27 May
2012

 Literature Review Of Psychological Autopsy

Kelly A. Burton

Walden University

Abstract

This literature review of Psychological Autopsy looks the the creation of the career field, issues, benefits and suggested areas for improvement.  The review looks at the concerns of the field where the lack of standards, provability in the courts and no training methods are hampering this field of psychological study.  The psychological autopsy generates many benefits, providing comfort and closure for the families left behind, warning signs to look for in suicidal clients, and evidence that can be utilized by the courts in insurance claims.  Suggestions for improving the validity of the results of the psychological autopsy are suggested. The primary two suggestions are the implementation of a standardized checklist for conducting the autopsy and a set of standard artifacts for documentation.

 

Literature Review Of Psychological Autopsy

Psychological autopsy is a relatively new field in forensic psychology that is still controversial in its application and validity as a science in the field of psychology.  This literature review will cover the origins of the psychological autopsy, how it became mainly utilized for suicides, the benefits and outcomes of the procedure, and some of the issues that are areas of concern for practitioners in the forensic psychology realm.  Research for this review is correlated from various professional journals and one book from the undisputed founder of the psychological autopsy Edwin S. Shneidman.

Background

Every author in my review that covered the origin of the psychological autopsy pointed to the same source Edwin S. Schneidman (Pouliot, De Leo, 2006), (Selkin, 1994), (Snider, Hane & Berman, 2006), (Ebert, 1987), (Henry, Greenfield 2009), and the creator himself in his book titled “Suicide as Psychache: A clinical approach to self-destructive behavior” (1995).  Schneidman in 1958 while working with the Los Angles Suicide prevention Center was asked by Chief Medical Examiner Theodore J. Curphey, M.D., to assist in helping him investigate an abundance of equivocal drug death cases that were overwhelming the corners office at the time.  This was the first time there was a combined investigation utilizing both medical and behavioral science methods in determining the cause of death.  The medical investigation is titled medical autopsy, leaving psychological autopsy as the obvious choice for Schneidman to label his efforts in the equivocal death investigations and the term that is used today for this new area of forensic psychology (Schneidman, 1995, p191).

Equated to Suicide

In the beginning, the psychological autopsy was utilized for equivocal deaths to help in the determination of the cause for death, this has morphed into utilizing the autopsy method for determining the mental state of the person before a suicide and if indeed the death was a suicide or an accidental death (Ebert, 1987).  The main purpose of determining if the death was a suicide or not is for insurance claims, some insurance policies will not pay benefits if the death is a suicide.  Additionally the psychological autopsy can give closure to the family left behind by helping them see that possibly it was a mental illness that was the cause of the suicide and not actions of the family, and utilizing the findings in preventing future suicides (Ebert, 1987).

Issues

Issues in this field are many and are the topics of this review.  Lack of standards, provability in court and lack of training were researched from several journal articles in order to provide an understanding of the field and the material for this literature review.

No Standards

Issues in this field are many, the first and most important is the ability to utilize the findings in court if needed.  In order to have provability in a court there are guidelines that must be adhered to and standards should be utilized in order to provide the best evidence.  The courts have a long history of setting standards for what is allowed as evidence in a trial.   From 1923 to 1993 expert testimony for a court case relied on the Frye Test from the court case Frye v. United States  in 1923, this court cased basically ruled that expert testimony must be based in science theories that were generally accepted (Ewing 2003).

The current standard for evidence related to psychology testimony or evidence is the Daubert standard and the implication that the judge is the final deciding factor if the evidence is allowed in the court, based on the opinions submitted by the experts (Ewing 2003).  The Daubert standard resulted from the U.S. Supreme court case Daubert v. Merrell Dow Pharmaceuticals 1993,  which is covered in research for psychological autopsies in an journal article titled “Standardizing the Psychological Autopsy: Addressing the Daubert Standard” (2006).  This study points out that in order for the findings of a psychological autopsy to be admitted in a court of law it must adhere to the following five guidelines: (Snider, Hane & Berman, 2006)

  • Whether the theories and techniques employed by the witness have been tested
  • Whether they have been subjected to peer review and publication
  • Whether the techniques employed have a known error rate
  • Whether they are subject to standards governing their application
  • Whether the theories and techniques employed enjoy widespread acceptance

