Mimesis and Suicide: A Review and Suggestions for Future Research

1. Mimesis and Suicide: A Review and Suggestions for Future Research Dr. Steven Stack, PhD* Director, Center for the Study of Suicide, Professor, Department of Psychiatry, & Department of Criminology, Wayne State University, Detroit, USA Conference on Mimetic Factors & Health, University of Warwick, Coventry, UK. October 14-15,2009 *aa1051@wayne.edu {MEDIA&Suicide.review&futureresearch.092209a}

2. Research on Copycat or Imitative Suicide • Between 1967-2009 at least 120 scientific studies were published on the possible link between media depictions of suicide and suicides in the real world. • Most studies measure the suicide rate before and after a widely publicized news story (or film) on suicide. • If the change in the suicide rate is positive, a copycat effect is reported. • Many investigations are based on a single story (e.g., Cheng, Hawton, et al. 2007. Influence of media reporting of a celebrity suicide. J of Affective Disorders, 103, 69-75.) • Some investigations explore mimesis effects for a large number of 30 or more media stories (Phillips, D 1974. The Influence of Suggestion on Suicide, Amer Sociological Rev, 39, 340-354; Kessler, et al 1988. Clustering of teenage suicides after television news stories about suicide: a reconsideration. American J of Psychiatry, 145, 1379-1383). • In large scale investigations, some of the time, research finds that after controls for confounding factors (such as seasonal effects, day of the week effects, unemployment trends, holiday effects) publicized suicide stories are associated with increases in one or more population suicide rates.

3. Individual Level Evidence of a Copycat Effect • At least 8 studies have documented direct copycat effects at the individual level. They include: • Marzuk et al (1994) found that suicide by asphyxiation increased 313% in NYC in the year following publication of Final Exit, a guide recommending that suicide method. • In 27.3% of the suicides, a copy of the book was found at the scene. • (Marzuk, P. et al., 1994, “Increase in suicide by asphyxiation in NYC following the publication of Final Exit,” Publishing Research Quarterly, 10, 62-68. • Simkin et al (1995) determined that 32% of suicide attempters at ER were aware of a recent suicide on British television, and 14% reported it had influenced their attempt. (Simkin, s et al 1995 Media influence on parasuicide, British J. of Psychiatry, 167, 754-759). • Hawton et al (1999) determined that 20% of suicide attempters reported that a recent suicide on British television had influenced their attempt (Hawton, et al., 1999. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning. BMJ, 318, 972-977. • Fekete found that 41% of suicide attempters in Hungary reported a suicidal role model from the media compared to 10% controls (Fekete, S & Schmidtke, A 1996. Suicidal Models. Omega, 33,3, 233-241.

4. Individual Level Evidence for & Against a suicide copycat effect - continued • Cheng et al found that 39% of 438 depressive patients exposed to a media report concerning a celebrity suicide reported that the media story had an influence on their subsequent suicidal behavior (Heng, A, Hawton, K. et al 2007. The influence of media reporting of a celebrity suicide on suicidal behavior in patients with a depressive disorder. J. of Affective Disorders, 103, 69-75. • Tousignant et al found that 13% of suicides after the highly publicized suicide of a well-known Quebec were influenced by the reporter’s suicide (Tousignant, Mishara, et al. 2005. The impact of media coverage of the suicide of a well-known Quebec reporter. Social Science & Medicine, 60, 1919-1926. • HOWEVER, Mercy found that suicide attempters were actually 80% less apt to report having been exposed to a media depiction of suicide (a dichotomous conglomerate measure of any exposure in newspapers, film, books, television, etc) in 30 days prior to the attempt (or interview) than a sample of community controls (Mercy, J. et al Is suicide contagious? American J of Epidemiology, 154,2, 120-127).

