Psychological Autopsy – A Way to Revealing the Enigma of Equivocal Death

What is Psychological Autopsy

In simple words, a psychological autopsy (PA) is an exploration of the death of a person by reconstructing what he/she thought, felt, and did before death, based on information gleaned from suicide notes, police, medical and coroner’s records, and interviews with families, friends, and others [4]. In the Operational domain, PAs are used to support death investigations and to facilitate case resolution. It is a postmortem, postdictive psychological investigative process by which a person’s circumstances and psychological state of mind at the time leading up to his/her death are reconstructed, in order to help determine the manner of death, whether suicide, homicide, or accidental. PA is most useful when the evidence of the deceased person’s intention is ambiguous. They entail reviewing medical and police reports, photos, drawings, and records; interviewing witnesses and people who knew the victim; visiting the scene; and using knowledge of personality theory, suicidology, and psychology in general, to form an integrated picture of the subject’s personality characteristics and state of mind, and the circumstances leading up to his/her death.

Purpose of Psychological Autopsy

A psychological autopsy is conducted due to four fundamental reasons. The principal goal is to determine the mode of death. Mode of death differs from the mean of death. The mean of death is how someone died (i.e. head trauma, gunshot injury, heart attack, or suffocation, etc.). The mode of death is to find out that whether the death occurred from natural causes, an accident, a suicide, or a homicide. The other purpose is to find out that why the deceased died at a particular time, date and place (i.e., was the deceased present in the wrong place at the wrong time, was this date an anniversary of a loved one’s death, was being in that particular area at this time a part of the deceased regular routine, etc.). Another purpose is to decide the motivation for the death. In this context, the motivation for death includes intentional (on purpose), sub-intentional (an act was meant to harm but not kill), and unintentional (an accident). The last reason for a PA is for the restorative esteem it can convey to the survivors of the deceased. The PA can offer answers that may help the family to comprehend what actually happened and proceed onward, particularly on account of a homicide. In the present review article the authors have briefly discussed the psychological autopsy, how it can be used to examine equivocal deaths chiefly suicides, methodology, applications in both civil and criminal prosecutions, status of PA in India, ethical issues along with admissibility in court, standardization in conduction of PA.

Methodology

How is a psychological autopsy led? A review of the literature indicates that PA has developed a few iterations to produce standard guidelines for leading PA, which mirrors the Shneidman 16 criteria methodology [5]. These criteria included:

1. Identifying information of victim’s age, sexual orientation, marital status, occupation status.
2. Details of the demise.
3. A brief outline of the victim’s history and past suicide attempts.
4. Psychiatric history of the family (i.e., suicides and state of mind issues).
5. Personality and lifestyle characteristics of victim’s
6. The victim’s reaction towards stress and emotional disturbances and periods of disequilibrium.
7. Recent Stressors (from the last few days to the last 12 months), pressures, tensions, or anticipation of trouble.

8. The role of alcohol or drugs in (a) overall lifestyle of the victim, and (b) his death. 9. Victim’s interpersonal social relationships (including those with physicians/mental health clinicians). 10. Fantasies, dreams, thoughts, premonitions, or fear of victim relating to death, accident, or suicide. 11. Brief Changes in the victim’s normal schedule, and habits just before death. 12. Life side information of the victim (i.e., triumphs and plans). 13. Lethality Rate of suicide method. 14. The reaction of informants to victim’s death. 15. Assessment of suicidal intention i.e., the role of the victim in his own demise. 16. Comments, any special feature.

