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Does printing crisis line numbers help or harm? || Reporting on Suicide Notes || What is 'excessive detail' in suicide coverage? ||

Does printing crisis line numbers help or harm?

Aug 27, 2015

I've reached the point in my suicide contagion project where new research is starting to fit very nicely into the final framework (which hopefully suggests I'm onto something, or alternatively that I've become blind to contrary information - either/or). Today I read some new research by Stack (2015) on if crisis phones on bridges were an effective means of suicide prevention.

What he found was a little unsettling. We know people use them (good!) and that these people tend not to jump (also good!) but did suicides on the bridge increase or decrease after their installation? They rose. Ah, but did the population increase? No. Did the local suicide rate increase as well? No it went down. Ah.

Stack draws attention to a blog that covers bridge suicides (as well as media coverage) that may be responsible in part for people choosing bridge suicide over another method. But he also notes (if we believe that 'suggestion' has influence on suicide) we should look carefully at those phones:

The suggestion thesis holds that the phones, which were installed with signs alerting suicidal people that they offer a link to help, will suggest suicide to vulnerable persons. These at-risk individuals may otherwise not have thought of suicide off the bridge (Beautrais, 2007; Glatt, 1987). The suggestion hypothesis assumes that such signs will affect only vulnerable persons at risk of suicide. It is unlikely that they would impact healthy person.

This last point is important - given we generally hold that at-risk people can be negatively affected by messaging we should consider this even when intentions are good.  Research on other public health interventions show we cannot rule out that things done in good faith to save lives will end up doing net harm.

Klimes-Dougan and Lee (2010) did a study on if suicide prevention billboards were effective - finding negative as well as positive effects. They found their billboard ("Prevent Suicide, Treat Depression – See your Doctor" ) was in general good at getting people to believe that treating depression was a good way to reduce suicide - but also that their high-risk group tended to end up with a stronger perceived link between depression and suicide after viewing a billboard. The worry here is that being too explicit about the connection to depressed people encourages a railroading of their future down that path. Their TV ad by contrast didn't have that effect - it used the phrase "it can even lead to suicide" as an escalation of symptoms of depression, making death one of several possible options.

The billboard group also ended up with lower help-seeking scores than the no-information group (A TV advert did better however, public health campaigns not completely doomed) - directly encouraging people to seek help might not have the results you hope for.

The lesson here is that this is tricky stuff - the words you use matter. A workshop on public messages for suicide prevention made the point that broad campaigns might be bad:

Broad-based campaigns that are likely to reach multiple audiences should determine how subgroups of intended populations (or nontargeted groups of a population) might have different attitudes about suicide, and may respond differently to messages geared towards increasing help-seeking behavior (Cauce et al. 2002).

But also that targeted campaigns might be bad:

For example, certain American Indian nations have very high rates of suicide. A campaign via popular Indian radio stations that highlights the high prevalence may inadvertently normalize suicide and send the message that such behaviour is expected and is inevitable. Groups with high rates may get the message that they have experienced an expected behaviour, and the groups with lower rates are simply "lagging behind" on what is seen to be inevitable.

You might say they're just being risk adverse - but we have to acknowledge that letting words loose into the world with the aim of saving lives is something we seem to know little about. As Beautrais, Fergusson, Coogan et al (2007) put it:

Until there is clear evidence that public health messages about suicide prevent, and do not normalize, suicide, and have no deleterious effects, the most prudent approach to this issue is not to include public health messages as part of a suicide prevention strategy.

This brings us to print crisis lines after newspaper articles in suicide - which are pretty clearly public health messages that are advocated frequently as part of a suicide prevention strategy.   Stack brings up Niederkrontenthaler et al (2010) who found that newspaper stories that printed the phone number of a crisis link seemed associated with an increase in suicide rates. Now for the record, the authors were more sceptical of this result than some of their others (they were checking for so many things and it was one of their least significant results - although still p < 0.05) - but I can't find anyone else who has suggested anything to the contrary. Others have done research on if suicide lines are effective on those they reach e.g Gould et al (2007) (answer: yes-ish - reduction in pain and hopelessness, but not an apparent reduction in intent to die), there seems to be very little work on if the advertisement of the lines is a good idea.

