Suicide and Schools
Suicide Contagion and Clusters—Part 1: What School Psychologists Should Know
By Scott Poland, Richard Lieberman & Marina Niznik
Volume 47 Issue 5, pp. 1, 21-23
The suicide of a student has a rippling effect in the school environment as well as in the greater community, as a single adolescent death by suicide increases the risk of additional suicides. The process by which a completed suicide (or at times, suicidal behavior) increases the suicidal behavior of others is called contagion. When multiple suicides occur close in time and geographical area, at a rate greater than normally would be expected in a given community, it is considered a cluster (Centers for Disease Control [CDC], 1988).
Adolescents are the most susceptible age group for imitating suicidal behavior; therefore, discussions of contagion often center on prevention efforts in the school environment, necessitating that school psychologists play a central role. Approximately 1–5% of teen suicides occur in a cluster after a youth dies by suicide (Gould & Lake, 2013). Though rare, contagion results in approximately 100–200 seemingly preventable deaths annually.
There are two main types of suicide clusters that may impact adolescents in the school environment. Mass clusters are characterized by a temporary increase in suicides during a time period (irrespective of geography) and are often associated with the influence that media reports may have, such as the suicide of a celebrity or a high-profile figure. Point clusters are characterized by an increase in suicides that are close in time or space and occur in communities (such as schools).
Mass clusters. The specific impact of a celebrity suicide on adolescents is not easily discernable, making it difficult to draw general conclusions; however, several case examples demonstrate the effects of unsafe messaging in news reporting. After Chris Cornell, lead singer of the band Soundgarden died (2017), vivid details of the police report of the moments leading up to his suicide were published (Pescara-Kovach, 2017). On Cornell's birthday, his close friend, Chester Bennington, lead singer from the band Linkin Park, died by suicide in a very similar manner. Several subsequent suicides by adolescent fans were linked to these deaths, as the methods utilized bore resemblance to the details shared in the celebrity cases. The impact was additionally noted via correlation, as the National Suicide Prevention Lifeline received a 14% increase in calls on the day after Bennington's death (Pescara-Kovach, 2017). Similarly, after the suicide death of comedian Robin Williams, there was an almost 10% increase in deaths by suicide, particularly among males ages 30–44 (Fink, Santaella-Tenorio, & Keyes, 2018). The impact of the recent deaths by suicide of the celebrities Kate Spade (2018) and Anthony Bourdain (2018) on subsequent suicides is not yet known; however, safe messaging was noted across several news outlets. For example, People magazine printed the National Suicide Prevention Lifeline phone number (1-800-273-TALK) on the masthead of their issue covering the stories that week and the Daily News printed suicide warning signs, as well. In contrast however, there was considerable discussion of the similar details of their methods in many articles.
The impact of entertainment media on suicide contagion has also been noted for fictional characters that die via suicide (Gould & Lake, 2013). This was particularly apparent with the fictional series 13 Reasons Why (NETFLIX), as there was a 19% increase (one million additional searches) in Internet searches about suicide immediately after the series aired (O'Brien, Knight, & Harris, 2017), including searches for the phrases “how to commit suicide” (26%), “how to kill yourself” (9%), and “commit suicide” (18%). Fortunately, some of the increased searches were for seeking help—including “suicide hotlines” (12%) and “suicide prevention” (23%). However, “Past studies have validated that Internet searches mirror real-world suicide rates, so suicide rates have likely gone up as a result of this program” (Ayers, Althouse, Leas, Dredze, & Allem, 2017). In fact, 25% of youth who died by suicide conducted a suicide-related Internet search shortly before their deaths (O'Brien et al., 2017).
Point clusters. More easily identifiable, suicide point clusters have occurred in several school communities such as those Poland and Lieberman worked with in Palo Alto, CA (2002, 2009, 2014); Fairfax County, Virgina (2014); Colorado Springs, Colorado (2017); and Salt Lake City, Utah (2018). Other clusters have likely gone undetected or were intentionally not reported. In some of these communities, epidemiology studies were conducted in conjunction with the CDC. Results were reviewed by Poland and Lieberman at the most recent National Association of School Psychologists (2018) and American Association of Suicidology (2017) conferences. They identified the following risk factors from these clusters: male gender, mental health issues, history of suicidal ideation or suicide attempt, substance abuse issues, relationship problems, a recent crisis, cutting behavior, parents not recognizing the severity of the mental health needs of their child, sleep deprivation, academic pressure, sexual orientation, and intimate partner violence (Annor, Wilkinson, & Zwald, 2017; Garcia-Williams et al., 2016; Spies et al., 2004).