Conduction of a Psychological Autopsy

Numerous circumstances may call for mental post- mortem examinations. A psychological autopsy usually is requested in civil litigation cases when an inquiry emerges with respect to whether benefits are to be granted to the deceased’s estate or to the surviving recipients. In criminal cases PA have been utilized to assess the mental condition of the deceased to get to the culpability of a criminal respondent. At times of suspected suicide, families may ask for a coroner/investigating officer to start a mental post-mortem examination. The police may sometimes ask about the methodology to enable them to decide if an evident suicide was really a murder in camouflage. The case of US v. St. Jean speaks to a criminal case in which a PA was asked for, to help decide if a man accused of murdering his wife was falsely accused, in the event his wife’s death was rather a suicide. In this case, Lieutenant St. Jean called the police for reporting the suicide of his wife, after allegedly discovered his wife dead in the bathroom with a handgun in the close by sink. Due to inconsistent statements given by husband of the deceased for having gun, the prosecution requested Dr. William Grant to conduct a psychological autopsy of the deceased wife. At trial, Dr. Grant testified that the victim did not fit the profile of a suicidal individual. St. Jean was convicted, and although he challenged the admittance of the psychological autopsy into evidence, the appellate court upheld the conviction [6]. Whatever methodology is chosen, each psychological autopsy includes gathering and investigating all relevant information on the deceased [7]. Cooper in her blog writes about the whole process of conducting a psychological autopsy in step by step. When conducting a psychological autopsy, a psychologist should always start with information from the crime scene. This information can be collected in the police report. As the individual of intrigue (i.e. the deceased) is not available in the psychological autopsy, so amid the investigation detective must entirely depend on collateral or “third party” sources of information. These collateral sources incorporates any records deserted by the deceased (letters, e-mails, journal entries, cell phone records, audio or video recordings, bank accounts, student or employee records) and information about the individual gathered from interviews with friends, family members, or colleagues who were in contact with the deceased prior to his or her death. Within the police reports the psychologist should also look for information such as relationships, support systems, and occupation. A crime scene analysis should be conducted with the photos and evidence collected at the crime scene. A thorough reconstruction of the crime scene can be very useful in a psychological autopsy. The next step would be to review the physical autopsy and toxicology reports. This could offer insight into the deceased’s state of mind at the time of death. https://criminologyjust.blogspot.in/search/label/Tabeth a%20Cooper#.WXiOyIiGNPY [8]. Keeping in mind the end goal to gather the information there are two noteworthy sources of data includes interviews and review of collateral records. Interviews: Generally, interviews are done with individuals who have a close personal relationship with the victim (parents, spouses, siblings, adolescent children and friends) but not necessarily a relative. The essential objective of conducting collateral interviews to acquire top to the bottom comprehension of the decedent’s everyday life style patterns, personality, behavioural patterns (response towards stress, adaptability, abrupt changes in habits or routine just before death), family factors, alcohol and drugs abuse history, conceivable intentions in past suicide endeavours. It must be remembered that family members and close friends may have feelings of guilt, anger, or shame, which may result in biased reporting. Usually for interview open-ended question are asked which are designed to encourage a full, meaningful answer using the subject's own knowledge and/or feelings. However, these individuals commonly know the most about the decedent's history and can give particular perceptions and chronological conditions pertaining to events and circumstances occurring shortly before his/her demise. The type of questions which should usually be asked during a PA can be found out at http://www.experts.com/Articles/Equivocal-Death- Questionnaire-Investigators-Experts-By-Dan-Vogel [9]. Collateral Records: Depending on the nature of the case and the concerned issue, collateral records that might be pertinent include:

1. Socio-economic factors (education, social status, employment history, and occupational status at the time of the death).
2. Alcohol and drug abuse
3. Medical status and history
4. Mental status and history
5. Physical and psychological stressors
6. Quality of interpersonal relationships, Behavioural, verbal and written communications.
7. Legal history and records

Assisting Medical Investigator

Equivocal deaths are those in which manner of death is questionable or, conditions surrounding the death are generally unclear. The following are typical equivocal death scenarios: a) Drug-related deaths b) Autoerotic asphyxia c) Self-induced asphyxia (e.g., the “choking game”) d) Vehicular deaths e) Russian roulette- the practice of loading a bullet into one chamber of a revolver, spinning the cylinder, and then pulling the trigger while pointing the gun at one's own head f) “Suicide by cop” g) Staged death scenes Other than discovering the way of death, the point of equivocal death investigation is to shape an informed conclusion whether crime, suicide, or a mischance in all likelihood happened.

