This article explains Malcolm Gladwell's model for how social epidemics spread, and
reviews his examples for suicide as a social epidemic [1]. Building on this,
we provide a different perspective on how suicide spreads, and how
it can be prevented.
Suicide is often viewed as an epidemic. A
social epidemic, infecting with
ideas rather than with biological organisms. Such epidemics are not necessarily
negative: it depends on the idea which is being transmitted.
It may seem strange to talk about suicide as an epidemic. The idea or message which is
transmitted is not clear. Furthermore, whether a person commits suicide appears to
be related more to their physical, social and psychological situation, rather than
to something which was communicated to them. One cannot become "infected" with
such a situation, as we would expect from an epidemic. However, in Micronesia,
a suicide epidemic is exactly what happened.
Before the early 1960's suicide on the Islands of Micronesia was a rare incident, but by the
end of the 1980s the suicide rate in Micronesia was the highest in the world: more than
seven times higher than the United States rate at the time. Suicides in
Micronesia were typically done by males, in their late teens, and triggered by a domestic
event, such as a dispute with family or a girlfriend. The prevalent suicide method was
hanging, where the rope was anchored to a low branch or doorknob. Leaning forward
caused the weight around the neck to cut the flow of blood to the brain.
The increase in suicide incidents started from a single incident. In 1966,
a charismatic son of one of the Island's wealthiest families committed suicide. Twenty-five
more suicide occurred in the next twelve years, most of them similar in nature to
this first suicide.
According to anthropologist Donald Rubinstein, the culture among adolescent
Micronesians transformed such that suicide became familiar and its lethality
was trivialized [4].
Under some circumstances, one act of suicide can lead to other suicides.
Sociologist David Phillips has conducted a number of studies
about this phenomena. He found an increase in suicide incidents
after reports about suicide appeared in prominent newspapers [5].
Furthermore, the suicide methods used, the age of those committing
suicide, and their circumstances, as reported by the media, evoked
similar suicides in their wake.
He also found that the number of traffic accidents increased
after suicide stories appeared in the media[6]. From this Phillips
concluded that one of the ways people commit suicide is by
deliberately crashing their cars.
An estimated 1.6% to 5.0% of vehicular fatalities are believed to be
suicides that escape detection [2][3].
Phillips' conclusion was that what was being communicated by the
media reports is a "permission" to engage in a deviant act,
similar to a pedestrian waiting at a red traffic light, when some
other pedestrian crosses before the light turns green. In such a
case, it is much more likely that the first person will decide to
cross as well.
An epidemic is a widespread outbreak of an infectious disease.
Infection starts from a small number of people and spreads
throughout a community affecting the infected individuals.
Social epidemics spread ideas instead of viruses and germs, ideas
which can potentially affect the "infected" person. The idea could
be anything. What shoe to buy, what movie to watch, what stock to
invest in, or what diet to take - all can be spread as
a social epidemic.
Suppose that suicide really is a social epidemic.
Is it possible to stop or even reverse it? The rest of this article
will be devoted to this question, but first we need to
understand how social epidemics start, spread and persist.
Social epidemics occur as a result of[1]:
- how the message is spread
- the content of the message
- the context
These factors determine whether a message will become a social epidemic,
since they allow a message to start from a small number of people,
and spread out to many. Special
people play a role in
spreading epidemics: Connectors,
Mavens, and Salesman.
Mavens are people who have a deep understanding in a subject. It
could be anything, from Economics to Fashion. Mavens are not
only knowledgeable, but are interested to share their knowledge
with others.
Connectors not only know many people, but know many people from
different social circles. Whereas most people spend most of their
time nurturing strong ties with their close friends, connectors
maintain weak ties with many people, and are thus able to spread
their message to many. Returning to Viral epidemics, Gaetan Dugas
was a Connector for the AIDS virus. He was a French-Canadian flight
attendant who claimed to have had 2500 sexual partners in North
America. Forty of the earliest cases of AIDS in California and
New York were linked to Dugas.
Salesman are able to adapt a message in order to "sell" it to
people. A fashion Maven may start a trend, yet it may be too
extreme to be followed by the masses. A Salesman would be able
to see the essence behind the trend, adapt it, and tone
it down to make it appeal to a larger audience.