Exposure to Suicide
Research has found that a death by suicide may touch approximately 135 people, one third of whom experience a severe life disruption as a result (Cerel et al., 2018). Exposure to a peer's suicide has been found to be associated with suicidal ideation or behavior in adolescents that can persist for up to 2 years. Among at-risk adolescents, a schoolmate's suicide appears to amplify preexisting negative life events and increase serious suicidal ideation or behavior. In other words, a single exposure to the suicidal behavior of another person does not result in imitative behavior in the absence of adolescent vulnerability factors. Such factors include: current or past psychiatric conditions, family history of suicide or past suicide attempts, substance abuse, stressful life events, access to lethal methods, incarceration, social impairments, environmental factors, and lack of protective factors (Gould et al., 2018).
Suicide is complex, particularly with regard to causality; yet, identifying individual students who are at-risk after a suicide is one of the primary tasks of suicide prevention efforts undertaken in the schools to prevent contagion (Lieberman, Poland, & Kornfeld, 2014). Research has supported the fact that though friendship with the student who died by suicide is associated with increased risk for suicidal ideation or behavior, it is not the closest friends, but rather the less close friends that knew the deceased who have the highest rates of suicidal ideation or behavior as a result (Gould et al., 2018). Though previously, a “continuum of survivorship” was assumed, we now know that focusing solely on those students closest to the student who took their life will likely leave many vulnerable students unidentified.
Preventing Suicide Contagion: Guidelines for Media
It has been well established that at-risk individuals with a recent history of suicide attempt or a concurrent severe depression are more likely to attempt suicide in the wake of a media report of suicide (Gould, Kleinman, Lake, Forman, & Midle, 2014). Specifically, media stories that were published after the index suicide (the first) and were associated with clusters employed: front page placement of story, headlines containing description of method, presence of a picture, and detailed description of the suicide (Gould et al., 2014). Therefore, organizations such as the World Health Organization (WHO, 2017) have set forth recommendations about how to contain a suicide cluster via safe messaging. These guidelines essentially state: refrain from using sensational language or normalizing suicide, avoid unnecessary repetition of the story, use neutral rather than emotionally charged photos, refrain from detailing the method of death, and take particular care when the suicide involves a celebrity (Meindle & Ivy, 2018; WHO 2017).
The CDC put forth a community response plan for the prevention and containment of suicide clusters (in 1988), as well as postvention strategies once a cluster has occurred, though it has not since been updated. In 2017, the CDC produced a Technical Package for Prevention of Suicide which includes strategies to help at the community and state level, but does not include strategies on the individual level (Stone et al., 2017).
Technology and Suicide Contagion
Estimates reveal that more than 90% of teens have smartphones (Bahrampour, 2018) and 95% have mobile access to the Internet (Pew Research Center, 2018), enabling adolescents to communicate using methods that distribute information almost instantly, to potentially hundreds of people simultaneously without geographical limitations; therefore, the effects of a student death by suicide may have even more far-reaching effects.
Because adolescents use media an average of 9 hours a day (including TV, movies, online videos, playing games, Internet, music, reading, and social media), it is not surprising that more adolescents get their news from online sources rather than traditional media. Among adolescents who use social media, 76% receive news from such sites (Pew Research Center, 2018). Even if traditional media outlets follow established safe reporting guidelines for deaths by suicides, social media messages may not. Adolescents are in the forefront of information dissemination when a suicide of a peer occurs, effectively becoming “citizen journalists,” (public citizens who are actively collecting, reporting, and disseminating information). In fact, one study found that 59% of individuals ages 14 to 24 were exposed to suicide-related content through Internet sources (Dunlop, More, & Romer, 2011, as cited in Luxton, June, & Fairall, 2012).