5. Classic Aggregate Level Example of Copycat Effects: Actress Marilyn Monroe & US National Suicide Count • Phillips (1974) found that there was a 12% increase in suicide the month following the widely publicized suicide of actress Marilyn Monroe. • Note: Suicide is not mentioned in the headline, conforms to guidelines for media reporting of WHO (2008). • However, death/suicide is given a positive definition as freeing the individual from stress. • Photo of her body being wheeled out from her home, violates a WHO guideline for reporting (no photos of suicide scene or body of suicide). • In general, the average increase in suicide was 2.51% after the 34 Newspaper stories analyzed (Phillips 1974)

6. Aggregate Level Findings: Evidence Against a Copycat Effect • In the largest study to date, Kessler at al. (1988) analyzed 87 Television News stories on suicide. No evidence was found for an increase in suicide in 65 out of 69 regression analyses (Kessler et al., 1988, American J of Psychiatry). (suggests research based on TV coverage may nullify the copycat effect, for some reason). • The first systematic meta analysis of 293 findings in 42 studies found that less than half of the findings supported a copycat effect (Stack, S. 2000, “Media Impacts on Suicide: A Quantitative Review,” Social Sci. Q., 81:957-971). • The suicide of “SUPERMAN” George Reeves, for example, was not associated with a copycat effect. • However, it failed to receive widespread page 1 coverage.

7. Plan of this Presentation • There is no automatic relationship between suicide in the news/media and copycat suicides • There is a need to search for the contexts that maximize or minimize the probability of finding a copycat effect. • This presentation • PART I. first reviews theories of media effects which suggest such moderating variables. Most theoretical leads have not yet been systematically researched. • PART II. Reviews the three existing meta analyses which document several known methodological and theoretical moderators. • PART III. Policy: reviews research on the WHO (2008) media guidelines that focus on story moderators thought to decrease the odds of mimetic effects. The degree of compliance and the effects of compliance are reviewed. • PART IV. Eight Suggestions for new research on moderators and other issues.

8. PART I. Key Theoretical Propositions on Media Effects on Suicide(A) Basic Dose-Response (B) Symbolic Inter-actionism( C) Social Learning Theory Dangerous Stories and Receptive Audience Characteristics

9. I (A) Dose-Response: Amount of & Priority of Coverage Proposition 1. All else being equal, the greater the coverage (e.g., column inches, seconds of TV news, number of networks or newspapers carrying the story) of a suicide story, the greater the copycat effect. Proposition 2. The greater the priority of coverage (e.g., page 1, lead story in TV news) the greater the copycat effect. However, The characteristics of the stories and the audience also need substantial consideration as providing moderators between sheer amount of coverage and copycat effects. Sub proposition, yet untested, Movies where the lead star suicides will generate more copycat suicides than movies where a minor character suicides. Movies where the motives for suicide are presented in detail will promote more copycat effects than heir counterparts

10. I (B). Symbolic Interactionism:Audience Receptivity & Mimetic Risk • A basic assumption in media effects research is that some members of the audience are more receptive to Media advertisements or messages than others (eg., Blumer,H. 1969 Suggestions for the study of mass media effects, Symbolic Interactionism, Prentice Hall; Stack 2005, SLTB). Media news stories affect mainly already vulnerable or high risk individuals. They are “on the edge” already. • Proposition 3. In suicide studies, groups with pre-existing protective factors protective factors against suicide will be less susceptible to mimetic effects. • Lack of pre existing psychiatric disorders predictive of suicide • Social protective factors including high religiosity, social support, economic security & satisfaction. • Proposition 4. Groups with pre-existing suicide risk factors will be more susceptible to mimetic effects. • Psychiatric risk factors including major depression & substance abuse disorders • Social risk factors such as economic strain (unemployment, home evictions), relationship strain (e.g., divorce; domestic violence); social isolation (e.g., living alone), death of a loved one, low religiosity, & altruism (suicide to relieve others from your being a perceived burden). • Physical illness and disabilities (e.g., dying of cancer, disabled from car accident, blind) • Comorbidity: risk increases with presence of multiple risk factors

11. INTERACTION: AUDIENCE CHARACTERISTICS Audience Receptivity Presumed Dangerous Stories COPYCAT EFFECT RISK + e.g., Major Depression Economic Strain Youth more impulsive e.g. Celebrities Front Page Sensational WHO Guidelines

12. I ( C). Social Learning Theory Story Characteristics: Positive vs. Negative Definition of Suicide • Suicide Guidelines and most work on media effects to date have focused more on story characteristics than audience characteristics in mapping media effects. • Media depictions of suicide are a fundamental component of social learning processes where individuals learn vicariously through watching the experiences of others, as opposed to limiting their learning solely to their own personal experience. • Media portrayals of suicide can promote the learning of both positive and negative definitions of suicide(e.g., Pirkis & Blood 2001a,2001b; Schmidtke & Schaller 2000; Stack 2000).