Insurance Claims

Life insurance payments following a person’s death represent is a civil litigation case for the legal challenge. Numerous life insurance policies contain a suicide provision that denies installment of advantages if passing outcomes from suicide inside a predefined day and age (more often than not 2 years) and without deliberation (insane suicide) [10].

Criminal Cases

In homicidal cases, the victim’s background must be checked to better understand how and why they were targeted by the perpetrator. There are valuable insights that should not be overlooked in any death case through the eyes and thoughts of the deceased. The PA may be used to establish whether the deceased was likely to have committed suicide, or whether the death should be viewed as a homicide [11].

Worker’s Compensation and Product Liability Cases

Worker’s compensation cases generally involve allegations that the decedent’s employer was by one means or another responsible for his suicide. Similarly, product liability cases alleged that the decedent’s use of a specific item (e.g., medication) made him commit suicide [12].

Medical Malpractice

In psychiatric malpractice cases including suicide, the offended party must demonstrate that the doctor’s negligence was a proximate reason of the victim’s suicide [12].

Previous Research on Psychological Autopsies of Suicide Victims

“Suicide is not chosen; it happens when pain exceeds resources for coping with pain. It is not a wish, it's a cry for help.” India alone accounts for approximately 30 percent of the world’s suicide deaths. In 2013 according to the website, Humanosphere, suicide was the most claimed reason for the deaths of more than a quarter of a million Indians. That’s five times greater than all global deaths due to war and natural disasters combined http://www.humanosphere.org/global- health/2016/08/suicide-deaths-india-increasing- alarming-rate/. [13]. Previous PA studies on suicide victims showed that in most of the cases the deceased could be diagnosed as having had a mental disorder or alcohol or drug problems. In psychological problems, especially mood disorders and depression, are given as the most relevant antecedent of suicide. In these PA studies often a causal link between mental illness and suicide is implied. It has been established through such PA studies, that on an average more than 90% who commit suicide had a retrospectively diagnosable mental disorder. But in recent years these findings have been contradicted by several studies. Hjelmeland and associate [14] questioned the validity of these PA studies and further added that these studies have serious methodological weaknesses. Freuchen, et al. [15] conducted study on adolescents and children under 15 years who had committed suicide or died in accidents in Norway from 1993 to 2004 (n = 84). The study revealed that victims showed less apparent warning signs in comparison of adults. They also found that 20% of suicide victims had diagnosable mental disorders, mostly anxiety disorder, depression, Asperger syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating), and conduct disorder, alone or in combinations. Broken relationships and interpersonal losses leaving a marked emotional footprint were experienced by 50% of the suicide victims in their study. Over 40% of victims had experienced suicide previously, either in the family or in the local community. . Different reviews centered upon the availability of firearms in the home of suicide completers, traumatic events in person’s lives, and other psychological and social factors. Worldwide it has been seen that 15- 35 age- group is at highest risk for suicide followed by the 50 plus age group and this is a statistic that is applicable to India also http://www.aasra.info/aboutus.html. [16]. Amid the exhaustive examination of any suicide, as a rule, it is perceived that alongside current psychiatric and physical sickness, identity unsettling influence, organic elements, family issues, and psycho-social stressors etc., there are other past variables are additionally responsible for instigating self-destructive aims. Presently, PA is regarded as the most direct, as well as a reliable and valid, method to study the relationship between various explanatory factors and suicide [14].