Evidence for “massive-scale contagion” via social networks has been found (Kramer, Guillory, & Hancock, 2014) as data revealed that emotions expressed by others on social media can influence our own emotions, even in the absence of in-person interaction and nonverbal cues, which may in turn affect a variety of offline behaviors. Essentially, this research shows that emotions can be spread on social media just like real life, which further supports the concept of contagion via exposure to a suicidal peer via social media (M. S. Gould, personal communication, April 2018).
Social proximity among adolescents is progressively transcending physical geography. As a result, adolescent deaths by suicide are no longer isolated, which enables contagion to occur in a broader and more rapid manner. Consequently, the task of predicting and managing contagion is vastly more difficult for educators.
Currently, there are few accepted guidelines to address safe messaging across social networks (Cox et al., 2012). However, in conjunction with a panel of experts, Suicide Awareness Voices of Education (SAVE) set forth recommendations for blogging on suicide, cautioning users, “It's important to note that readers’ attitudes and behaviors can be influenced by what and how you write about suicide, mental health, crisis, and suicidal ideation—both negatively and positively” (p. 2), adding, “certain content related to suicide can have harmful or even fatal effects on vulnerable individuals who may be contemplating suicide themselves…. Bloggers can help reduce the risk of suicide and avoid spreading stigmatizing, counterproductive, or harmful messages” (p. 3).
What More Can We Do?
Following suit, perhaps educating the users, in this case adolescents, about safe messaging would be a promising future direction to continue to mitigate the impact of widespread messages on suicide contagion among youth, particularly since teens most often seek help from their peers. Empowering adolescents to be part of the development of safe messaging for other teens, in conjunction with suicide prevention experts and media representatives, might also be beneficial. The full impact of what some are calling, “social-media contagion” (Luxton et al., 2012) is not yet clear with regard to adolescent suicide prevention and may need to be more clearly defined in order to develop relevant postvention strategies in the schools.
Additionally, efforts to prevent suicide contagion need to consider the research that supports safe messaging, including: publishing stories that educate and shape attitudes while avoiding misinformation; avoiding sharing the initial, unrealistic, and extreme immediate responses of those closest to the deceased; avoiding reports of denial or minimization of warning signs; acknowledging multiple contributing factors to suicide (i.e., not just bullying); and disseminating stories of positive coping, receiving or offering help, and the availability of services (Gould, 2018).
The use of technology to deliver mental health support has grown exponentially (e.g., teleweb services, digital self-help, and mobile apps), increasing the accessibility of online support services to deliver interventions to young people at times of the day when suicidal ideation or thoughts may escalate quickly. Leveraging the communication networks used by adolescents can be an effective way to quickly respond, mobilize resources, and disseminate information to large groups of adolescents following a suicide and to reduce the likelihood of a cluster.
Preventing Contagion: Guidelines for Schools
Successful suicide postvention is dependent upon a timely, efficient, and targeted response to a student suicide and increasingly, the ability of school personnel to recognize the possibility of contagion.
Need for timeliness. Since predicting where a suicide cluster will occur is not possible, it is critical to develop a set of postvention strategies that are ready to implement following the identification of a cluster (Cox et al., 2012). The timely implementation of a response plan following a suicide cluster in a school setting has been associated with fewer students showing negative symptoms (e.g., PTSD; Poijula, Wahlberg, & Dyregrov, 2001). Doing so is complicated, however, by the fact that increasingly, due to the speed of information exchange in our technology-connected world, students are often aware of a peer's suicide prior to the knowledge reaching educators and parents, narrowing the window during which adults can intervene and prepare affected students. School, parents, and communities need to find ways to intervene and provide information and support to students sooner.
Need to utilize best practice resources. Among the myriad of easily downloadable best practice resources schools have access to is After a Suicide: Toolkit for Schools (second edition). This important resource will be discussed more fully in Part 2 of this series.