13. Positive Definitions of Suicide in the Media Positive Definitions of Suicide may include: Social Rationalizations or motives for suicide including ill health, marital trouble, job loss, romantic strains Individual Rationalizations including suicide as a implied solution to a battle with life long battle with depression, substance abuse Perceived Rewards. If suicidal persons desire to hurt significant others, grieving relatives of suicide might comprise a “reward” for the behavior. Focus on the positive aspects of victim’s life- e.g., attractive photo, high school sports hero, honor student, father of 4, wealthy person. Glorification of Deceased- e.g., fly the school flag at half mast Long Term and sensational coverage- captures attention, attention getting.

14. Negative Definitions of Suicide Negative Definitions of Suicide include: • Focusing on victim’s disfigurement/pain (e.g. pictures of rotting bodies at the Jonestown mass suicide in 1978). • Stressing that suicide is wrong, wasteful, even stupid (e.g. coverage involving Kurt Cobain’s widow after the rock star’s suicide in 1994) • Discussing alternatives/solutions to suicide (e.g., crisis hotlines, counseling) • Example: media coverage of grunge rock celebrity Kurt Cobain was often quite negative and did not spark a blip up in the suicide rate (Jobes et al., 1996, The Kurt Cobain suicide crisis, Suicide & Life Threatening Behavior, 26, 260-271). • Note on Suicide & Media History: The editor of the NYT thought that publicizing every single suicide in the NYT would discourage suicide by shaming the suicide victims. After a period of hyper media coverage during 1913-1914, he abandoned his idea since the suicide rate did not go down as he had hoped (Gundlach, J & Stack, S 1990. The effect of hyper media coverage on suicide, New York City, 1910-1920. Social Science Quarterly, 71,3, 619-627. Sheer coverage is not in itself a negative definition.

15. Proposition 5. The greater the excess of positive over negative definitions of suicide in the news story, the greater the chance for finding a copycat effect. • However, media coverage of suicide has typically covered far more neutral/factual and/or positive definitions of suicide than negative ones (e.g., Blood 2001, Fekete, Schmidtke et al, 1998, Michel et al., 2000; for a review see Schmidtke & Schaller 2000: 686-688). • Researchers studying a large number of stories often just lump them all together without searching for negative definitions. Strong negative definitions are uncommon. • Auxiliary, sub component propositions: • Proposition 5A The greater the negative definitions of suicide in a news story will minimize the odds of finding a copycat effect. • Proposition 5B. The greater the positive definitions of suicide, the greater the copycat effect.

16. Social Learning, Story Characteristics: Differential Identification Theory • Since the work of Tarde (1903) in the Laws of Imitation, there has been a proposition that the inferior tend to copy the behavior of the superior. • Proposition 6. ( Vertical Identification) Persons will tend to copy the suicidal behavior of superior people (e.g., well known celebrities) more than the suicidal behavior of common people. (Tarde, G. 1903. The Laws of Imitation, NY: Henry Holt. Wasserman, Ira. 1984, Imitation & Suicide: A Reexamination of the Werther Effect, American Sociological Review 49, 427-436. Stack,S. 1987, Celebrities & Suicide: A Taxonomy & Analysis. American Sociological Review, 52, 401-412.) • In vertical identification, persons high in individual and/or social risk factors for suicide, would presumably be more apt to think “if Marilyn Monroe with all her beauty, fame, & money chooses death over life, why should I (possibly ugly, unknown, & poor) go on living? “ than if they hear about some ordinary person suiciding. • As we shall see, widely publicized celebrity suicides are the most likely ones to apparently trigger copycat suicides.

17. Horizontal Identification. In this view, Proposition 7. Persons will be more apt to copy the behavior of others like themselves than persons unlike themselves. Dimensions of horizontal identification may include: • Demographic Identification: • AGE, GENDER, Nationality, Marital Status (e.g., males more be more apt to copycat suicides of males than those of females) • Problem or Motive Centered Identification: • Individual Stressors. Physical & Mental Illness. Persons dying of cancer may be most apt to copycat highly publicized suicides of similar persons. • Social Stress (e.g., unemployed persons may be most apt to copycat the suicides of other unemployed persons; divorced persons may copy cat the media-based stories of divorced persons who suicide). • Note: Vertical and Horizontal identification are not mutually exclusive but can occur together (e.g., Marilyn Monroe was a celebrity, but also had long term marital problems, substance abuse problems that serve as points of horizontal identification). • Note: there is ample evidence that both celebrity and noncelebrity publicized suicide are often associated with increases in the social suicide ate (e.g., Stack, S. 1990 A re-analysis of the impact of noncelebrity suicides, Social Psychiatry & Psychiatric Epidemiology, 25, 269-273).can

