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The Psychological Autopsy: What, Who, and Why

Authors:

Abstract

More psychological autopsy investigators and suicidologists are needed, as they in relatively short supply. Suicide rates in the United States have been steadily increasing, even when not considering intentional and unintentional misclassification. In spite of some warranted criticism, the psychological autopsy is an underutilized research method that is valuable in understanding the phenomenon and in implementing suicide prevention efforts. The psychological autopsy often satisfies the Frye standard of admissibility in court, but has difficulty meeting the Daubert standard. The psychological autopsy history, process, and future directions are discussed.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
The Psychological Autopsy:
What, Who, and Why
Chris G. Caulkins1,2
1Strub Caulkins Center for Suicide Research, Woodbury, MN, USA;
2Century College, White Bear Lake, MN, USA;
Abstract
More psychological autopsy investigators and suicidologists are needed, as they in relatively
short supply. Suicide rates in the United States have been steadily increasing, even when not
considering intentional and unintentional misclassification. In spite of some warranted criticism,
the psychological autopsy is an underutilized research method that is valuable in understanding
the phenomenon and in implementing suicide prevention efforts. The psychological autopsy
often satisfies the Frye standard of admissibility in court, but has difficulty meeting the Daubert
standard. The psychological autopsy history, process, and future directions are discussed.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
The purpose of this paper is to raise awareness of the psychological autopsy (PA) process
including its history, who the subject(s) of the study are, why we do it, and what the process
entails. I have been board certified as a psychological autopsy investigator (PAI) by the
American Association of Suicidology (AAS) since 2013 and have had the opportunity to conduct
several in that time. It is my contention that the PA is an underutilized investigative and research
tool that many people are unaware exists. It is my hope that this paper will ignite a passion in
readers to become suicidologists and PAIs. As of my last inquiry in 2017, there were only 21
PAIs in the U.S. and two in my home state of Minnesota (A. Kulp, personal communication,
August 22, 2017). The vast majority of people attending the PAI courses do not go on to earn
their certification, which requires a case study to be conducted and submitted to the AAS as part
of the final approval process.
The rate of suicide in the U.S. have been steadily increasing for decades with half the
states experiencing an increase in suicide rates by 30% since 1999 (Stone et al., 2018). Suicide
is the tenth leading cause of death in the U.S. with 44,965 being the official number from the
Centers for Disease Control and Prevention (2018). Because of misclassification—intentional
and unintentional—the suicidology community believes the actual number is 25-30% greater
than the official number (Bakst, Braun, Zucker, Amitai, & Shohat, 2016; Cwik & Tiesmann,
2017; Katz, Bolton, & Sareen, 2016).
The psychological autopsy (PA) is a systematic process used in a death investigation to
come to an educated conclusion as to the manner of the death when the manner is in question.
When a death is due to the actions of the decedent, the manner is typically either suicide
(intentional) or accidental (unintentional). While the PA can be particularly helpful in cases
where the manner of death is equivocal or indeterminate, it can also be used when the cause and
manner are not in question. In these cases, the PA may provide insight as to why the death
occurred—the perfect storm of circumstances. The majority of cases I have research are at the
behest of the surviving families with a need to understand their loved one’s death.
PA investigators apply knowledge and theories from multiple disciplines including
psychology, sociology, biology, epidemiology, and anthropology, to analyze a substantial
amount of data and make a qualitative determination of manner of death. The PA is not a
replacement for law enforcement or medical examiner (ME) investigations, rather it is a
complimentary investigation that draws on their findings and then draws on additional resources
and methods.
A PA can be viewed as having four major goals. The first is to provide insight into the
circumstances surrounding the death, regardless of intent. This insight may help loved ones of
the deceased through the grieving process. The second is to arrive at a conclusion as to the
manner of death that is consistent with the evidence. The third objective is to contribute to the
body of research on suicide. The last goal is to refine suicide assessment and prevention
techniques with a goal to reduce the number suicides.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
It is important to note that the process often benefits survivors of loss by allowing greater
acceptance of the death, the provision of meaning by helping further research into suicide, and
enhancing social connection (Henry & Greenfield, 2009). Negative reactions are uncommon and
can be mitigated by the preparation of the PAI. This preparation includes familiarization of
resources in the area if the interviewee should find themselves at increased stress levels (p. 22).