Need for interventions of longer duration. Generally, we have observed that postvention assistance in schools after a suicide is often too short in duration. In fact, research has found that 30% of students continue to show signs of PTSD as long as 6 months after a suicide cluster occurs in a school (Poijula et al., 2001). For identified students who are vulnerable prior to a student's death and are further triggered by a peer suicide, the support needed at school can last even longer. We have noted that the sibling, best friend, or partner of the deceased often gains “celebrity status” in their school and must navigate changes in the way peers and adults interact with them, all the while dealing with the very real aspects of grief and trauma over time, requiring longer-term intervention.
Need to intervene more broadly. In our experience in the schools, too often postvention efforts focus on an insufficient number of students. As supported by experience and confirmed by research, the impact of a youth suicide on the student population is much wider than the victim's closest friends (Gould et al., 2018). Though there are varying degrees of impact among those exposed, research has shown that among those exposed, a significant portion report persistent distress (Cerel et al., 2018) and will require substantial support at school.
Clearly, schools cannot do it alone. It takes a village—a collaborative effort among schools, community agencies, mental health practitioners, medical personnel, law enforcement, clergy, parents, survivor groups, and even youth. Community members, medical personnel, clergy, and mental health professionals can assist school personnel in screening exposed teen populations for individuals who are at greatest risk of contagion and imitation. Community personnel with training can make themselves available to school staff to provide resources and support in advance of a student death.
School psychologists need to stay informed of the emerging and relevant factors related to the potential of suicide contagion in the schools to avoid suicide clusters, while simultaneously keeping in mind that it is quite rare. A foundational base to prevent suicide and contagion in the schools can be built on a school climate of positive connections between students and adults, within the community and the school building, while ensuring students consistently and genuinely receive the clear message from all adults that “We are here to help.”
Part 2 in this series, titled “Suicide and Contagion: What School Psychologists Can Do,” will appear in the next issue of Communiqué.
Annor, F., Wilkinson, A., & Zwald, M. (2017). Epi Aid #2012-019: Undetermined risk factors for suicide among youth aged 10–17 years Utah 2017. Retrieved from https://health.utah.gov/wp-content/uploads/Final-Report-UtahEpiAid.pdf
Ayers, J. W., Althouse, B. M., Leas, E. C., Dredze, M., & Allem, J. (2017). Internet searches for suicide following 13 Reasons Why. JAMA Internal Medicine, 177(10). 1527–1529. doi:10.1001/jamainternmed.2017.3333
Bahrampour, T. (2018, January 22). Teens who spend less time in front of screens are happier—Up to a point, new research shows. The Washington Post, Retrieved from https://www.washingtonpost.com/news/inspired-life/wp/2018/01/22/teens-who-spend-less-time-in-front-of-screens-are-happier-up-to-a-point-new-research-shows/?utm_term=.a2d7dd92c68b
Centers for Disease Control. (1988). CDC recommendations for a community plan for the prevention and containment of suicide clusters. MMVR, 37 (s-6), 1–12.
Cerel, J., Brown, M. M., Maple, M., Singleton, M., Van de Venne, J., Moore, M., & Flaherty, C. (2018). How many people are exposed to suicide? Not six. Suicide and Life-Threatening Behavior. doi:10.1111/sib/sltb.12450
Cox, G., Robinson, J., Williamson, M., Lockley, A., Cheung, D., & Pirkis, J. (2012). Suicide clusters in young people: Evidence for the effectiveness of postvention strategies. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33(4). 208–214. doi:10.1027/0227-5910/a000144
Fink, D. S., Santaella-Tenorio, J., & Keyes, K. M. (2018). Increase in suicides the months after the death of Robin Williams in the US. PLOS. doi:10.1371/journal.pone.0191405
Garcia-Williams, A., O'Donnel, J., Spies, E, Zhang, X., Young, R., Azofeifa, A., & Vagi, K. (2016). Epi Aid 2016-018: Undetermined risk factors for suicide among youth ages 10-24—Santa Clara County, CA. Retrieved from https://www.sccgov.org/sites/phd/hi/hd/epi-aid/Documents/epi-aid-report.pdf
Gould, M. S. (2018, April 26). The expert overview: Suicide contagion and media. Symposium presented at Media and Youth Suicide: Best Practices for Reporting and Storytelling. Stanford University, Sunnyvale, CA.