18. PART IITHREE META ANALSES of COPYCAT EFFCETS RESEARCH • There are three quantitative meta analyses of the research on copycat suicide. • These suggest some of the key predictors or moderators that promote finding a link (or not finding a link) between stories and social suicide rates. • However, most propositions suggested from theories of media effects have not been systematically tested.

19. META ANALYSIS I:42 StudiesStack, S. 2000, “Media impacts on suicide,” Social Science Quarterly, 81,4, 957-971.) • Logistic Regression Analysis 293 findings from 42 studies. 14 on Fictional & 28 on real stories. • where 1=copycat effect noted in a finding, 0=lack of a copycat effect. • Key significant methodological/theoretical predictors of reporting a copycat effect included • celebrity status, • real vs. fictional stories, • media type (TV vs. Newspapers).

20. Dose-Response Theory: Television vs. Newspaper Stories (OR=0.21) Research findings based on television news stories on suicide are 79% less apt to report an imitative effect than ones based on newspaper stories.. Relates to the amount of coverage. TV stories usually last less then 20 seconds, can go unnoticed, easily forgotten. Newspaper stories are much longer. Also, Newspaper stories, unlike TV ones, can be easily saved, & re-read.

21. Differential Identification Theory: Entertainment/Political Celebrity Status, OR=14.3 • Studies measuring the presence of either an entertainment or a political celebrity were fully 14.3 times more apt than studies based on other kinds of stories to report a copycat effect. • The limited work on other celebrity subtypes (e.g., celebrity villains such as spies or mass murderers who suicide; foreign celebrities; economic celebrities) suggests that these other categories of celebrity suicide do not have a copycat effect. • The mass audience apparently identifies with entertainment celebrities, well known movie stars, in particular. Stars represent the celebration of the ordinary (Stack, S 1987. Celebrities and Suicide, Amer Sociological Review, 52, 401-412; Dyer, R 1979. Stars. London: British Film Institute)..

22. Differential Identification Theory: Real vs. Fictional Suicide Stories, OR=4.03 Research based on real suicide stories (as opposed to fictional stories) was 4.03 times more likely to report a copycat effect than research based on fictional suicides such as those in movies. There is a general agreement that research based on real suicide stories is more apt to report copycat effects than research based on make-believe or fictional stories (e.g., suicide in movies & soap operas). Gould, M. 2001. “Suicide and Media,” Annals of the NY Academy of Science. Pirkis & Blood 2001a. “Suicide & the Media Part I, Crisis. Pirkis & Blood 2001b. “Suicide & the Media Part II, Crisis. Schmidtke & Schaller (2000) “Role of the mass media in suicide prevention,” Int’l Handbook. of Suicide & Suicide Prevention, NY: John Wiley. However, this finding may be a function of poor measurement of exposure to fictional media such as film. The measurement of cumulative exposure to films containing suicides of stars has not been measured.

23. META ANALYSIS II: 55 Studies on Non Fictional StoriesStack, S. 2005. Suicide in the Media: A Quantitative Review of Studies Based on Nonfictional Stories. Suicide & Life Threatening Behavior. 35,2 121-132. Similar methodology to Stack (2000) Expands sample of studies focused on non fictional (REAL) suicides from 28 in Stack (2000) to 55.

24. The 55 studies (by first author)

25. Dose-Response Theory: Amount of Coverage Findings based on televised suicide stories were 79% less likely than findings based on newspaper stories to report a copycat effect. Page 1 newspaper articles are longer, have more detail. Can be easily re-read and copies easily saved for future reference. TV coverage typically last about 10 seconds. Some evidence that research based on one network coverage (as opposed to multiple network coverage that reaches a larger audience) has no impact at all on suicide rates.

26. Differential Identification Theory: Entertainment/Political Celebrity Stories, OR=5.27 • Findings based on entertainment/political celebrity suicide news stories were 5.27 times more likely than findings based on other stories to report a copycat effect. • The OR here is smaller than in Stack (2000) since fictional stories are left out (they have no celebrity suicides).