The problem here is the population who is exposed to the advertisement but who will not be exposed to any positive effect of the helpline - if this group contains at-risk individuals (which it does) then there is the prospect of harm. That printing a suicide number could be negative is consistent with research that billboards can have a harmful effect and the idea that crisis phones on bridges might not be universally fantastic.

That certain wordings of these crisis line adverts might be worse than others is consistent with the idea that suicide contagion is more powerful when people can identify (and have similarities) with the subject of the article. If the wording asks you if you identify ("If you're affected..." - "ooh, am I?") it might create or intensify a one-to-one relationship with the subject of the article upon introspection. This suggests that they shouldn't be viewed as a corrective or an addendum to the article but part of the text and so part of any journey of identification.

There clearly isn't enough evidence to say this is something papers should stop doing - but I think it's something we need to think more carefully about.  I find it worrying I can create a hypothesis based on the same theoretical framework the rest of contagion works on - and that's consistent with the evidence we do have - that says we are possibly making things worse.  Even if we take Niederkrontenthaler et al.'s scepticism seriously and move their result to the 'not proven' column it is deeply concerning that we have almost no positive evidence we can point to and say "printing the phone number makes the suicide rate go down" . The idea that the message can never have a negative effect on non-callers needs to have more thought put into it to justify the pre-eminence of this advice.

Stack's main point is that crisis phones are not a good substitute for barriers on bridges (just much cheaper). It's not clear what a more effective alternative to crisis line ads following suicide stories would be. I find the fact that most people who suffer from suicidal thoughts end up not taking their own life a reassuring idea - a disclaimer built around this idea encourages identification with the living rather than the dead (and creates a universe larger than the reader and the subject) could be an approach to explore. But there's no evidence on if this would be a good approach or not.

The final section of my project will deal more generally with how little evidence there is for a lot of suggested interventions - but I wanted to share a glimpse into just how much of an unknown doing anything 'positive' in this area can be.


Stack, Steven. “Crisis Phones – Suicide Prevention Versus Suggestion/Contagion Effects.” Crisis, no. August (2015): 1–5. doi:10.1027/0227-5910/a000313.

Chambers, David A, Jane L Pearson, Keri Lubell, Susan Brandon, Kevin O Brien, and Janet Zinn. “The Science of Public Messages for Suicide Prevention : A Workshop Summary” 35, no. April (2005): 134–45.

Gould, Madelyn S, John Kalafat, Jimmie Lou Harrismunfakh, and Marjorie Kleinman. “An Evaluation of Crisis Hotline Outcomes Part 2 : Suicidal Callers” 37, no. June (2007): 338–52.

Klimes-Dougan, Bonnie, and Chih-Yuan Steven Lee. “Suicide Prevention Public Service Announcements: Perceptions of Young Adults.” Crisis 31, no. 5 (January 2010): 247–54. doi:10.1027/0227-5910/a000032.

Beautrais, A., Fergusson, D., Coggan, C., Collings, C., Doughty, C., Ellis, P., Hatcher, S. et al. (2007). Effective strategies for suicide prevention in New Zealand: A review of the evidence. The New Zealand Medical Journal, 120, 1–11.

For quoted sections:

Beautrais, A. (2007). Suicide by jumping: A review of research & prevention strategies. Crisis, 28 (Suppl. 1), 58–63.

Cauce, A.M., Domenech-Rodriguez, M, Paradise, M., Cochran, B.N., Shea, J. M., Srebnik, D,. et al. (2002) Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70, 44-55

Glatt, K. M. (1987). Helpline: Suicide prevention at a suicide site. Suicide and Life-Threatening Behavior, 17, 299–309

Reporting on Suicide Notes

Jan 01, 2015

An article went up on The New Statesman today arguing that people sharing the suicide note of a trans-person were actually endangering the very people they were trying to raise awareness of. This is based on The Samaritans guidelines that journalists should not print the content of suicide notes because of the idea of 'suicide contagion' - arguing that including details of suicide notes can make it more likely people will try and emulate the note's author.