The authors point out that it is with these guidelines the field of forensic autopsy is lacking.  There are no set standards for conducting forensic autopsies or set of artifacts that are utilized in the courts as pointed out in the article “Equivocal Death Investigation: Case Study Analyses (2008).  Even in the beginning with the work of Schneidman, he points out that he had no set methodology for conducting the autopsy, each case was conducted as he and his team deemed fit (Schneidman, 1995), and almost 50 years later there are still no set standards (Lacks, Westveer & Dibble, 2008).  The lack of standards can have a negative impact on a court proceeding with the worst case scenario being the evidence of the psychological autopsy is deemed inadmissible by the court in the trial ( Snider, et., al, 2006).  The above study looked at the following factors of the autopsies to determine if they could proved in court, Reliability, Validity, Peer review, Error rate, and general acceptance.

Reliability is argued to be checked by comparing the results of those that complete the suicide verses those that are not completed, however it is pointed out that the mindset of the two groups could be different and therefore not a valid measure of reliability.  Another method suggested would be to take the results from the autopsies and have someone not in the field look at the results and determine if the death was equivocal or a suicide.  Over all the authors point out that without a standard methodology there is really no good way to prove reliability as the variables would be too numerous to compare (Snider, et., al., 2006).  This finding is confirmed in “Psychological Autopsy: Scientific Psychohistory or Clinical Intuition? (1994), where the authors point out that there are no fixed or agreed upon standards for the autopsy proceedings and that there must be a standard to prevent information from being omitted from the findings (Selkin, 1994).  Selkin also points out that many autopsies that are not brought to a conclusion is from the lack of standards or agreed upon methodology for conducting the procedure (1994).

Validity was determined to be not attainable, there is no standard and the subject deceased so the no method of validation can be determined.  Peer review was met with the same results are there were no standards to compare the findings with.  Error rate fell under the same scrutiny as there is no standard or validity so error rate is not measurable.  General acceptability among the forensics community is non existent due to the fact that everyone utilitizes their own methodology for conducting the autopsy. (Snider, et., al., 2006).

Provability in Court

The lack of standards in psychologies is one of the biggest disadvantages when it comes to provability in a court of law.  While Schneidman points out that the psychological autopsy is a behavioral science look at the reason for death, there is very little repeatable science in the procedures (Schneidman, 1994).  This is an area that must change in order to advance the field and provide the court with repeatable methods that can obtain measurable results on a consistent basis. In the article “Equivocal Death Investigation: Case Study Analyses (2008), the authors point out that while the psychological autopsy is effective and can provide useful information in many cases there is scrutiny in the scientific community due to the lack of research, standards and documentation in the field (Lacks, Westveer & Dibble, 2008).  The authors suggest following the 26 areas of investigation that are created by Ebert (1987), and concur that this is a good starting area for creating a standard for conducting the investigation, Ebert’s guidelines are in appendix A (Lacks, et., al., 2008).  The provability nature of the psychological autopsy can have lasting effects on the remaining family members, as an example, in the 1989 explosion of the USS Cole, the cause of death was determined to be a suicide of a sailor on board that killed several of his shipmates along with himself.  The evidence that was given to the Armed Services Committee was not determined to be hypothesis and not based on any valid scientific methods.  The ruling was reversed and the deaths were deemed an accident.  The result was that the family members of the sailor who was believed to have committed suicide were able to collect the death benefits and the other families were able to sue the United States Navy for negligence (Lacks, et., al., 2008).  Because the results of the psychological autopsy can have legal ramifications for the remaining family members we in the field need to develop a standard that meets the needs of the Daubert criteria.  Once a standard is developed and instituted all psychologist will need to receive standardized training to ensure that all autopsies are carried out following the standard.

Training

Due to the lack of standards in the field of psychological autopsy there is no formal training process for psychologists.  This is an area that needs to change in order to add validity to the result of the investigations.  Research reveals that not only psychologists would benefit from this training, in the article “Religiosity and Suicide: Findings from a Nation-wide Psychological Autopsy Study” (1996), the authors point out that members of the clergy are very involved with the victims of suicide and the family members.  This opens the need for them to obtain training in suicide prevention training and working with the family members after a suicide. Because of the relationship of clergy with the family they are in a good position to obtain information from the family concerning the evidence that led up to the suicide event.  Training them on psychological autopsy procedures would aid in the collection of information needed for the investigations (Sorri, Henriksson & Lonnqvist, 2006).