27. Social Learning Theory, Negative Definitions of Suicide (OR=.01) • Findings based on suicide stories stressing negative definitions of suicide were 99% less likely than their counterparts to report a copycat effect. • E.g., The 12 days of coverage of the rotting bodies, cult-like mass suicide in Jonestown, was actually associated with a drop in suicide, a drop of 58 suicides (Stack 1989, The effect of Jonestown on suicide, Pp. 135-151, Rebecca Moore, New Religious Movements, Mass Suicide, & People’s Temple, NY: Edwin Mellon.). • Cobain’s widow defined his suicide as a total waste, thereby decreasing the odds of imitation.

28. OTHER RESULTS • Audience Receptiveness: Findings based on the rate of female suicide were 4.89 times more likely to report a copycat effect than findings based on male suicide. • Model Fit: 77.3% of the 419 findings were correctly classified by the model.

29. Summary: Odds that a study will report a copycat effect by methodological Issue

30. META ANALSYSIS III 26 Studies on Fictional Stories (e.g., Movies)Stack, S. 2009. Copycat effects of fictional suicide: A Meta Analysis. Chapter 17 in Stack, S & Lester, D. (eds), Suicide and the Creative Arts. NY: Nova Science. Expands analysis in Stack (2000) from 14 to 26 investigations.26 studies contain 146 findings.

31. Matching of Model’s Method with Audience Method of Suicide, OR=4.40 Studies that matched the method of suicide in the role model (usually an actor in a movie) with that of the audience were 4.4 more times apt to report a copycat effect than Studies that did not do so. It is often not clear if the model’s suicide Had a significant effect on suicides by other means. Possibly there was no overall increase in suicide But a transference in methods. However, at the aggregate level, Jamieson (2003) reports that the Number of suicides in film/year explained the upswing in Overall youth suicide between 1950-2000. Jamieson, P. 2003 Changes in US Popular Culture Portrayal of Youth Suicide, 1950-2000. PhD dissertation. Philadelphia: U Penn. Tip: Suicide of super star Bruce Willis, Sin City (2005) An Unstudied image

32. Audience Receptivity: Youth Suicide, OR=4.39 • Research findings based on youth suicide rates are 4.39 times more apt to report copycat effects than research findings based on other suicide rates. • Consistent with the view that youth are more susceptible to suggestion • Consistent with the view that youth are the most apt age group to watch movies. • Tip: There is no research to date assessing the characteristics of he model- their motives, star status, etc. • Tip: There is research yet on the reactions of the survivors to the suicide. • Tip: There is no research to date measuring cumulative exposure to suicide films.

33. Part III:PolicyGuidelines for Media Reporting (WHO 2008)Promoting vs. Preventing Copycat Behavior

34. Media Guidelines for the reporting of Suicide • Since the mid 1990’s various organizations have produced guidelines for the reporting of suicide. • Most Recent: World Health Organization & Int’l Association for Suicide Prevention (2008) issued Preventing Suicide: A Resource for Media Professionals. Available at: http:www.who.int/mental_health/prevention/suicide/resource_media.pdf.

35. The Eleven WHO(2008) Media Guidelines • 1. Take the opportunity to educate the public about suicide • 2. Avoid language that sensationalizes or normalizes suicide, or presents it as a solution to problems • 3. Avoid prominent placement & undue repetition of stories about suicide • 4. Avoid explicit description of the method used in a completed or attempted suicide • 5. Avoid providing detailed information about the site of a completed or attempted suicide • 6. Word headlines carefully • 7. Exercise caution in using photographs or film footage • 8. Take particular care in reporting celebrity suicides • 9. Show due consideration for people bereaved by suicide • 10. Provide information on where to seek help • 11. Recognize that media professionals themselves may be affected by stories about suicide. • World Health Organization & Int’l Association for Suicide Prevention (2008) issued Preventing Suicide: A Resource for Media Professionals. Available at: http:www.who.int/mental_health/prevention/suicide/resource_media.pdf.