My opinion of the Samaritan’s guidelines is they offer good generalised advice that should be read and often followed. That said, specific guidance is often detached from supporting evidence and shouldn't be used as an authority to beat people with. There are circumstances where blindly following guidance has the potential to do harm and I think this is one of them.

To understand why the contagious understanding of the suicide note is a bit narrow we need to know a bit more history. I go into this in far more detail in the finished piece but my basic premise is that over the last few centuries’ media coverage of suicide played a significant part in making us a better, kinder society more understanding of those amongst us most in pain.

To quickly summarise historian Michael MacDonald’s argument [1] - newspapers secularised suicide by making it a mundane fact of life. The syndication of suicide stories made the fact of suicide a constant low-level noise as opposed to something that would happen in smaller communities incredibly infrequently. From stories of the devil stalking the earth and taking lives, suicide was enveloped in statistical reporting. Coverage was often (but not universally) sympathetic. The focus on the stories of individuals and a large written audience for stories about suicide created the literary genre of the suicide note (sometimes helped along by journalists providing them when absent). Through these notes people tried to shape the narrative of their death for their community and the wider world.

In step with these developments came near total resistance to sanctions for the deceased or their survivors, which led to subsequent law changes. Naturally social change was more complicated than that but the role of newspapers was important. They made the reader’s world bigger and the quietest voices louder.

Working from that history I am uncomfortable with the idea that it is always wrong to print suicide notes and that no good can come of reporting suicides.

There isn’t a reason given in the Samaritans guide as to why suicide notes shouldn’t be reported, but working from the general theory of suicide contagion the fear is that it risks increasing identification with the deceased and identification might lead to imitation. I dislike the view that suicide notes should only be seen as infectious spores. They might also be the last way to understand a person available.

While the evidence for suicide contagion exists (more patchy than often stated, but still worth taking seriously) this doesn’t apply to all guidelines proposed. Restrictions on printing suicide method are well evidenced, most other areas are more theoretical (and I suspect often derive from backwards engineering terrible reporting – printing suicide notes is in most cases tacky).

There is a small scientific field concerned with analysing suicide notes but there is very little published on their effect on suicide contagion. Niederkrotenthaler and colleagues[2] did investigate if citing a suicide note effected suicide rates but found no effect – and this lack of outcome merited no discussion. It’s just not a particular active question in the field. The only area where a suicide note was discussed at length I can find was an instance where releasing extracts from a suicide note was seen as positive. I don’t buy this but it’s worth looking at to understand solid ground is very hard to find here.

The idea of suicide contagion is best established with celebrity suicides (Stack’s 2005 meta-analysis of the literature found no ecological effect on suicide rates had been definitively proven outside of celebrity studies[3]). As such after Kurt Cobain’s suicide there were a few attempts to detect an effect in suicide rates. These failed to find an effect (which is a good thing), and the explanations given for this in the literature are interesting.

Martin, Graham. “Media Influence to Suicide : The Search for Solutions.” Archives of Suicide Research 4, no. 1 (2007): 51–66:

One major difference appears to be the attitude actively promoted by Cobain’s widow Courtney Love, by his family and subsequently by the media. Immediately following the death Love made an audiotape containing excerpts from a note left by Cobain; she commented in a negative fashion on each part (Gaines, 1994, p. 107). For instance; “I don’t have the passion anymore, so remember – (And don’t, because this is a f…ing lie) – It’s better to burn out than fade away (God, you asshole.) (Sandford, 1995, p.244)”

Gould, M S. “Suicide and the Media.” Annals of the New York Academy of Sciences 932 (April 2001): 200–214 :

Yet, celebrity suicides do not always yield imitative suicides, as evidenced by the lack of a significant increase in suicides following the death of Kurt Cobain. [...] [T]he substantial efforts by Kurt Cobain's widow, Courtney Love, to present his suicide in a negative fashion may have counteracted any potential glamorization of his death.

