The “sick-lit” question and the death education answer. Papageno versus Werther effects in adolescent suicide prevention

Adolescence between suicide and youth culture

Everyday, the world of media creates an uncountable number of messages portraying death in fantastic and terrifying ways, which may attract or influence adolescents. The problem should be considered in the context of formal education settings (Noppe, 2007), but neither teachers nor parents try to deal with it in any way (Fonseca & Testoni, 2011). This and the common conspiracy of silence on mortality (Lowton & Higginson, 2003; Testoni, Lazzarotto, & Di Lucia Sposito, 2013) leads to many difficulties, among them, the dysfunctional and sometimes dangerous feeling that life is never-ending and the risk that youngsters may be the recipients of messages which could inspire suicidal ideas. In fact, among people aged 15-29 years, suicide is the second leading cause of death globally (Haw & Hawton, 2011; World Health Organization, 2014). Suicide risk factors include particularly important ones that promote the copycat effect, such as low self-esteem related to feelings of helplessness, social isolation, and perceiving reality as meaningless (see Evans, Hawton, Rodham, & Deeks, 2005; Ronconi, Testoni, & Zamperini, 2009; Steiger, Fend, & Allemand, 2015). As terror management theory (TMT) affirms, self-esteem is one of the most important protective factors in the subjective management of death-related anxieties because it influences social-inclusive relationships (Pyszczynski & Kesebir, 2013). Furthermore, in adolescence, this dimension develops through peer imitative behavior, which is functional to improve the reciprocal imitative and selective behavior (Donders & Verschueren, 2004). Indeed, it is a constitutive aspect in the construction of youth culture and its symbolic system through which youngsters share parameters and interpret the world on the basis of their needs (Janssen, Dechesne, & Van Knippenberg, 1999; Rice, 2008; Williams, 2007). Since death-related thoughts, imitative behavior and low self-esteem are significantly associated with suicidal ideation, they are given serious consideration in preventive educational programs (Fergusson, Woodward, & Horwood, 2000; Mann, Hosman, Schaalma, & De Vries, 2004), and since the need for peer-imitation may initiate the Werther effect, this study analyzed a recent phenomenon which may be included in youth culture: sick-lit.

Sick-lit and the Werther effect

Sick-lit is a genre of story writing rooted in illness, self-harm, suicide, sufferance, violence and death. This kind of narration seems to be becoming increasingly attractive amongst adolescents and differs from other kinds of classical literature featuring illness because of the realistic way in which the degeneration is described, combined with technical and medical terminology, and sometimes because suicide is a positively represented suicide. On the internet, sick-lit has been criticized because it trivializes serious issues but it is also appreciated for its focus on mortality. It first began to be disseminated in Canada about ten years ago and quickly reached all Anglophone countries and Italy, and it is important to underline that, with the exception of Italy, these areas correspond to countries where rates of suicidal behaviors are remarkably high.

The Werther effect is the emulation of a suicide that the person attempting suicide knows about either from local knowledge or the cultural diffusion of narratives describing such a choice (Jonas, 1992). This problem is related to emulative behavior, which is particularly relevant in adolescence. Indeed, based on Bandura’s perspectives (Bandura, 1986), differential association theory (DAT) proposed that adolescents with low self-esteem become deviant or commit suicide to assume an identity that is otherwise impossible, adopting such solutions through the imitation of cultural sources (Stack, 1990; Stack, Lester, & Rosenberg, 2012). The correlation between the construction of social identity and the copycat effect has been widely confirmed (Cheng et al., 2007), and many studies have shown how the Werther effect is associated with the mass media diffusion of news concerning suicide (see Blood & Pirkis, 2001; Tousignant, Mishara, Caillaud, Fortin, & St-Laurent, 2005). Despite some research having refuted this association (Peterson, Safer, & Jobes, 2008), specific analyses have demonstrated a relationship between a preference for specific music genres, youth culture and suicide (Lacourse, Claes, & Villeneuve, 2001; Lewis, 2014; Phillipov, 2010; Stack, Lester, & Rosenberg, 2012).

