Psychological Autopsy: Utility for Coroners in Cases of Equivocal Death

1. Psychological Autopsy:Utility for Coroners in Cases of Equivocal Death Dr Tess Crawley School of Psychology, University of Tasmania Parts of this paper were presented by Crawley & Robertson (2007) at the International Congress of Psychology & Law

2. Global Suicide RatesWorld Health Organisation, 2007 • > 13 per 100,000 • 6.5 – 13 per 100,000 • <6.5 per 100,000 • No data

3. Available Regional RatesWorld Health Organisation, 2007

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Equivocal Death • 5% - 20% of reportable deaths are equivocal • (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)

11. Equivocal Deaths US Drug Abuse Warning Network survey (2003) found ongoing need for psychological autopsy in drug deaths 75% - 90% in some American jurisdictions (e.g., Maryland, Utah) unable to be determined suicide / accident

12. Psychological 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 intent of deceased Drug overdoses – deliberate/accidental Autoerotic asphyxia vs suicidal hanging “Death by Cop” Vehicular suicide vs single vehicle accident Russian Roulette “Even suicidal people die accidentally”

13. Factors Considered in Psych AutopsyScott, et al., 2006 Cause of death How the person died (medically) Mode / Manner of death Circumstances leading to cause of death N.A.S.H Motive Why the decedent [might have] committed suicide (Caution re “single cause”)

14. Factors Considered in Psych AutopsyScott, et al., 2006 Intent Resolve of individual in carrying out own death Majority of suicidal individuals express their intent to trusted others 134 consecutive suicides over 1 year period (Robins, et al., 1959) 69% - verbally communicated intent to numerous people 75% - expression of intent was recent and atypical 98% - clinically ill prior to suicide Expression of intent unrelated to age, sex, marital status, religion, living alone, clinical diagnosis, occupational status, income, education US data suggests cultural differences in expressions of intent Caucasians more likely than Asian-Americans and Pacific Islanders to disclose suicidal intent (Zhang et al., 1998)

15. Factors Considered in Psych AutopsyScott, et al., 2006 Lethality Probability of individual successfully killing self Shneidman’s examples: High lethality Unequivocal decision made by individual to kill themselves Gunshot wound to head at home alone without possibility of rescue Medium lethality Individual played important role in hastening death via conscious or unconscious means Disregarding lifesaving medical treatment, potentially lethal use of drugs/alcohol, high-risk activities tempting fate Low lethality Small but not insignificant role in bringing about death Absent lethality No role in own death Evidence individual wished to live

16. Factors Considered in Psych AutopsyScott, et al., 2006 Sane vs Insane Suicide Implications for insurers Insane Suicide (insurer liable?) Severity of decedent's emotional state Relationship of emotional state to appreciation of consequences of self-harm Power to resist impulses With growing focus on depression as a “potentially fatal disease”, this issue may become more prominent

17. Guidelines for Determining Suicide Evidence of self-inflicted cause of death must be apparent Explicit or implicit evidence that the victim understood their actions to be potentially lethal Indicators of intent to die should also be apparent How do we access these internal / psychological processes post-mortem?

18. Indicators of Intent to Die (Litman, 1989) Special preparations for death Expressions of farewell or desire to die Expressions of hopelessness Great emotional or physical pain or distress Precautions to avoid rescue Previous suicide attempts or threats Recent stressful events or losses Serious depression or mental disorder But … do these indicate INTENT at the time of death, or simply pre-mortem suicidality? How do we differentiate?

19. 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

20. 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

21. Alcohol history Suicide notes Writing/diaries Books Status of relationships on day prior to death Marital assessments Mood Psychosocial stressors Pre-suicidal behaviours Language Drug history Medical history Pre-death mental state Psychological history Laboratory studies Medical examiner’s report Motive assessment Reconstruction of events Feelings regarding death, preoccupations, fantasies Military history Death history of family Family history Employment history Educational history Familiarity with methods of death Police reports Young’s (1992) Guidelines

22. 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

23. 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

24. Shortcomings of Psychological Autopsy “… a relatively unstructured clinical technique in which a mental health professional attempts to discern the mental state of a deceased person at some previous time” Ogloff & Otto (1993) No standardised techniques Issues of content validity and reliability Development and practical utility of actuarial methods? E.g., Jobes, et al. (1991) - ECDS

25. Shortcomings Different institutions / jurisdictions have different approaches to psychological autopsy Equivocal Death Analysis FBI / Law Enforcement investigative technique Psychological Autopsy Psychological / Psychiatric investigation Admissibility of evidence? Gilfoyle case Court ruled psychological autopsy evidence inadmissible “… unstructured and speculative conclusions are not the stuff of which admissible expert evidence is made”

26. Question of Validity The question of validity is warranted But if focus is on utility of psychological autopsy as a tool … Rather than source of an “answer” … Does it add something otherwise lacking in the pursuit of justice? Would psychological autopsy be more valid as an aid to the investigation of equivocal deaths?

27. Complementary Frameworks- Psychology & Law - Carson (2006) Facts vs Evidence Approaches to information gathering Psychological approach – Big Picture? Legal approach – Admissible Evidence? FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT

28. Complementary Frameworks- Psychology & Law - Carson (2006) Facts vs Evidence Approaches to information gathering Psychological approach – Big Picture? Legal approach – Admissible Evidence? FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT FACT

29. Complementary Frameworks- Psychology & Law - Carson (2006) Facts vs Evidence Approaches to information gathering Psychological approach – Big Picture? Legal approach – Admissible Evidence? FACT FACT FACT FACT EVIDENCE EVIDENCE EVIDENCE FACT EVIDENCE EVIDENCE EVIDENCE FACT FACT FACT

30. Complementary Frameworks- Psychology & Law - Psychological autopsy aids in big picture development Perhaps more scope in coronial than homicide investigations But … May justify homicide investigators’ pursuit of additional [admissible] evidence Psychological autopsy to develop hypotheses for testing? Hypotheses tested by admissible evidence?