The argument essentially goes “there was no imitative effect, therefore the response did something right”, yet I suspect if you asked Martin if we should be printing but dismantling suicide notes he wouldn’t argue for that forcefully. This argument is grasping at straws a little and paints an overly progressive picture of the media response to Cobain’s death. If it really was a good response we might need to change media guides more. After all, the Seattle Times printed a front page image of Cobain's dead bodythe next dayon the grounds that:

[T]his picture met that test by establishing an essential reality about Cobain’s death. Our concern was that Cobain’s suicide would be romanticized by some – suicide, the ultimate high.

As one editor said, the photo showed, ‘This wasn’t cool, it was death and that’s the result of suicide.’

Naturally, media guides would advise against such a thing but they’re essentially working from the same hymn sheet that you shouldn’t glorify the dead. Why are the Samaritans right and the Seattle Times wrong?

I want to dismantle the idea of expert opinion a bit here. I don’t think anyone has any particularly good evidence why there was no detectable effect after Cobain's suicide and I don’t think anyone has any evidence that you shouldn’t print suicide notes. I trust well-intentioned people working at charities trying to save lives a little more than I trust well-intentioned people who also like to sell newspapers, but simply having the right intentions is not enough.

Take this situation; we have two sets of well-intentioned people – one set want to bring wider light to a story in the hope of saving lives, the other set think this is dangerous because telling this story could kill more people. This is important stuff, who is right?

Here are the key questions. The Samaritans explicitly state their guidelines are only advisory; has suicide contagion been demonstrated to such an extent that there can be no exceptions to guidance? I'd argue not. Is there any evidence suggesting suicide notes in particular cause harm? Again, the answer's no.

By all means, be concerned - but let's not pretend anyone knows which course of action saves more lives.

A side point, but after The Samaritans’ Radar controversy worth thinking about.

My thinking on this hasn't solidified yet, but there’s a touch of a paternalistic attitude towards the mentally ill in the advice not to print suicide notes. We’re told “avoid the suggestion that a single incident […] was the cause” - after all suicide is complicated and often involves mental illness - but also not to report why they said they did it. The implication here is that these people were not qualified to tell you why they were suffering. This is even more unsettling when written by a member of a group who specifically highlights their treatment as part of that group: “They can’t know what they’re talking about, they’re ill." I think this is accepted uncritically a bit wider than it should be.

[1] MacDonald, Michael. Sleepless Souls: Suicide in Early Modern
England. Oxford: Clarendon Press, 1990.
[2] Niederkrotenthaler, Thomas, Martin Voracek, Arno Herberth,
Benedikt Till, Markus Strauss, Elmar Etzersdorfer, Brigitte Eisenwort, and Gernot Sonneck. “Role of Media Reports in Completed and Prevented Suicide: Werther v. Papageno Effects.” The British Journal of Psychiatry : The Journal of Mental Science 197, no. 3 (September 2010): 234–43. doi:10.1192/bjp.bp.109.074633.
[3] Stack, Steven. “Suicide in the Media: A Quantitative Review of
Studies Based on Non-Fictional Stories.” Suicide & Life-Threatening Behavior 35, no. 2 (April 2005): 121–33. doi:10.1521/suli.

What is 'excessive detail' in suicide coverage?

Aug 12, 2014

This is an excerpt from a much longer piece on the history of suicide and journalism.  It contains description of suicide methods only in so far as they are required to demonstrate the point being made.

Across a number of countries there are media guidelines on suicide reporting (most voluntary, but New Zealand’s are governed by law). These arrived in the UK in 2006 when the Press Complaints Commission (PCC) added a new clause to the Editors’ Code of Practice, extending the guidelines on reporting on topics likely to involve personal grief with an explicit prohibition on publishing ‘excessive detail’ about suicide methods. The article now reads:

>5. Intrusion into grief or shock

>i) In cases involving personal grief or shock, enquiries and approaches must be made with sympathy and discretion and publication handled sensitively. This should not restrict the right to report legal proceedings, such as inquests.

ii) When reporting suicide, care should be taken to avoid excessive detail about the method used.

