Psychological Autopsy: Utility for Coroners in Cases of Equivocal Death

Psychological Autopsy:Psychological Autopsy:

Utility for Coroners in Utility for Coroners in Cases of Equivocal DeathCases of Equivocal Death

Dr Tess Crawley Dr Tess Crawley

School of Psychology, University of TasmaniaSchool of Psychology, University of Tasmania

Parts of this paper were presented by Crawley & Robertson (2007) at the International Congress of Psychology & Law

Global Suicide RatesWorld Health Organisation, 2007

> 13 per 100,000

6.5 – 13 per 100,000

<6.5 per 100,000

No data

Available Regional RatesWorld Health Organisation, 2007

0

5

10

15

20

25

30

35

40

45

5-14 15-24

25-34

35-44

45-54

55-64

65-74

75+

Age

Rat

e p

er 1

00,0

00

Australia (2003)

Japan (2004)

New Zealand (2000)

Philippines (1993)

Singapore (2003)

Thailand (2002)

Canada (2002)

USA (2002)

Problems Identified by W.H.O. Lack of awareness of suicide as a major

problem Taboo in many societies to discuss it

openly Reliability of suicide certification and

reporting is an issue in great need of improvement

Reporting Issues Jurisdictional and individual differences in

suicide determinations / guidelines Suicide note

Some require it before suicide can be determined Age of deceased

Some require age >10

Impact of reporting on funding and prevention strategies

How Can We Improve Accuracy? Better understanding of suicide

Training of investigators / coroners Community awareness

Addressing implications of suicide determinations Stigma Insurance issues Individual and community postvention

Better access to decision-making aids for coroners Psychological autopsy

Psychological Autopsy as Evidence

Comprehensive retrospective post-mortem investigation which assesses the intention of the deceased What was the victim’s intentions relating to being

dead

The aim is to assist the coroner in reaching an accurate determination

History of Psychological Autopsy Dr Theodore J Curphey

L.A. County chief medical examiner and coroner 1958 Drug overdoses

Manner of death unclear Approached psychologists from L.A. Suicide Prevention

Centre Edwin Schneidman

Psychologist Co-director of the L.A. Suicide Prevention Centre Coined the term Psychological Autopsy

Psychological Autopsy A process designed to assess a variety of

factors relating to the deceased (Ebert, 1987)

Behaviours Thoughts and feelings Relationships

Originally as a means of resolving equivocal deaths Particularly accident vs suicide in cases of OD

Equivocal Death 5% - 20% of reportable deaths are equivocal

(Scott, Schartz, & Warburton, 2006)(Scott, Schartz, & Warburton, 2006)

Consider a drowning death Cause of death is clear

Asphyxiation due to water in lungs

Manner of death unclear Did victim struggle and drown (accident) Did victim enter pool with intention of drowning (suicide) Was victim held underwater until drowning occurred

(homicide)

Equivocal DeathsEquivocal Deaths

US Drug Abuse Warning Network survey US Drug Abuse Warning Network survey (2003) found ongoing need for (2003) found ongoing need for psychological autopsy in drug deathspsychological autopsy in drug deaths 75% - 90% in some American jurisdictions (e.g., 75% - 90% in some American jurisdictions (e.g.,

Maryland, Utah) unable to be determined suicide Maryland, Utah) unable to be determined suicide / accident/ accident

Psychological AutopsyPsychological Autopsy Most commonly used to assist coroners to

determine if death meets the criteria for suicide Self-inflicted fatal injury with intent to die

Contentious issue of determining Contentious issue of determining intentintent of of deceaseddeceased Drug overdoses – deliberate/accidentalDrug overdoses – deliberate/accidental Autoerotic asphyxia vs suicidal hangingAutoerotic asphyxia vs suicidal hanging ““Death by Cop” Death by Cop” Vehicular suicide vs single vehicle accidentVehicular suicide vs single vehicle accident Russian RouletteRussian Roulette

““Even suicidal people die accidentallyEven suicidal people die accidentally””

Factors Considered in Psych AutopsyFactors Considered in Psych AutopsyScott, et al., 2006Scott, et al., 2006

Cause of deathCause of death How the person died (medically)How the person died (medically)

Mode / Manner of deathMode / Manner of death Circumstances leading to cause of deathCircumstances leading to cause of death

N.A.S.HN.A.S.H

MotiveMotive Why the decedent [might have] committed Why the decedent [might have] committed

suicidesuicide (Caution re “single cause”)(Caution re “single cause”)