36. Suicide Prevention & Media: Two Issues: Compliance & Effectiveness • (1) Compliance with the Guidelines. Can the Media be convinced to change the amount and/or type of their reporting on suicide/ to conform to the WHO Guidelines? • (2) Do the Guidelines really work? Are the criteria in media guidelines really predictive of suicide, independent of the amount of coverage (Phillips 1989). Or is decreasing the sheer amount of coverage, of any kind, the main way to prevent imitation?

37. 1. Compliance. Have the Media Followed the Guidelines? Guidelines have been disseminated by many organizations including WHO, CDC, AFSP, & AAS (e.g., Satcher, 2001, National Strategy for Suicide Prevention, 106-111). Cross sectional research at one point in time often suggests a gap between elements of the guidelines and actual press coverage. An Australian study of 410 press reports determined that only 6.5% provided information on where to seek help, e.g., suicide hotline number as recommended in WHO (2008) guideline #10 (Pirkis 2002).

38. Compliance. Evidence from Switzerland A Swiss study explored the impact of a 1992 press conference between the media, Swiss Medical Association, & Suicidologists. The media were urged to follow Guidelines for reporting suicide. (Michel, Frey, Wyss & Valch 2000, “An Exercise in Improving Suicide News Reporting in the Media,” Crisis, 21:71-79). • A content analysis of stories over an eight month period before and after distribution of the Guidelines illustrated a substantial change in the quality of reporting. • However, at the same time, the quantity of reporting on suicide tripled from 151 to 468 stories. The media officials apparently ignored this key guideline.

39. Percent of stories containing presumed dangerous content before (1991) & after (1994) Dissemination of Media Guidelines, Switzerland(Michel et al., 2000)

40. Australia: Degree of Compliance of the Australian Media with WHO Media Guidelines (Pirkis et al 2002. Reporting of Suicide in the Australian media. (Australian & New Zealand J of Psychiatry, 36, 190-197).

41. 2. Do Media Guidelines Actually Work? It is widely believed that the type of presentation of suicide in news stories influences the incidence of copycat suicide. However, only one previous rigorous study to date tests associations between selected aspects of media guidelines and copycat suicide (Phillips, David P., Carstensen, L. & Paight, D., 1989 “Effects of mass media news stories on suicide with new evidence on story content,” Pp. 101-116 in Peiffer, Cynthia (ed), Suicide Among Youth: Perspectives on Risk & Prevention. Washington, D.C.: American Psychiatric Press.

42. Media Guidelines & Teen Suicide: An Inconvenient Truth? • Phillips, et al. (1989) studied five characteristics of 32 televised suicide news stories & their impact on teen suicide in the US. • Controlling for the amount of coverage of the story (seconds of TV time), none of the five characteristics of the story actually affected the incidence of teen suicide. • (Phillips, David P., Carstensen, L. & Paight, D., 1989 “Effects of mass media news stories on suicide with new evidence on story content,” Pp. 101-116 in Peiffer, Cynthia (ed), Suicide Among Youth: Perspectives on Risk & Prevention. Washington, D.C.: American Psychiatric Press.

43. T-tests for effect of Five Story Characteristics on Teen Suicide, controlling for the amount of coverage(Phillips et al., 1989)

44. Dose Response Theory & Tips • The sheer amount of coverage was a significant predictor of teen suicide, thus supporting the classic dose-response theory of imitation effects. • Tip: Results controlled out the influence of the amount of coverage. Without this control some story presentation variables may have been significant. • Tip: Phillips did not measure six aspects of today’s suicide guidelines (e.g., sensationalism). Future work should do this. • Tip: These findings refer only for teenagers. Possibly other age groups would respond to dangerous story content.

45. PART IVEightSuggestions for Future Research on Suicide and Mimesis (a) Cumulative Non laboratory Exposure Index: Example of Smoking Initiation Research & Film (b) Motive-Identification & Feature Films (c) Long Term Mimesis Effects: Deer Hunter (d) What explains the Variation in Compliance with Media Guidelines? (e) Large Sample Aggregate Level Research: little since 1990’s (f) Work on the elderly as a vulnerable group (g) Suicide in Popular World Literature and Copycat Effects (h) Age/Gender matching of model and Audience