Some areas suggested for training, teaching that not all suicide are linked to mental illness. Gavin and Rogers point out in their article titled “Narratives of suicide in psychological autopsy: Bringing lay knowledge back in” (2006), that while many suicides are a result of mental illness, many are not linked to mental illness at all. The automatic linking of suicide and mental illness can place artificial limits on the investigation.  They recommend that psychologists entertain all avenues of the person’s life in addition to just looking for signs of mental illness, further they cover theories that many suicides are based on social factors not psychological ones. (Gavin & Rogers, 2006).  They further point out that the study of the non completed suicides can help the field gain more insight than just studying the completed suicides.  This might give insight if there is a key factor in those that are successful in their attempt to those who are not, allowing psychologists to look for these factors in their patients who have shown a tendency toward suicide.  One interesting factor on the sociological aspect is one study found that those who had religion and practiced regularly had more completed suicides then those that did not. This could stem from additional social pressure that is levied on them based on their religious faith and solidifies the need for the clergy to obtain training in psychology to help see the warning signs of suicide (Sorri, Henriksson & Lonnqvist, 2006).  A study on spinal cord injury (SCI) suicide victims also points out that social and physical injury can lead to suicide and mental illness.  Studies on this type of suicide is of great benefit to doctors and psychologists as it give an insight to factors to consider when someone sustains an injury that alters their outlook on life both emotionally and physically and should be included in training for psychological autopsies (Kewman & Tate, 1998).  The studies that can guide what is trained in the field of psychological autopsy are also beneficial to the field of forensics and the those left behind from suicide.

Benefits

The benefits of the psychological autopsy are many, aiding life insurance claims, helping the survivors of the suicide cope, detecting  patterns in suicidal patients for possible prevention measures, and finding new areas of focus for the field of psychological suicide. The article titled “Issues in the Psychological Autopsy of a Controversial Public Figure” (1979), provided many benefits for the families of Vietnam Prisoners of war (POW) and the importance a psychological autopsy can have.  After the Vietnam war a collection of POWs were returned to the United States and were under scrutiny for their alleged collaborating with the enemy.  One of the POWs committed suicide as the result of his treatment from the government.  An investigation was ordered into his death and it was found that there was inadequate psychological care given, which worsened his condition and caused him to take his life.  The results, once made public forced, the government to drop the charges against the other POWs and paved the way for better care for our returning veterans (Selkin & Loya, 1979).  Studies like this one place in the public eye the fact that not all suicides are clear cases and that there can be external factors that attribute to the person’s actions.  Additionally it can aid the families in obtaining the benefits from insurance policies if the death is shown to stem from external factors that attributed to the death, as in the POW case (Selkin & Loya, 1979).

In a study of SCI related deaths the benefit of psychological autopsies helps doctors and psychologists look for suicidal indicators in order to obtain treatment for their patients who suffer life altering injuries, this information could be utilized to help lower the suicide rates among SCI clients, who have a suicide rate five times higher than the non SCI population ( Kewman & Tate, 1998).

While prevention of suicide is important, looking after those that are left behind is critical and an important part of the psychological autopsy.  In the article “Therapeutic Effects of Psychological Autopsies, The Impact of Investigating Suicides on Interviewees” (2009), the authors point out some great benefits to the the surviving families.  The interviewing process opens up communication and helps the families deal with the loss and help to relieve their guilt from the suicide, additionally the communication process helps them to seek help in support groups.  Participants in the interview process of an autopsy take comfort in the knowledge that with their participation they can help others cope with their situation and possibly help psychologists identify more suicide indicators (Henry & Greenfield, 2009).  Dealing with death is hard on people and psychologists were concerned about the effects of interviewing of the family in a suicide case, “Research Participation Experiences of Informants of Suicide and Control Cases (2010), that the interview process could cause distress and bring up the pain and suffering of the event all over again.  The authors research found that when sufficient time was allowed to pass before the interview process that the families were willing and generally felt better after talking about the events prior to the suicide (Wong, Chan, Beh, Yau, Yip & Hawton, 2010).