IntentIntent Resolve of individual in carrying out own deathResolve of individual in carrying out own death

Majority of suicidal individuals express their intent to trusted Majority of suicidal individuals express their intent to trusted others others

134 consecutive suicides over 1 year period 134 consecutive suicides over 1 year period (Robins, et al., 1959)(Robins, et al., 1959) 69% - verbally communicated intent to numerous people69% - verbally communicated intent to numerous people 75% - expression of intent was recent and atypical75% - expression of intent was recent and atypical 98% - clinically ill prior to suicide98% - clinically ill prior to suicide

Expression of intent unrelated to age, sex, marital status, religion, Expression of intent unrelated to age, sex, marital status, religion, living alone, clinical diagnosis, occupational status, income, living alone, clinical diagnosis, occupational status, income, educationeducation

US data suggests cultural differences in expressions of intent US data suggests cultural differences in expressions of intent Caucasians more likely than Asian-Americans and Pacific Caucasians more likely than Asian-Americans and Pacific

Islanders to disclose suicidal intent Islanders to disclose suicidal intent (Zhang et al., 1998)(Zhang et al., 1998)


LethalityLethality Probability of individual successfully killing selfProbability of individual successfully killing self

Shneidman’s examplesShneidman’s examples:: High lethalityHigh lethality

Unequivocal decision made by individual to kill themselvesUnequivocal decision made by individual to kill themselves Gunshot wound to head at home alone without possibility of rescueGunshot wound to head at home alone without possibility of rescue

Medium lethalityMedium lethality Individual played important role in hastening death via conscious or Individual played important role in hastening death via conscious or

unconscious meansunconscious means Disregarding lifesaving medical treatment, potentially lethal use of drugs/alcohol, Disregarding lifesaving medical treatment, potentially lethal use of drugs/alcohol,

high-risk activities tempting fatehigh-risk activities tempting fate Low lethalityLow lethality

Small but not insignificant role in bringing about deathSmall but not insignificant role in bringing about death Absent lethalityAbsent lethality

No role in own deathNo role in own death Evidence individual wished to liveEvidence individual wished to live


Sane vs Insane SuicideSane vs Insane Suicide Implications for insurersImplications for insurers Insane Suicide (insurer liable?)Insane Suicide (insurer liable?)

Severity of decedent's emotional stateSeverity of decedent's emotional state Relationship of emotional state to appreciation of Relationship of emotional state to appreciation of

consequences of self-harmconsequences of self-harm Power to resist impulsesPower to resist impulses

With growing focus on depression as a With growing focus on depression as a “potentially fatal disease”, this issue may “potentially fatal disease”, this issue may become more prominentbecome more prominent

Guidelines for Determining SuicideGuidelines for Determining Suicide

Evidence of Evidence of self-inflictedself-inflicted cause of death must be cause of death must be apparentapparent

Explicit or implicit evidence that the victim Explicit or implicit evidence that the victim understoodunderstood their actions to be potentially lethal their actions to be potentially lethal

Indicators of Indicators of intentintent to die should also be apparent to die should also be apparent

How do we access these internal / psychological How do we access these internal / psychological processes post-mortem?processes post-mortem?

Indicators of Intent to Die Indicators of Intent to Die (Litman, 1989)(Litman, 1989)

Special preparations for deathSpecial preparations for death Expressions of farewell or desire to dieExpressions of farewell or desire to die Expressions of hopelessnessExpressions of hopelessness Great emotional or physical pain or distressGreat emotional or physical pain or distress Precautions to avoid rescuePrecautions to avoid rescue Previous suicide attempts or threatsPrevious suicide attempts or threats Recent stressful events or lossesRecent stressful events or losses Serious depression or mental disorderSerious depression or mental disorder

But … do these indicate INTENTBut … do these indicate INTENT at the time of death at the time of death, or simply pre-, or simply pre-mortem suicidality?mortem suicidality? How do we differentiate?How do we differentiate?