To promote safe media reporting of suicide, the World Health Organization developed guidelines for media professionals (World Health Organization, 2008). Nevertheless, little attention has been paid to other aspects of everyday social communication. Furthermore, the existing studies on the portrayal of suicide in movies, songs and novels are either inaccurate or insufficient, and can contribute to misunderstandings about the nature of suicide while affecting the way in which suicide prevention programs develop (Gould, 2001). Since teenagers adopt imitative behaviors (Fenstermacher & Saudino, 2006; Wilmshurst, 2013), and it is assumed that they watch movies, listen to music and read novels, some researchers have suggested that suicide media guidelines be expanded to include films and other cultural expressions (Stack & Bowman, 2011). However, given the unpredictability and the irreproachability of artistic production, this hypothesis would hardly be effective. More research is needed and, as we will see shortly, we think that so-called death education could be an appropriate preventive strategy instead.

Death education and the Papageno effect

Since suicide risk in adolescence has been widely highlighted, many primary prevention initiatives have been disseminated through educational agencies around the world. An analysis of self-harm behavior predictors in adolescence showed that school-based mental health paths reduced the incidence of depression and suicidal problems (Gould, 2001). The School Based Suicide Prevention Programs promoted by the American Foundation for Suicide Prevention, the Life Skills Education Program (World Health Organization, 1997) and the EUREGENAS program (2008-2013) have transformed school into an educational space able to promote the development of protective factors (Aseltine, James, Schilling, & Glanovsky, 2007; Eggert, Thompson, Herting, & Nicholas, 1995; Fortune, Sinclair, & Hawton, 2008; Haney & Durlak, 1998; Goldsmith, Pellmar, Kleinman, & Bunney, 2007; Mann et al., 2005). Indeed, they revealed which activities improved the health principle and self-esteem, both of which help reduce social isolation.

However, nowadays this may be insufficient because of the lack of existential reflection on the relationship between death-related thoughts and the meaning of life. Despite the fact that many authors have underlined the importance of raising awareness on existential issues during school activities (Andriessen & van den Brande, 2001; Chagnon, Houle, Marcoux, & Renaud, 2007), the almost total absence of any form of rational discussion on mortality may abandon adolescents to irrationally adhering to dangerous attitudes toward death. Since the problem is underestimated by parents and teachers; that is, in the opinion of some researchers (Testoni, Di Lucia Sposito, De Cataldo, & Ronconi, 2014; Vail et al., 2012; Wolfelt, 1997), and by the Terror Management Health Model (TMHM), educational processes should help young people to interiorize a sense of limit and the value of life (Goldenberg & Arndt, 2008). Death education encompasses everything individuals need to learn about death during their lifetime, and is the conceptual basis on which they realize that their lifespan is limited (Noppe, 2007). It could be taught in the context of formal education, transforming the risk of the Werther effect, a result of adolescent interest in mortality, into a positive elaboration of death-related thought aimed at valorizing and creating meaning in life.

The ‘Papageno effect’ is the opposite of the Werther effect and refers to Mozart’s opera, The Magic Flute, in which a young man who is determined to die by suicide survives thanks to his friends’ intervention (Niederkrotenthaler et al., 2010). As experience has already shown, death education may be very useful in the management of suicide risk (see Heuser, 1995; Kalafat & Ryerson, 1999; King, 2001; Leenaars & Wenkstern, 1990), and in this educational setting, it could be possible to transform the Werther effect into Papageno effect.

The research

Method

Our qualitative study (Camic, Rhodes, & Yardley, 2003) followed the CORE-Q check-list (Tong, Sainsbury, & Craig, 2007). Two judges performed a thematic analysis, a specific approach to qualitative research developed from grounded theory (Glaser & Strauss, 1967), which enables data sources to be analyzed in terms of principal concepts or themes (Braun & Clarke, 2006). This process may be based on prior categories and on categories that become clear only as the analysis proceeds. The process is divided into six main phases: “Preparatory Organization”, including the preliminary selection of the eligible texts; “Generation of Categories or Themes”, which consists of recognizing emerging patterns; “Coding Data”, which transforms the categories into electronic format; “Testing Emergent Understandings”, in which the theoretical constructs are highlighted; “Search for Alternative Explanations” and “Writing the Report”.

