internet — must be careful. With suicide, psychologists say it's critical to communicate that suicide is often connected to a treatable mental illness. And with cutting, it's important to communicate that it isn't necessarily indicative of one.
"The goal is to try to understand cutting, because stigmatizing it and demonizing it doesn't help the people who need it to help themselves," Adler says.
How to help
Look for warning signs. Wearing long sleeves in warm weather can be a clue. Also look for changes in behavior that might indicate someone is becoming more isolated or withdrawn.
Validate the person. If someone you care about is self-injuring, it can be a hard conversation to start. You can open by simply saying,"It seems like you're in a lot of pain."
Create a safe atmosphere: It can be alarming as a parent to discover a child is engaging in self-harm, but try your best to get your child to open up by creating a safe atmosphere. In other words, don't freak out.
Ask questions about intent. Non-suicidal self-injury is a way of averting a desire to make a suicide attempt, and most people who self-injure are not suicidal. But the International Society for the Study of Self-Injury does consider self-harm a risk-factor for suicide, since evidence suggests those who have self-injured are more likely to attempt suicide. Don't use euphemisms, experts say, when asking about intent. If you want to know if someone is thinking about killing themselves, don't ask, "Are you thinking about hurting yourself?" Do ask, "Are you thinking about suicide?"
If you engage in self-harm, there are ways you can help yourself. Those with the urge to self-injure should try to distract themselves with a substitution behavior. Cornell University has different recommendations for different emotions.
If you're a member of the media, be responsible when covering or depicting suicide and self harm. Mental health organizations have concrete recommendations. Talk about treatment, prevention and alternate coping strategies. Make sure people understand there are resources to get help. Make sure they know they're not alone.
If you're thinking about suicide, you can call the National Suicide Prevention Lifeline 24/7 at 1-800-273-8255. You can also text the Crisis Text Line at 741-741 to connect with a trained crisis counselor right away. If you're thinking about self-harm, you can call 1-800-DONT-CUT or visit the Cornell Research Program on Self-Injury and Recovery for resources on getting help.
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