Kizza, et al. [17] showed a different scenario of the cause of suicide in Ugandan women. They found that the women all had been through traumatic experiences attributable to the protracted war/conflict between the rebel groups and Ugandan Government armed forces. Nevertheless, the decision of self-inflicted death seemed to have been due to a combination of unpleasant experiences/events that prevailed within the last 3 months prior to the suicide. They also found those changes in the traditional gender roles, men's quest for their lost masculinity, and women's attempt to fight for their rights that were perceived as a cultural transgression contributed to the women's suicides. Infidelity and husbands marrying second wives instigated a lot of bitterness and unrest in the homes of these women. In an attempt to influence change, these women could either complain bitterly or refuse to carry out their marital obligations. Chachamovich, et al. [18] investigated the 120 cases of suicide by Inuit that occurred in Nunavut between 2003- 2006. The psychological autopsy approach was carried out and a total of 498 individuals were directly interviewed, and medical and correctional charts were also reviewed. They found that the psychological autopsy method was well received by participants as they appreciated the opportunity to discuss the loss of a family member or friend by suicide. During interviews, informants readily identified symptoms of psychiatric disorders, although culture-specific rather than clinical explanations were sometimes provided Populations. Puranik and colleagues [19] investigated a case where investigating agency claiming the death of a girl to be a case of suicide while the family of deceased claimed it to be a case of homicide. They concluded that the possibility of homicide cannot be ruled out completely. Padubidri, et al. [20] conducted a psychological autopsy of 29 years old medical graduate who was found in a hotel room hanging from the metallic hook with multiple ligatures turns around his neck. Initially, the investigating officer established a doubt of homicide by seeing the number of loops around his neck. It is only after postmortem examination and the psychological autopsy of the deceased relatives, the manner was finally concluded as suicidal in nature. All these studies indicate that PA led by experienced suicidologists, can help the investigation agencies, judge and jury figure out which variables were most related to the suicide/homicide/accident specific case.

Status of Psychological Autopsy in India and Western Countries

The majority of PA studies are attempted to examine the suicide risk factors and its prevention. These studies have been conducted in developed as well as in developing countries as North America, Europe, Australia, New Zeeland, Israel, Taiwan, China and India [21]. There is a long list of cases which shook the India and as a whole and to date, their perpetrators have not been caught. Rajiv Dixit murder case, Aarushi Murder case, Sunanda Pushkar case, Rohit Vamula case, are some of the cases which agitated the general public and the truth behind these deaths are still to be revealed. In western countries the PA is performed as per the need of the case. In many courts of United State opinions from professional psychologists, about the mental condition of the deceased, have been drawn upon in the United States, United Kingdom, Australia and strongly influenced the judgements [22]. In contrast, if we consider the Indian scenario, investigation is typically done by police officer (usually inspector rank) and they don’t have any idea about the PA. We didn’t come across any reported case where a PA was especially done to solve any case.

Ethical Consideration

Ethical consideration is the major and sensitive issue. It deals with emotional demands and disturbances on victim’s acquaintances and usually required while directing psychological autopsy. This requests that prior conducting psychological autopsy procedure, the interviewees are to be fully informed about the review and can only be interviewed if they give informed consent to participate, and have full right to refuse at any point in time. For research purposes, a 2–6-month interval between the suicide and the interview is recommended [23]. The integrity of the deceased should be respected. This may some of the time be troublesome when, e.g., the deceased suffered from a personality disorder, pathology or abused substances; however, even then can research questions be formulated in a respectful and understanding manner, rather pointing out the ultimate suffering of the victim.

Admissibility in Court

In Indian legal system all the forensic reports or expert’s opinion or opinion of third party when relevant, are admissible under Section 45. Section 45 to Section 51 of the Act deals with the expert evidence [24]. There are some critical issues regarding which should be answered before implication of PA, e.g. (i) whether it is mandatory to get consent of the interviewee; (ii) whether it is mandatory to explain about the process of psychological autopsy/retrospective death analysis to the interviewee; (iii) whether there is any court order/verdict/law to protect the rights of the interviewee; and (iv) whether the interviewee has the right to express his/her willingness to get interviewed for the psychological autopsy/retrospective death analysis. As an issue of admissibility in criminal justice system, the absence of standards methodology is a noteworthy impediment. Being a piece of behavioural science, PA is utilized to take a gander at the reason for death, however once in a while this may have a long traumatic impacts on rest of relatives and associates by uncovering the real reason for death, so need is required to catch up an institutionalized methodology instead of the to pick–up random investigative procedures. So once a standard is created, the therapist would be in the impulse of preparing to guarantee that all mental post-mortem examinations are done take after the guidelines and not having any lawful repercussions.