The analysis was performed using Atlas.ti, powerful qualitative analysis software which provides support during data analysis and produces network graphics. The output consists of the production of network graphs that describe the logical relationships between categories.

First phase: analysis of the sick-lit argument on the Web

The first phase of the research looked at representations of the problem on the internet between October 2013 and January 2015. In order to elaborate them, we conducted a database search using “sick-lit” and “youth culture” as keywords. The following search engines were utilized: Google, Google Trend, Bing, Duck Duck Go, Yahoo Search and Virgilio. Our search yielded about 300,000 sites. Twenty-five sites (14 English and 11 Italian) were selected because the texts were sufficiently structured and clear (reviews of books, blogs and prevention articles). To be included in the analysis, the e-texts had to directly discuss the sick-lit problem and its relationship with youth culture, and be in English or Italian.

As shown in Figure 1, the internet discussion on sick-lit is substantially ambivalent. On one hand, it underlined the risk of the Werther effect; on the other, it proclaims a positive role resulting from the social need to make youngsters aware of mortality. This contradiction justifies the second part of the research.

Figure 1

Results

The protagonists of the novels are adolescent youngsters between 10 and 20 years of age who are brought up in Western wealthy families. Their subjective characteristics are quite ordinary and may activate significant horizontal identification processes in Western countries. Vertical identification may be produced by prestige bias, which allows a person to identify with someone who is socially superior. Indeed, the main characters of the novels are quite ordinary but lead high lifestyles. The protagonists do not come from disadvantaged social or family backgrounds but live very comfortably. Furthermore, being featured in the narration, they automatically assume privileged status in the eyes of the reader. We thus claim that the six sick-novels may activate identification processes with the protagonists, influenced by both similarity and prestige effects.

With respect to the representation of death, it appears both as absolute annihilation and as a passage, with some similarities and significant differences between the two representations. Both of them are associated with reflections on mortality and disease and are characterized by an inability to speak about death, which, despite being judged as unjust, is an accepted state. For example, in Before I die, the awareness of death is the pivot of the narration

Death straps me to the hospital bed, claws its way onto my chest and sits there. I didn’t know it would hurt this much. I didn’t know that everything good that’s ever happened in my life would be emptied out by it (p. 237),

and, consequently, is the leitmotiv with which the entire narrative is interwoven

I have a diagnosis. She has two parents who live together. I got out of my bed this morning and there was sweat on the sheets. I’m driving now. It’s my face in the car mirror, my smile, my bones they’ll burn or bury. It’ll be my death. Not Zoey’s. Mine. And for once, it doesn’t feel so bad (p. 145);

She’ll understand what I already know – that death surrounds us all (p. 170);

After he’s gone, a bird lands on the window ledge. It’s not a spectacular bird, not a vulture or a phoenix, but an ordinary starling. A nurse comes in, fiddles about with the sheets, fills up my water jug. I point the bird out to her, joke that it’s Death’s lookout. She sucks her teeth at me and tells me not to tempt fate. But the bird looks right at me and cocks its head (p. 241).

The essential indication is that death is a choice:

I want to die in my own way. It’s my illness, my death, my choice (p. 249).

At the end, the fundamental suggestion is that dying is becoming nothing:

The sound of a bird flying low across the garden. Then nothing. Nothing. A cloud passes. Nothing again. Light falls through the window, falls onto me, into me. Moments. All gathering towards this one (p. 296),

and this is the background against which the moral of “keeping-death-away spells” (pp. 274-275) stands, consisting in living any experience knowing that nothing is the final destination of life.