The main two benefits noted in this research is in the aiding of the families in coping with the suicide of a family member and identifying suicidal indicators for all psychologists in the field of psychology.  Another benefit is the aiding of the courts in deciding insurance cases and ensuring benefits are paid to the families that are left behind.

Suggested Ideas

Checklists and Artifacts

From the various research articles there are many suggestions to implement in the field. One of the most important being the need for a standardized checklist utilized in the process.  I found Ebert’s (1987) to be the most thorough and included his checklist as Appendix A.  The implementation of checklists would ensure uniformity in evaluations and provide continuity in the field.  Psychologists could, of course, include more than what is in the checklist as needed but should be required to implement all aspects of the standard checklist as a minimum for evaluation.  A standardized set of artifacts as mentioned by (Pouliot & De Leo, 2006) should be implemented as well ensuring the courts receive the same set of information in a consistent manner from all psychologists conducting autopsies.

Conclusion

The main take away I found in my research of psychological autopsy is the need for standards.  The court is very clear on what the requirements are for evidence in a court case, in order to meet these needs and validate the field of psychological autopsy, there needs to be standards implemented by the APA.  The checklist created by Ebert (Appendix A) is a good foundation for what is needed to conduct a through autopsy.  The creation of standard artifacts for an autopsy is also needed, this gives the court a uniform set of documents to base their decision on and creates the needed templates for all forensic psychologists to use in their reports.

An area of further research is conducting psychology autopsies on returning military veterans that commit suicide.  The report conducted on the Vietnam POW provides an excellent case study as to why this type of research is important.  Those that serve their country area faced with extreme work conditions that can cause various mental disorders, and the nations they serve owe it to them to provide them the very best care.  The field of forensic psychology can aid in this care with research and finding suicide indicators and methods to help them before they take matters into their own hands.

The field of psychological autopsies is still in it’s infancy and only through the hard work of research and standardization will it become one of solid science instead of mere opinion.  Those choosing to work in this field will be rewarded with being part of a pioneering effort of making this new field of psychology a standard and allowing them a chance to work in a field that can save lives and enrich the lives of the families that are left behind in suicide cases.

 

References

Ebert, B. W. (1987). Guide to conducting a psychological autopsy. Professional Psychology: Research And Practice, 18(1), 52-56. doi:10.1037/0735-7028.18.1.52

Ewing, C. P. (2003). Expert testimony: Law and practice. In A. Goldstein & I. Weiner (Eds.), Handbook of Psychology Volume 11 Forensic Psychology (pp. 55-66). Hoboken, New Jersey: John Wiley & Sons.

Gavin, M., & Rogers, A. (2006). Narrative of suicide in psychological autopsy: Bringing lay knowledge back in. Journal of Mental Health, 15(2), 135-144.

Henry, M., & Greenfield, B. J. (2009). Therapeutic effects of psychological autopsies: The impact of investigating suicides on interviewees. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 30(1), 20-24. doi:10.1027/0227-5910.30.1.20

Kewman, D. G., & Tate, D. G. (1998). Suicide in SCI: A psychological autopsy. Rehabilitation Psychology, 43(2), 143-151. doi:10.1037/0090-5550.43.2.143

Pouliot, L., & De Leo, D. (2006). Critical Issues in Psychological Autopsy Studies. Suicide And Life-Threatening Behavior, 36(5), 491-510. doi:10.1521/suli.2006.36.5.49

Lacks, R., Westveer, A. E., Dibble, A., & Clemente, J. (2008). Equivocal death investigation: Case study analyses. Victims & Offenders, 3(2-3), 150-164. doi:10.1080/15564880801938292

Selkin, J., & Loya, F. (1979). Issues in the psychological autopsy of a controversial public figure. Professional Psychology, 10(1), 87-93. doi:10.1037/0735-7028.10.1.87

Selkin, J. (1994). Psychological autopsy: Scientific psychohistory or clinical intuition?. American Psychologist, 49(1), 74-75. doi:10.1037/0003-066X.49.1.74

Shneidman, E. (1995). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham, MD: Rowman & Littlefield Publishers, INC.