This rule has now been in effect for eight years and there have now been sufficient cases to make determinations on what exactly this rule has meant in practice. How have complaints turned out? What exactly is ‘excessive’ detail?

There have been forty-six complaints under this clause - most complaints are brought by relatives of the deceased, with a small number being triggered by suicide prevention organisations or elected officials. In one case the PCC itself brought the complaint against fourteen newspapers over the same story.

Many complaints are resolved with an apology or a voluntary redaction of their online archive by the newspaper - but in some cases the PCCs reasoning over what level of detail is or isn’t ‘excessive’ becomes clearer. Examining all rulings involving 5.ii, I found that the PCC to date have chosen to interpret it as a rule against popularizing or explaining unusual or technical methods of suicide. Details tend to be allowed when the method can in some sense be seen as ‘obvious’. To use specific cases, it is wrong to tell people how many pills are a fatal dose or how a suicide involving a balloon kit was accomplished but it is acceptable to describe someone as having hung themselves with their shoelaces.

In the case of hanging (a minority of PCC complaints but the most common method of suicide in the UK), the PCC has repeated argued the material used to perform the act does not constitute part of the method. In the very first complaint under 5.ii it was argued [] that the inclusion of a “photograph taken from the centre’s CCTV footage of [a man] walking towards a stairwell with a bed sheet tied around his neck” was not excessive as the rule was ‘designed to prevent the inclusion of detail in newspaper reports that might provoke ‘copycat’ suicides. The inclusion of a photograph of the complainant’s father before his death did not raise an issue under this part of the Code.’ Similarly, in 2011 [] a complaint that about including the fact that someone had hung ‘himself with shoelaces’ was included in the headline was rejected, arguing that “the article had only referred to the material with which the complainant had hanged himself. The Commission found that the reference under complaint did not represent an excessive detail such that would represent a breach of the Code.”.

The PCC also rejected a complaint in 2008 that inclusion of a picture of a noose in a story about suicides in Bridgend was an excessive amount of detail - “It had to have regard to the fact that – regrettably – there had been a spate of deaths by hanging, and that this fact was well-known. The picture of the noose did not make public anything new about the deaths, or describe the actual process by which individuals had used particular materials to take their own lives.”

This approach is a problem because contrary to the idea that everybody already knows how to hang themselves, information about exact hanging techniques varies and even minor details can change how attractive the idea of hanging is to a person. Biddle et al. [1] conducted a study with people who had attempted suicide explicitly aimed at finding out why they did or didn’t choose hanging as a method. People who tried hanging believed it would be quick, easy and could be done with materials to hand. People who did not believed it would be slow, painful or that they lacked the technical know-how or rope to make the noose. This last point is especially important, for hanging object is method - this is information that change the desirability of the method. The PCC fixation on technical or pharmaceutical suicides misses the purpose of the rule - the concealment of unnecessary elements that might change the likelihood someone puts into practice a given method.

As shown earlier [in not published sections], method and suicidal intent is highly interlinked - restricting methods (either through physical restrictions or by creating ignorance) is the most effective way of having an effect on suicide across a society. This is the area where the scientific evidence is most certain and if journalists can be convinced of this solitary point it would account for most of the effect any wider restrictions would give. The PCC (or its successor body) needs to take into scope ‘obvious’ suicide methods and descriptions that might make them more salient in the mind of a reader. These are after all the most common and so an area where efforts would be likely to have the most impact.

1. Biddle, Lucy, Jenny Donovan, Amanda Owen-Smith, John Potokar, Damien Longson, Keith Hawton, Nav Kapur, and David Gunnell. “Factors Influencing the Decision to Use Hanging as a Method of Suicide: Qualitative Study.” The British Journal of Psychiatry : The Journal of Mental Science 197, no. 4 (October 2010): 320–25. doi:10.1192/bjp.bp.109.076349.