In Wintergirls, the self-identity of the narrating subject is material and intrinsically linked to the body represented as already dead: “‘Dead girl walking’ […]. I am that girl. I am the space between my thighs, daylight shining through. I am the bones they want, wired on a porcelain frame” (pp. 24). In fact, the boundaries between life and death (“You’re not dead, but you’re not alive either” – p. 195) and inside/outside reality (“Do I want to die from the inside out or the outside in?” – p. 20) are apparently blurred. Furthermore, the indication of further dimensions beyond material reality is considered a mere delusion: “In one aspect, yes, I believe in ghosts, but we create them. We haunt ourselves, and sometimes we do such a good job, we lose track of reality” (p. 204). In this novel, the representation of further dimensions after life takes inspiration from classical figures in the horror literature

Maybe I am one of the undead. Vampires are pale, cold, and skinny like me. They secretly hate the taste of blood, hate the way they make people cry, hate graveyards and cof ns and the beast that drives them. They will lie about hating it until someone drives a stake through their heart (p. 220),

but it immediately subtracts from them any transcendental vision, re-conferring on them the mere material expression with a lightning narrative device that pierces the description: “… body alone …” (p. 220). The same ambivalence is illustrated in The fault in our star, where the invalidated figure of salvation is God (“God knows that’s what everyone else does”, p. 11), since he is not the solution to death or annihilation

when all of us are dead. All of us. There will come a time when there are no human beings remaining to remember that anyone ever existed or that our species ever did anything. There will be no one left to remember Aristotle or Cleopatra, let alone you. Everything that we did and built and wrote and thought and discovered will be forgotten and all of this […] will have been for naught. Maybe that time is coming soon and maybe it is millions of years away, but even if we survive the collapse of our sun, we will not survive forever. There was time before organisms experienced consciousness, and there will be time after. And if the inevitability of human oblivion worries you, I encourage you to ignore it (pp. 10-11).

Also The lovely Bones, which narrates the history of an adolescent victim of rape and murder, presents dead Susie as a deprived subject who narrates and participates in the facts from an empty dimension.

In this form of annihilating afterlife, suicide seems to be a solution as to how to represent death. The idea of absolute annihilation occurs with the use of medical language, which manifests the real facts, rationalizing the idea of the disintegration of the body, and death results as freedom from pain. Similarly, in the representation of death as a passage, death is accepted since it is a consolation (release from pain) and a positive opportunity.

The representation of the non-sense of life is connected to the reflection on death and disease, where the medical language reveals the true reality of the body in hospital, unveiling the concreteness of life. The biological and technical lexicon, which particularly characterizes The fault in our star (“I suspect Cancer Perk.” Cancer Perks are the little things cancer kids get that regular kids don’t” – p. 9), illustrates the mere reality of the body, and the description of its degradation makes explicit the material nature of the disease, where self-harm may be a solution against suffering because it gives the person the power to control events that produce pain, and the distinction between a human and an animal body is lost. For example, in Speak, the cadavers of animals are discussed throughout the narration (“keeping an eye out for interesting roadkill. We get a lot of dead deer in the suburbs. Sometimes poor people take the venison for their winter’s meat”; “Little rabbit heart leaps out of my chest and scampers across the paper, leaving bloody footprints on my roots” – p. 160) and the manipulation of their corps is considered funny (“Cutting dead frogs is cool” – p. 81), meanwhile the description of the operation is plain (“David pins her froggy hands to the dissection tray. He spread her froggy legs and pins her froggy feet. I have to slice open her belly” – p. 81) or artistic (“The turkey-bone sculpture gives off a faint rotting odor. […] Maybe there’s a dead rat decomposing in the wall right near the hot air vent” – p. 151). The human and subjective body are considered to be similar biological material.

I saw a movie once where a woman was burned over eighty per cent of her body and they had to wash all the dead skin off. They wrapped her in bandages, kept her drugged, and waited for skin grafts. The actually sewed her into a new skin. […] I just need to hang on long enough for my new skin to graft (pp. 124-5).

In this image, where death is considered to be a passage, it is seen as an acceptable opportunity for release from the pain. When it is considered to be annihilation, it is a fundamental injustice and the absolute deprivation of any sense, which makes the experience of pain, loss and death inexpressible, so that self-harm is the substitutive symbolic strategy aimed at dominating the biological causes of pain. The readers of sick-lit novels are faced with a vicious circle, where the reasons for dying by suicide really seem to be latently present in any of the senses in which death is represented.

In sick-lit narration, there is an absence of any form of heroism and eschatology or moral teaching because of the implicit negation of any metaphysical reference which could make sense of the experience of loss and pain. In fact, the global conceptual structure of suicide is portrayed by the intersecting of different factors (Figure 1). The incapability of accepting death and disease is derived from their being both unjustifiable and meaningless, as an expression of negative faith (“misfortune”). Furthermore, death releases the person from the pain and disease which are manifestations of the real and unbearable condition of bodily life, epitomized entirely in a materialistic way.