While the PA is a well-established investigative and evidentiary tool, it is an evolving
medical and social science practice as we in the scientific community broaden our understanding.
In one case, I adapted the PA to study a geographic area with a high suicide rate. The question
was whether or not suicidality could be detected on a community level (Caulkins, 2014). I call
this technique the anthropological biopsy or anthropsy for short. My findings support the notion
that suicidality can be detected on a macro-level.
A Brief History
The PA began in 1958 when clinical psychologist and director of the Los Angeles
Suicide Prevention Center, Edwin Shneidman, and Norman Farberow and Robert Litman first
developed a tool to assist the Los Angeles County medical examiner in death investigations
(Botello, Noguchi, Sathyavagiswaran, Weinberger, & Gross, 2013). In a two-year period
between 1966 and 1969, Shneidman led the National Suicide Prevention Program within the
National Institute of Mental Health, the leading scientific organization dedicated to the study,
treatment, and cure of mental illness in the United States. During that time, the number of
suicide prevention centers in the U.S. grew from three to 200 and the term suicidology was
coined to cover the formal, scientific study of suicide (Shneidman, 2004). Shneidman founded
the AAS, which today provides training and certification in the area of suicide study and suicide
prevention. The AAS is also a resource for information and research on suicide in the U.S. and
internationally. Finally, the AAS provides support, education, and resources to members of the
public and those bereaved by suicide (AAS, n.d.). As of 2011, the new structured PA program
provides formal credentials awarded by the AAS. Additional information on the AAS and the
PA certification process is available at http://www.suicidology.org.
The Psychological Autopsy Process
In describing the process, I must disclose that, while the basic framework of how the PA
is conducted is the same between PAIs, how they go about their study may be very different.
The process I describe here is my own. My background is eclectic with education in the biologic
sciences, social sciences, public health, and interdisciplinary research. This background is
reflected in my work. I employ Atlas.ti software to perform qualitative analysis and SPSS if
there is any quantitative element requiring a higher level of analytical sophistication. I also
record and transcribe interviews. Other PAIs may or may not spend as much time and may not
submit their results in a final report that meets the academic quality level of published research.
As a serious researcher, who is has been left behind to ponder the suicide deaths of both my wife
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
and brother, I am dedicated to quality and thoroughness. One of my colleagues so eloquently
says that suicidologists who are survivors of loss take a more “rich and meaningful approach”
(Caulkins et al., 2017). I recommend you ask many questions of a PAI if you are considering
having a PA conducted to ensure the process and rigor is a good fit for your needs.
The PA is complex and requires several hundred hours of work applying multiple
disciplines. The depth to which the investigation is able to go, the amount of time it takes, and
the confidence of conclusions vary on a case-by-case basis. There are three broad activities
conducted in a PA investigation—historical review, interviews, and analysis. I begin with the
presupposition that the manner of death is undetermined, even if other authorities have officially
declared a manner of death. While we perform an analysis using the metrics gained from
empirical research examining the phenomenon of suicide, we understand it is also possible the
death was not a suicide. The research serves to rule in or out certain known risk factors.
The historical review examines any available medical and mental health records, police
and medical examiner reports, the victim’s personal belongings and living quarters, the
decedent’s internet presence including—browser, and social networking histories—and may also
have formal forensic analysis of devices used the by the decedent conducted. I take copious
notes while looking at the artifacts of the deceased person’s life.
Another very important part of the PA are the semi-structured interviews. Interviews are
conducted with a wide variety of people who can give insight into the decedent’s life. While an
interview subject can be just about anyone close to the decedent, the best subjects tend to be
family members, close friends, and co-workers. Because the interview necessarily involves a
human subject, important precautions are taken to protect the interviewee and their
family/friend’s identities during and after the interview—even between those I interview about
the same case. My interviews generally take about 90 minutes but have gone longer. A
requirement of pro bono work is the granting of permission to allow me to use the case for
research and educational purposes. Anonymity is still protected.