It is these three groups of people that can make a message
contagious. Mavens start a trend, Connectors spread it, and
Salesman sell it.
Of course the
content of the message is crucial. If the message
is not memorable then it will not be passed on. If the message
does not cause the person to act accordingly (e.g., adopting
a specific fashion) then the person cannot be considered "infected".
For a message to drive a social epidemic, it has to be "sticky".
It has to be memorable, and evoke personal action. Furthermore, the longer the
message sticks, the longer it can be passed to others.
Finally, the larger
context affects the ability of messages to
become epidemics.
If suicide is indeed a social epidemic perhaps we can
find the factors which cause it: how
it is communicated, how sticky it is, and what context
allows it to thrive.
Current prevention policy aims at all stages of possible infection.
Media reports are self-censored to hold back information which may
"infect" others. To counter the message of "giving permission" to
commit suicide, authorities send a message that suicide is wrong,
it hurts others, and can be easily "treated".
Preventing access to suicide methods changes the
context of suicide.
Viewing suicide as a social epidemic
suggests a more focused approach for suicide prevention. If we can
detect the critical stages which fuel an epidemic, we can focus
only on those in order to stop it. But what are the critical stages of the
suicide epidemic?
Suiciders rarely communicate their intentions to each other. So if we are
to talk about how suicide spreads from a small number of people, it spreads
not by communication between people, but by the act itself, as in Micronesia, or through mass media.
Although the media has been instructed
to report less about suicide, it cannot be avoided completely, since there are suicide
cases of clear public interest (e.g., by politicians or figures in popular culture ).
On top of this, personal knowledge of suicide cases can continue to spread the
message, regardless of mass media. So this kind of transmission cannot be stopped.
The message of "giving permission" to commit suicide is difficult to counter,
since there are no real arguments for why suicide should not be permissible, or
why it is necessarily bad. These are still debated in philosophical circles.
The common arguments against suicide are easily undermined. It is difficult to
make suicide less "sticky".
What is left is to change the context.
New York City in the 1980s was at one of the worst crime epidemics
in its history. Crime was on the streets and in the subway system from petty
details like graffiti to violence and murder. Crime, as an epidemic, is a bit like
suicide, since we tend to attribute these to the psychology and personality of
the person - who commits an act under great personal danger - rather than an
epidemic. But the crime epidemic was stopped - it was stopped by changing
the context.
According to the broken window theory[7], crime is a result of disorder. In a place where windows are left broken, people will assume that nobody cares, resulting in more broken glass. Inaction encourages more serious crimes, since it becomes obvious that even small crimes are not prevented by authorities, thus leading to anarchy. In this example, the context of broken windows serves as
the means of contagion, instead of a network of mavens, connectors, and salesman.
But what is the relevant context which fuels suicide epidemics? One way to find out would be
to follow the route of the message which is communicated, by looking at media reports.
These convey not only the way media portrays suicide, but the way society and various
authorities perceive it. How does a suicidal person relate to
the kind of reports prevalent in current media?
Although media reports may communicate that suicide is permissible, the media
are aware of this problem, so reports are balanced with other messages. The pain
of family and friends is frequently the main story, showing the damage suicide causes.
Readers are encouraged to look for signs of suicidal tendencies in others, and people who are suicidal are encouraged
to seek help.
However, in many reports about suicide, the pain of the suicider is trivialized and deemed to not justify suicide.
Emphasis is put instead on how the person was smart, nice, good looking, and appeared
not to be in any pain. Such articles, usually quoting relatives, continue to portray
the suicide as unjustified, and perhaps impulsive. The trivialization of the suicider's pain
creates alienation in suicidal readers who see how pain is dismissed.
The contrast between the personal experience of pain, and how it is portrayed
almost as an insignificant factor causes disbelief in authorities to properly understand
and address it.
This is even more evident in media reports about cases of euthanasia. In such cases,
people with terminal diseases undergoing severe pain have to fight legal battles in
order to end their lives. Such reports typically acknowledge pain to a greater degree,
however, the message to the reader is similar: authorities will not take pain into
serious consideration. This is where the broken windows theory resurfaces for suicide.
If in even such obvious cases, authorities act in such cruelty, refusing to regulate
suicide even in the most extreme situations, dragging individuals in great pain through
legal proceedings, then what are other people to expect with regard to treatment for their
own suicidal desires?