Gould, M. S., Kleinman, M. H., Lake, A. M., Forman, J. & Midle, J. B. (2014). Newspaper coverage of suicide and initiation of suicide cluster in teenagers in USA, 1988–96: A retrospective, population- based case-control study. Lancet Psychiatry, 1(1), 34–43. doi:10.1016/S2215-03666 (14) 70225-1
Gould, M. S., Lake, A. M., Kleinman, M., Galfalvy, H., Chowdhury, S., & Madnick, A. (2018). Exposure to suicide in high schools: Impact on serious suicidal ideation/behavior, depression, maladaptive coping strategies, and attitudes toward help-seeking. International Journal of Environmental Research and Public Health, 15, 455–471 doi:10.3390/ijerph15030455
Gould, M., & Lake, A. M. (2013). The contagion of suicide behavior: Impact of media reporting on suicide. Forum on Global Violence Prevention: Based on Global Health Institute of Medicine, National Research Council: Washington DC: ational Academics Press.
Kramer, A. D. I., Guillory, J. E., & Hancock, J. T. (2014). Experimental evidence of massive-scale emotional contagion through social networks. PNAS, 111(29). doi.org/10.1073/pnas.1320040111
Lieberman, R., Poland, S., & Kornfeld, C. (2014). Best practices in suicide intervention. In P. Harrison & A. Thomas (Eds.), Best practices in school psychology: Systems-level services, Bethesda, MD: National Association of School Psychologists.
Luxton, D. D., June, J. D., & Fairall, J. M. (2012). Social media and suicide: A public health perspective. American Journal of Public Health, 102(2), 195–200. doi:10.2105/AJPH.2011.300608
Meindle, J. N., & Ivy, J. W. (2018). Reducing media-induced mass killings: Lessons from suicide prevention. American Behavioral Scientist, 1–18. doi:10.1177/0002764218756918
O'Brien, K. H. M., Knight, J. R., Jr., Harris, S. K., (2017). A call for social responsibility and suicide risk screening, prevention, and early intervention following the release of the Netflix series 13 Reasons Why. JAMA Internal Medicine. doi:10.1001/jamainternmed.2017.3388.
Pescara-Kovach, L. (2017). The contagion effect as it relates to public mass shootings and suicides. The Journal of Campus Behavioral Intervention, 39(5), 35–45.
Poland S., Lieberman, R., Dickinson, C., & Hinson M. (2018, February). Responding to suicide clusters in schools. Presented at annual conference of the National Association of School Psychologists, Chicago, IL.
Poland S., & Lieberman, R. (2017, April). Responding to suicide contagion in schools: Best postvention practices shared from three school districts. Invited Presention at the 50th annual conference of the American Association of Suicidology, Phoenix, AZ.
Anderson, M., & Jingjing J. (2018). Teens, social media & technology 2018. Pew Research Center. Retrieved from http://www.pewinternet.org/2018/05/31/teens-social-media-technology-2018
Poijula, S., Wahlberg, K. E., & Dyregrov, A. (2001). Adolescent suicide and suicide contagion in three secondary school. International Journal of Emergency Mental Health, 3(3), 163–168.
Spies, E., Ivey-Stephenson, A., VanderEnde, K., Lynch, S., Dean, D., & Gleason, B. (2104). Epi Aid 2015-003: Undetermined risk factors for suicide among youth, ages 10-24 Fairfax County, VA, 2014. Retrieved from https://www.fairfaxcounty.gov/health/sites/health/files/assets/images/suicide-epi-aid-final-report.pdf
Stone, D. M., Holland, K. M., Bartholow, B., Crosby, A. E., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policies, programs, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
World Health Organization. (2017). Preventing suicide: A resource for media professionals. Update 2017. Geneva, Switzerland: Author.
Scott Poland, EdD, is a professor at college of psychology and the codirector of the Suicide and Violence Prevention Office at Nova Southeastern University. Richard Lieberman is a lecturer in the Graduate School of Education at Loyola Marymount University in Los Angeles, California. Marina Niznik, PhD, earned her doctorate in school psychology from The University of Texas at Austin and consults with school districts in Northern California