Once the investigation is complete, all notes, records, and transcripts of interviews are
uploaded into Atlas.ti. After thematic coding and analysis are complete, I write a formal
document that may be as many as 40 pages in length. I conduct a thorough literature search and
then cite and reference all assertions. I also borrow from the discipline of anthropology and draft
a kinship chart (see Figure 1). Once the report is complete, I meet with the person(s) who
commissioned the report and review my conclusions with them. Sometimes distance means this
is done via Skype, but I prefer in-person.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
Figure 1. Kinship Chart Based on Mental Illness and Suicidality
Note. Only a portion of this chart is shown to maintain the anonymity of the family.
Research Metrics
The PA process retroactively identifies evidence-based risk factors. Central to this is the
mnemonic, IS-PATH-WARM, which prompts investigators to remember suicidal ideation,
substance abuse, purposelessness, feeling trapped (in a situation or place), hopelessness,
withdrawing from social circles and activities, excessive anger, recklessness, and mood swings
(AAS, 2013). Beyond the mnemonic, many other factors are screened for including sleep
problems, a history of mental health problems, perfectionism, obsessions with death, genetic
history (see Figure 1), and others (AAS, 2013).
The Equivocal Death
Ambiguous, unknown, undecided, uncertain, disputed debatable, unanswered,
contentious, and many other terms are synonymous with equivocal. Often equivocal deaths are
classified indeterminate, which is one of five manners a can be categories into. It may be helpful
to use the acronym NASHI as a memory aid. NASHI stands for natural, accident, suicide,
homicide, and indeterminate. Indeterminate is an alternative to undetermined or unknown,
which may be what appears on the death certificate. Manner is different from cause, which may
be blunt force trauma, asphyxiation, kidney failure, etc.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
I will relay the following fictitious death to illustrate an example of an equivocal death.
A man goes skydiving and falls fatally to his death, never having deployed his parachute.
Without more information, this death could be classified into any of the NASHI manners. The
medical examiner (ME) performs an autopsy and can find no evidence of a disease process or
medical condition—such as a heart attack resulting in unconsciousness—that could have
rendered the man incapable of pulling his chute cord. The pilot and his mechanics look over the
plane to see if anything could have resulted in an accident that caused the death—poorly packed
chute, stray bolt on the floor causing him to trip and hit his head before falling out of the plane,
etc. The ME and law enforcement also look for signs of an accident, but also homicide. Did
someone push the man, hit him in the head with a blunt object, etc. In other words, was this
death a homicide? Next, the ME and law enforcement look for evidence of suicide—wound
patterns, suicide note, statements to witnesses, etc. If the death cannot fit into the NASH part of
the acronym, it is often categorized into the indeterminate category. Sometimes the ME will
make a declaration of manner depending on their philosophy of practice (Jentzen, 2009). Thus,
the PA is a useful method in determining a manner of death that is equivocal—either formally or
because the manner was assigned by virtue of a philosophy. The following is a note I made on a
PA I conducted several years ago in which I was particularly taken aback by a philosophical bias
of an ME.
The question before us is one of intent. The decedent either intentionally strangled
himself in an act of suicide or was an unwitting victim of the “choking game” gone
wrong. If it is the latter, the intent was to gain a high from the decreased blood and
oxygen flow to the brain, the result would be an accidental death. The medical
examiner’s (ME) office that handled the case and determined the manner of death as
suicide was contacted to see how manner of death is determined in cases where the
choking game is a possibility. The ME office responded that “realistically, a single
individual couldn’t partake in the choking game” and for that reason “we don’t think that
it’s even a viable situation.” This demonstrates a clear lack of understanding of the
choking game. Loss of consciousness results in 13-18 seconds with the majority of the
fatalities being males performing the act alone 96% of the time (Andrew, MacNab, &
Russell, 2009).
Forensic Testimony and Evidence
There are two legal standards used to establish the validity and expertise of those
testifying in court—the Frye and the Daubert standard. The standard used varies by state, with
the Daubert standard requiring a higher threshold of evidence. The PA, and PAI as an expert
witness, meet the Frye Standard, but not necessarily the Daubert standard because a known error
rate is difficult to determine post-mortem (AAS, 2013).
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
The Frye standard holds that evidence is admissible if it has “general acceptance” within
the scientific community and that methods must be considered valid by those in the applicable
discipline or field (Steadman & Konigsberg, 2016). Additionally, the judge does not rule on
whether or not evidence is appropriate for submission under the Frye standard, but rather is a
point of debate between opposing legal counsel (p. 63).
