Psychological Autopsy: Utility for Coroners in Cases of Equivocal Death

1
Psychological AutopsyUtility 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

• gt 13 per 100,000
• 6.5 13 per 100,000
• lt6.5 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 gt10
• Impact of reporting on funding and prevention
  strategies

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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

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Psychological Autopsy as Evidence

• Comprehensive retrospective post-mortem
  investigation which assesses the intention of the
  deceased
• What was the victims intentions relating to
  being dead
• The aim is to assist the coroner in reaching an
  accurate determination

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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

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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

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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)

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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

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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

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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)

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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)

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Factors Considered in Psych AutopsyScott, et
al., 2006

• Lethality
• Probability of individual successfully killing
  self
• Shneidmans 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

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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

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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?

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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?

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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

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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

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Youngs (1992) Guidelines

1. Alcohol history
2. Suicide notes
3. Writing/diaries
4. Books
5. Status of relationships on day prior to death
6. Marital assessments
7. Mood
8. Psychosocial stressors
9. Pre-suicidal behaviours
10. Language
11. Drug history
12. Medical history

1. Pre-death mental state
2. Psychological history
3. Laboratory studies
4. Medical examiners report
5. Motive assessment
6. Reconstruction of events
7. Feelings regarding death, preoccupations,
   fantasies
8. Military history
9. Death history of family
10. Family history
11. Employment history
12. Educational history
13. Familiarity with methods of death
14. Police reports

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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

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Limitations

• Lack of uniformity among coroners
  decision-making processes
• Different legislation across jurisdictions
• Coroners discretion re role/importance/relevance
  of psychological autopsy
• Lack of uniformity among psychologists
  methodologies
• Questionable validity of instrument

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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

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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

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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?

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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
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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?