Crime in New York declined by first tackling graffiti in the subway. This is hardly a
crime, but New York officials, acting under the broken windows theory, decided to start by fixing
the broken windows instead of attacking the larger problem of crime. Once they managed
to change the context, they moved on to more serious issues. This started in the
subway - after persisting in the battle against graffiti, they moved on to catch petty
crimes - like people avoiding the entrance fair to the subway by skipping over the
turnstiles. This may seem petty, however, such crimes were frequent and highly visible,
contributing to the existing context of broken windows.
In addition police also managed to capture many more serious
offenders, just by screening those who cheated on the subway fair. Subsequently, crime in
the subway declined dramatically, and the same methods, exercised in the city,
caused a similar decline as well.
Police in New York were active during the epidemic, trying to prevent crime, but
what changed the situation was the initial
focus on context, which managed to reverse the crime epidemic. Broken windows is
an apt analogy to a context which is hospitable to a crime epidemic, but in
suicide epidemics something else is broken: trust.
Trust in the willingness and ability of society and mental health practitioners
to acknowledge the possibility and significance of severe pain - physical or mental, to acknowledge
the possibility that although "there is always hope" the chances of improvement may in fact be low,
to treat suicidal people with dignity, and to respect their personal liberty and moral rights.
Yet trust is crucial for preventing tragic cases of suicide.
Media reports frequently quote family of a person who committed suicide, claiming that
there were no signs of any intention to commit suicide. Hiding intentions is due
to lack of trust in family and psychologists that one's desire to exit be taken
seriously, instead of being twisted as a "cry for help", to be prevented at all costs. Consider that
had trust been established, communication between a suicidal person and his family
would allow to surface issues which could be resolved possibly by therapy. Lack of trust
cuts the communication lines, isolating and alienating the suicidal. Without the
possibility to consult with somebody which can be trusted, bad decisions are more likely,
increasing the suicide rate.
Many who oppose Euthanasia use the slippery slope argument as a deterrent. Their claim being
that if Euthanasia is legalized, additional cases of suicide would be legalized, and we
would not be able to draw the line. It is ironic to consider that this very resistance
of Euthanasia legislation is fueling a suicide epidemic, perhaps triggering more suicides
than what we would have had, had Euthanasia been legalized.
We should follow the footsteps of the NYC crime fighters. Instead of
targeting the most severe cases, the tragic suicides, address
obvious cases first. To establish trust, start treating the most obvious
cases with decency and compassion. This will surface a new context of listening and trust.
The suicidal will feel that they are listened to, that their problems can be addressed
by authorities and by society; and the tragic suicide cases will be prevented.
Changing the context means that we, as a society, need to start with the obvious cases,
press hard to advance euthanasia legislation, and even allow suicide for cases of severe
mental pain. Only after establishing trust can the rest of the effort
for suicide prevention have any real impact.
Thanks to hrafn and colombo for commenting on drafts of this article.
[1] Malcolm Gladwell, The Tipping Point: How Little Things Can Make
a Big Difference, 2000
[2] Peck DL, Warner K. "Accident or suicide? Single-vehicle car
accidents and the intent hypothesis". Adolescence. 1995. 30:463-472;
[3] Schmidt CW, et. al. "Suicide by vehicular crash". Am J Psych. 1977;
134:175-178 .
[4] Donald H. Rubenstein, "Epidemic Suicide Among Micronesian Adolescents",
Social Science and Medicine, 1983, vol. 17, p. 664.
Quoted in [1], p. 216.
[5] D.P. Phillips, "The influence of Suggestion on Suicide: Substantive and Theoretical Implications
of the Werther Effect", American Sociological Review, 1974, vol. 39, pp. 340-354.
Quoted in [1], p. 222.
[6] David P. Phillips, "Suicide, Motor Vehicle Fatalities, and the Mass Media: Evidence toward a Theory of Suggestion", American Journal of Sociology, 1979, vol. 84, no. 5, pp. 1150-1174.
Quoted in [1], p. 222.
[7] George L. Kelling and Catherine M. Coles, Fixing Broken Windows, 1996.
Quoted in [1], p. 141.
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EverDawn