When the judge makes the decision concerning admissibility the Daubert standard is
applied. Criteria to meet the Daubert standard include whether the scientific methodology is
relevant, reliable, peer reviewed, has a known error rate, and is replicable (p. 63). As a result,
those satisfying the Frye standard would only be required to point out “consistencies between
antemortem and postmortem data” rather than back up assertions with odds ratio statistics as
required under Daubert (p. 65). Adhering to Frye standards for identification rather than
Daubert, would allow in more circumstantial (presumptive) evidence rather than direct (positive)
evidence backed up with scrutiny of the scientific method (Wiersema, Love, & Naul, 2016,
p.82). It is important to remember that the PA is an expert opinion with scientific value (Young,
1992).
Criticism
In addition to not necessarily satisfying the Daubert standard, the primary criticism of the
PA is the use of it for retroactively diagnosing a person with a mental health disorder. Because
not all suicidologists or PAIs—like me—are necessarily mental health practitioners, this further
complicates the issue because of an absence of clinical experience conducting diagnoses. I do
not believe Shneidman developed the tool for retroactive diagnosis. Somewhat contentiously,
many in the suicidology community hold up aggregated PA research as evidence that 90% of
people who die by suicide have a mental health disorder (Hjemeland, Diesrud, Dyregrov,
Mkizek, & Lenaars, 2012). The CDC’s latest findings indicate that 54% of those who have
suicided had no diagnosis of a mental health disorder (Stone et al., 2018).
Future Directions
I have three things I would like to see the PA used for in the future. Similar to the death
investigation procedure since 1994 in Queensland, Australia (Potts, Kõlves, O’Gorman, & De
Leo, 2016), I propose that 100% of all suicide, indeterminate, and accidental deaths suspicious
for suicide receive a PA.
The second is that the PA is an investigatory method in all cases of law enforcement
officer involved shootings (OIS). Researchers reviewing 707 cases of OIS found that 36% of
those cases were actually suicide-by-cop (Mohandie, Meloy, & Collins, 2009). The effect of
having to use deadly force exacts a heavy toll, with the majority of officer’s leaving their
profession within five years after use of deadly force (McNally & Solomon, 1999). I see three
potentially valuable outcomes, (1) diminished psychological impact on the officer, (2) diffusing
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
of conflict owing to perception of officer culpability, and (3) diminished liability for law
enforcement agencies as long as no acts or omissions contributed to the event unduly.
Last, I recommend continuation of the anthropsy process (Caulkins, 2014). This will
enable suicide prevention specialists to take action on cultural issues that underlie high suicide
rate areas. The Golden Gate Bridge is one such area that has a strong cultural component to the
suicide problem in San Francisco (Caulkins, 2015) that could benefit from such an investigation.
Summary
Suicide is a significant public health problem in the United States that has been steady
increasing for a long time (Stone et al, 2018). The PA is a valuable, yet underutilized
investigatory and research tool. In spite of the method being in existence since the 1950s,
relatively few people credentialed by the AAS to conduct the PA to their established standards.
An academically rigorous study incorporates multiple interviews, use of technology, and
includes an extensive search of the literature. Done well, the PA can aid in the differentiation of
manner of death, provide answers as to the perfect storm of factors that lead to the suicide,
benefit the emotional health of those left behind, and inform prevention efforts. With the advent
of the formalization of the training by the AAS in 2011, the process carries more legal weight
and alleviates—at least in part—one of the primary criticisms of the PA. Employing the PA to
diagnose mental health disorders retroactively is a contentious debate among suicidologists,
which may portray the role of mental illness in suicide inaccurately (Hjemeland et al., 2012). I
recommend that all suicide and deaths suspicious for suicide have a PA conducted, that officer
involved shooting incidents all be subjected to the PA, and that we use the framework of the PA
to study suicidality on a community level.
The Forensic Mental Health Practitioner, Vol. 2, Issue 1, 2019
A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
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... In addition to the misclassification prevalence among medical examiners (Timmermans, 2005), different medical examiners within the state may differ in the criteria and philosophical approach in the determination of manner of death. Thus, it is possible that some medical examiners will rule some deaths indeterminate that another examiner may declare accidental when presented with the same case (Caulkins, 2018b) and therefore I cannot assure complete reliability. ...
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One of the most established "truths" in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants' relationships with the deceased.