Discussion

The broad commonality of the characters in the six sick-lit novels is congenial to the identification processes; besides, the copycat effect may be reinforced by the wide structure of justification of suicide in some novels, which underlines the fact that committing suicide releases the person from pain and from difficulty. This fearful trait is linked to the representation of death as a passage and as annihilation but without any reference being made to the transcendental dimension. Since adolescence is the age at which abstract thinking begins, and logical coherence develops, a myriad questions about the sense of death and life emerge and since religious factors help young people manage death-related thoughts in their search for existential meaning (Dezutter, Luyckx, & Hutsebaut, 2009; Gailliot, Stillman, Schmeichel, Maner, & Plant, 2008; Vail et al., 2010), its absence may be dangerous. Besides, since adolescence is a difficult age and one at which self-esteem drops and identification with peers is almost unavoidable, and, since in sick-lit, life and existence are represented in a nihilistic and materialistic way, the intersecting of these features may result in (permitted) access to suicidal ideation when young people face difficulty and defeat. Despite it being possible to derive emulative actions from sick-lit novels, and since it is therefore not a valuable instrument for reaching an awareness of mortality, it is nevertheless impossible to censor it. Whether or not its success results from a need for young people to define death, the only way to reduce the recourse to such products is death education, which would make it possible to include discussion on the content of the sick-lit novels read by the participants.

Conclusion

The desirability of death education courses, aimed at managing youth culture products like sick-lit novels, is confirmed by the denunciation in these creations of the absence of a shared dialogue about death, sufferance and disease.

In the phase of life when young people’s levels of self-esteem are critical and the need to find cultural means to reduce the anguish created by death-related thoughts, teenagers wish to talk about mortality. That is why youth cultural products that explicitly address the topic of death are gaining in popularity. However, young people encounter unskilled adults who seem to live in an endless ‘here and now’ and the questions regarding the meaning of life and death posed by adolescents without the assistance of competent interlocutors go together with self-harm and suicide behaviors. This problem could be partially prevented if existential themes were considered effectively.

The current trend in public health is to ascertain how protective factors can counter risk factors; however, most of the time they are just two sides of the same coin. In this article, we considered the Werther and Papageno effects as two such sides, where the first may be the result of the fear of talking about death-related issues which leaves people suffering in isolation to deal with the copycat influence, whilst in the second, as is the case with Papageno, the person copes well, thanks to intervention by friends. The Papageno effect could be activated through death education at school. The aim is to provide information on death and the appropriate language for understanding the emotions released by the thought, triggering reflections on the meaning of life and strengthening rational and critical thinking abilities, sharing emotions and experiential learning with friends and classmates. A program of this nature may be effective for ensuring good mental health in teenagers as it would allow them to consider death realistically, reducing both anguish and egocentric fantasies. Health-promoting activities may be most effective when they encourage the sharing of narratives by individuals who have refrained from adopting suicidal plans and instead adopted positive coping mechanisms in adverse circumstances.

In activities of this kind, it is possible to manage the themes derived from sick-lit, promoting discussion and raising awareness of the reality of death whilst reflecting on spirituality and transcendence. For example, it would be possible to discuss the “keepingdeath-away spells” and the content described in Before I die in order to valorize life and all possible daily experiences and consider them in parallel with the relationships between the values signifying life and its relationships with afterlife. The opportunity this solution presents is derived from the fact that in sick-lit narration any form of heroism and eschatology or moral teaching—which could make sense of the experience of death, loss and pain—are absent. Death education could open up the debate and illuminate the scenarios human history has created to signify themes of this nature, leading to personal reflection and facilitating comparisons of contemporary commercial products and the symbolism of cultural ones.

As a concluding note, it is important to underline that the complete absence of any objective data on the dangers presented by this kind of youth cultural product poses many problems for those researching suicide prevention. However, a strategic solution is possible, which would include the protocol of a psychological autopsy of an analysis of the books people read before committing suicide.