Gathering Evidence Archival data

Letters, bank account balances, medical records, personal writings, work performance reviews or school reports

Interviews Family, friends, colleagues Witnesses Relevant others (e.g., treating professionals)

Scene information Photos, other evidence

Physical evidence reports

Recommendations Mental health professionals conducting

psychological autopsies need to interpret all available information in light of Diagnosable psychological condition prior to death Suicidality prior to death Intent to die

Young (1992) recommends 26 elements to provide structure to psychological autopsy

Young’s (1992) Guidelines1. Alcohol history2. Suicide notes3. Writing/diaries4. Books5. Status of relationships on day prior

to death6. Marital assessments7. Mood8. Psychosocial stressors9. Pre-suicidal behaviours10. Language11. Drug history12. Medical history

13. Pre-death mental state14. Psychological history15. Laboratory studies16. Medical examiner’s report17. Motive assessment18. Reconstruction of events19. Feelings regarding death,

preoccupations, fantasies20. Military history21. Death history of family22. Family history23. Employment history24. Educational history25. Familiarity with methods of death26. Police reports

Cautions – Watch for internal biases Age of victim?

E.g., Crawley & Bell (2007)

Social stigma of suicide? Impact of suicide verdict on family?

Implications for evidence gathering and validity of interview data

Implications for coroners in reaching decisions

Limitations Lack of uniformity among coroner’s

decision-making processes Different legislation across jurisdictions Coroner’s discretion re

role/importance/relevance of psychological autopsy

Lack of uniformity among psychologists’ methodologies

Questionable validity of instrument

Shortcomings of Psychological AutopsyShortcomings of Psychological Autopsy

“… “… a relatively unstructured clinical technique in a relatively unstructured clinical technique in which a mental health professional attempts to which a mental health professional attempts to discern the mental state of a deceased person at discern the mental state of a deceased person at some previous time”some previous time” Ogloff & Otto (1993)Ogloff & Otto (1993)

No standardised techniques No standardised techniques Issues of content validity and reliabilityIssues of content validity and reliability Development and practical utility of actuarial Development and practical utility of actuarial

methods?methods? E.g., E.g., Jobes, et al. (1991)Jobes, et al. (1991) - ECDS - ECDS

ShortcomingsShortcomings

Different institutions / jurisdictions have different Different institutions / jurisdictions have different approaches to psychological autopsy approaches to psychological autopsy Equivocal Death AnalysisEquivocal Death Analysis

FBI / Law Enforcement investigative techniqueFBI / Law Enforcement investigative technique Psychological AutopsyPsychological Autopsy

Psychological / Psychiatric investigationPsychological / Psychiatric investigation

Admissibility of evidence?Admissibility of evidence? Gilfoyle caseGilfoyle case

Court ruled psychological autopsy evidence inadmissibleCourt ruled psychological autopsy evidence inadmissible “… “… unstructured and speculative conclusions are not the unstructured and speculative conclusions are not the

stuff of which admissible expert evidence is made”stuff of which admissible expert evidence is made”

Question of ValidityQuestion of Validity

The question of validity is warrantedThe question of validity is warranted But if focus is on utility of psychological autopsy But if focus is on utility of psychological autopsy

as a as a tool …tool … Rather than source of an “Rather than source of an “answeranswer” …” …

Does it add something otherwise lacking in the Does it add something otherwise lacking in the pursuit of justice?pursuit of justice?

Would psychological autopsy be more valid as an Would psychological autopsy be more valid as an aid to the aid to the investigationinvestigation of equivocal deaths? of equivocal deaths?

Complementary FrameworksComplementary Frameworks- Psychology & Law -- Psychology & Law -

Carson (2006)Carson (2006) Facts vs EvidenceFacts vs Evidence Approaches to information gatheringApproaches to information gathering

Psychological approach – Big Picture?Psychological approach – Big Picture? Legal approach – Admissible Evidence?Legal approach – Admissible Evidence?FACT

FACTFACT

FACT

FACT

FACT

FACT

FACTFACT

FACT

FACT

FACT

FACTFACT




FACTFACT

FACT

FACT

FACT

FACT

FACTFACT

FACT

FACT

FACT

FACTFACT




EVIDENCEEVIDENCE

EVIDENCE

EVIDENCE

EVIDENCE

FACT

FACTFACT

FACT

FACT

EVIDENCE

FACTFACT


Psychological autopsy aids in big picture Psychological autopsy aids in big picture developmentdevelopment Perhaps more scope in coronial than homicide Perhaps more scope in coronial than homicide

investigationsinvestigations But …But …

May justify homicide investigators’ pursuit of May justify homicide investigators’ pursuit of additional [admissible] evidenceadditional [admissible] evidence

Psychological autopsy to develop hypotheses for Psychological autopsy to develop hypotheses for testing?testing? Hypotheses tested by admissible evidence?Hypotheses tested by admissible evidence?

Documents

Psychological Autopsy: Utility for Coroners in Cases of Equivocal Death