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Purpose: Official suicide statistics often produce an inaccurate view of suicide populations, since some deaths endorsed as being of uncertain manner are in fact suicides; it is common, therefore, in suicide research, to account for these deaths. We aimed to test the hypothesis that non-suicide death categories contain a large potential reservoir of misclassified suicides. Methods: Data on undetermined intent and ill-defined death causes, and official suicide deaths recorded in the district of Tel Aviv for the years 2005 and 2008 were extracted. Based on supplementary data, cases regarded as probable suicides ("suicide probable") were then compared with official suicides ("suicide verdicts") on a number of socio-demographic variables, and also in relation to the mechanism of death. Results: Suicide rates were 42 % higher than those officially reported after accounting for 75 probable suicides (erroneously certified under other cause-of-death categories). Both death classifications ("suicide probable" and "suicide verdicts") had many similarities, significantly differing only with respect to method used. Logistic regression confirmed that the most powerful discriminator was whether the mechanism of death was considered "less active" or "more active" (p < 0.001). Indeed, deaths among the less active group were 4.9 times as likely to be classified as "suicide probable" than were deaths among the more active group. Conclusions: Caution is needed when interpreting local area data on suicide rates, and undetermined and ill-defined deaths should be included in suicide research after excluding cases unlikely to be suicides. Improving suicide case ascertainment, using multiple sources of information, and uniform reporting practices, is advised.
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Purpose – The purpose of this paper is to examine the Golden Gate Bridge (GGB) as a work of art and the role of the bridge in shaping community identity and discourse. Particular attention is focussed on the discourse surrounding mental illness and suicide, which perpetuate the problem of suicides involving the bridge as a means and mechanism of death. An analysis of the person who attempts or completes suicide is also performed. Design/methodology/approach – Multiple research articles, writings, and a cinematic production are drawn on to frame the argument in terms of Michel Foucault's adaption of Pantopticism Theory and Jacques Lacan's Mirror Theory, which includes the concepts of the Real, the Imaginary, and the Symbolic. Findings – The GGB is a major factor in shaping the discourse on mental illness and suicide in the San Francisco community. The influences the GGB exerts combines with and exacerbates a culture of stigma, which perpetuates negative discourse and increases the risk of suicides in those already vulnerable. Research limitations/implications – The research for this paper was performed at a distance and was conducted, with the exception of one personal communication, by literature search and application to theory. Ethnographic research would be a logical next step to study the phenomenon further. Practical implications – Theory developed from this paper could be used in determining a relevant course of action for adding to existing suicide prevention efforts in the San Francisco Area and any other community with a prominent icon, such as the GGB, that may be exerting a negative influence on the suicide rates of that area. Social implications – An awareness of how art, culture, and psychology interact would increase awareness of the creation of a stigmatized environment and perhaps precipitate a change in the underlying negative discourse. Originality/value – This paper takes a fresh look at the phenomenon of violent death by suicide where a physical object/icon (the GGB) is used as a means to die. The particular theories and approach used to explain the interactions that intensify the suicide death rate have never been combined and interwoven in such an interdisciplinary way to seek an explanation.
Article
The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner-Coroner's Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedent's state of mind and intention at the time of death. It was used initially in "equivocal" deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner-Coroner's suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroner's Department. Research findings, the use of this approach in high-profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.
Article
Several authors have observed a therapeutic impact of the psychological autopsy on the interviewee, although they do not explicitly define what aspects of the process were helpful. This article aims to identify these therapeutic effects and to discuss their potential impact on participants' narratives. This article derives from 35 psychological autopsy interviews that were conducted to better understand adolescent and young adult suicide. Interviews lasted approximately 6 to 8 h each and consisted of both a battery of questionnaires and open-ended questions. They were mostly conducted with the families of the deceased, including parents and siblings, and on occasion were done with a single family member or friend. The time elapsed since the suicide ranged from 6 to 18 months. Psychological autopsies were helpful to interviewees in allowing them to find meaning in the suicide, to find purpose through their altruistic participation, to obtain psychological support, to experience connectedness with others, to accept the loss as real, and to gain insight into their functioning. Negative reactions to the interviews, albeit uncommon, are also briefly described. We recommend that interviewers receive preparatory training and ongoing supervision while conducting interviews, to assure a reflective and professional stance.