46. IVa. Cumulative, Non Laboratory Index of Media Exposure: Smoking Initiation Research • Some of the best work on mimesis and risk behavior has been done in smoking initiation research. • Therein researchers developed a new measure of exposure to media messages regarding smoking: the number of films which respondents reported having watched where the stars of the film smoked. • A meta analysis of 40 studies concluded that the greater the number of such films watched the greater the likelihood that teens imitated smoking at follow-up (Charlesworth & Glantz, 2005, “Smoking in the movies increases adolescent smoking”, Pediatrics, 116:1516-1528). • Importantly, in some of the best designed studies, such cumulative exposure to film was the most single important predictor of teen smoking initiation. The film exposure index was more predictive of smoking than traditional predictors including peer smoking, parental smoking, GPA in school, and others. (Dalton et al., 2003, “Effect of Viewing smoking in the movies on adolescent smoking initiation: a cohort study,” Lancet, 362:281-285. • The strong results of this body of research resulted in Walt Disney Productions decision to take smoking behavior out of their films (Marr, M. 2007 Family-Friendly Disney studio turns silver screen into ‘no smoking area,’” Wall Street Journal, July 26, 2007, p. B-2). • Media work on suicide has not yet adopted this lead. Much work on film’s effects is still done in the lab, and, as such, highly suicidal youth, the most likely to be responsive to suicide films, are often screened out of the study for their own protection. This can minimize the chances of finding copycat effects.

47. IVb. Film Suicides: Motive-Identification with Star Suicides in Film • Watching movies is the number one leisure time pursuit in the US. As such suicides in film may have an important impact, if measured properly. Recently I have finished analyzing 1,100 suicides appearing in American feature films from 1900-2009. • Seven broad categories of motives for suicide appear in the films. • Possibly different audiences identify with some motives more than others. • Work will be needed to ascertain the extent to which, if any, various audiences (sex/age/race) differentially identify with which of these 7 motive categories. • I suggest that the suicides of major film stars of each generation (e.g., James Cagney, Clint Eastwood, Ben Kingsley, Kris Kristofferson) might be especially apt to foster identification and mimesis among persons of that generation.

48. Examples of the Seven Suicide Motives in American FilmStack & Bowman (2011) Suicide Movies: Social Patterns, 1900-2009. Terminal Illness: John Wayne, suicide by outlaw, The Shootist (1976) Psychiatric/addiction Kris Kristofferson, A Star is Born. (1976) Death/grieving: Ben Kingsley, House of Sand & Fog (2004) Psychiatric/ ThePsychopath: James Cagney White Heat (1949) Economic Strain: John Travolta, Mad City (1997) Social strain, Rejection in Love, Officer & a Gentleman (1973) Altruism: Clint Eastwood, Gran Torino (2008) Altruism: Bruce Willis, Sin City (2005)

49. IVc. Long Term Effects of Specialized Media Exposure: Deer Hunter, Assisted Suicide • There is almost no work on the possible long term effects of media depictions of suicide, although time series analyses of large samples usually finds the largest copycat effect within ten days of a publicized suicide. • The film Deer Hunter, which was released in 1978, influenced at least 33 copycat suicides during 1980-1985, and additional suicides after its release in DVD format in 2002 (Coleman, L. 2004 The Copycat Effect. New York: Paraview). • Frei et al (2003) reported that the highly publicized assisted suicide (sponsored by the right to die organization, EXIT) of a prominent couple in Switzerland affected assisted suicides for two years (Frei < a. et al 2003. The Werther effect and assisted suicide. Suicide & Life Threatening Behavior, 33,2, 191-200). • It is likely that the suicide images and stories from the narratives in film, books, and music contribute to some suicides over the long term. The nature & degree of this association need exploration. A first step is for suicidologists to compile an exhaustive list of suicide depictions in popular cultural media.

50. IVd. Have/ How Much have the WHO Media Guidelines Affected the Content of Suicide Reporting, & What Explains Cross-National Variation? • Suicide prevention strategies generally have included a media prevention component. • Suicide guidelines have been available for 15 years. It is not very clear what impact, if any, they have had in most nations world. • Are news reports, films, and other media presentations of suicide any different today than the pre guidelines era? • Evidence based research from Austria, Australia, Hong Kong, New Zealand, and Switzerland is mixed. The variance in media compliance with WHO guidelines needs an explanation. • For example a survey of 57 journalists in the US found that most were not aware of the Suicide Guidelines for the Media (Jamieson, Jamieson, & Romer 2003, The responsible reporting of suicide in print journalism, American Behavioral Scientist, 46,12, 1643—1660).