Shneidman, E. S. (1994). The psychological autopsy. American Psychologist, 49(1), 75-76. doi:10.1037/0003-066X.49.1.75

Snider, J. E., Hane, S., & Berman, A. L. (2006). Standardizing the Psychological Autopsy: Addressing the Daubert Standard. Suicide And Life-Threatening Behavior, 36(5), 511-518. doi:10.1521/suli.2006.36.5.511

Sorri, H. H., Henriksson, M. M., & Lönnqvist, J. J. (1996). Religiosity and suicide: Findings from a nationwide psychological autopsy study. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 17(3), 123-127

Wong, P. C., Chan, W. C., Beh, P. L., Yau, F. S., Yip, P. F., & Hawton, K. (2010). Research participation experiences of informants of suicide and control cases: Taken from a case-control psychological autopsy study of people who died by suicide. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 31(5), 238-246. doi:10.1027/0227-5910/a00002

 

Appendix A

Psychological Autopsy Guidelines (Ebert 1987)

 

  1. Alcohol History
    1. Collect family history
    2. Research amount ingested regularly
    3. Research evidence of binge drinking
    4. Research evidence of blackouts (known from friends, family, acquaintances
    5. Research evidence of driving under the influence of alcohol
    6. Research evidence of alcohol-related offenses
    7. Research evidence of family problems (alcohol related)
    8. Research evidence of work difficulties connected to alcohol
    9. Research evidence of blood level (BAL) g/1 at time of death
  2. Suicide Notes
    1. Examine content
    2. Examine style
    3. Have handwriting expert review writing style
  3. Writing
    1. Review any past writing by the deceased
    2. Peruse any diary of the deceased
    3. Examine school papers for topics of essays or term papers
    4. Read letters to friends, family, co-workers, acquaintances
  4. Books
    1. Examine books of the deceased
      1. Look for books on the occult, life after death, death
      2. Look for actual books on suicide
      3. Assess books checked out of local libraries
  5. Relationship Assessments
    1. Interview people who knew the deceased including:
      1. Close friends
      2. Close intimate heterosexual or homosexual companions
      3. Acquaintances
      4. Mother, father, siblings
      5. Co-workers and supervisors
      6. Other relatives
      7. Physicians and/or mental health professionals
      8. Teachers
      9. Construct level of intimacy on the basis of discussions with “close” friends
      10. Assess people’s reactions to the victim’s death
      11. Secure a history of marriages and divorces
      12. Examine relationship with children
      13. Look for anger directed to particular people
  6. Marital Relationship
    1. Note any significant problems that may have made the deceased person depressed
    2. Look for history of extramarital relationships
    3. Assess the overall quality of the relationship
  7. Mood
    1. Identify mood fluctuations
    2. Look for symptoms of depression:
      1. Weight loss
      2. References to depression
      3. Problems with memory
      4. Fatigue
      5. Sleep disturbances
      6. Withdrawal
      7. Decreased libido
      8. Appetite and/or taste changes
      9. Constipation and diarrhea
      10. Look for mood indicators during last few days:
        1. Interview friends and family
        2. Interview anyone surrounding the deceased
  8. Psychosocial Stressors (note and chart importance on Holmes & Rahe Scale factors)
    1. Recent loss: deaths of people or pets
    2. Relationship separations: divorce, breakups of significant relationships
    3. Loss of job
    4. Legal and financial problems
    5. Demotion, promotion, and so on
    6. Reaction to stressors
    7. Move to a new location
  9. Presuicidal Behavior
    1. Giving away important possessions
    2. Paying up insurance policies
    3. Payment of debts
    4. Arrangements for children and pets
    5. Sudden order in deceased’s life
    6. Change or initial creation of a will
  10. Language
    1. Identify any specific references to suicide (deceased may have stated, “Have a party in remembrance of me,” or “You won’t have to worry about me anymore”)
    2. Note any changes in language before suicide
    3. Analyze language (tapes, recollections of conversations, writing) for morbid content
  11. Drugs Used
    1. Identify all drugs used by deceased
    2. Assess interactional effects of legal and illegal drugs in use
  12. Medical History
    1. Review complete medical history
    2. Note any unusual symptoms or diagnoses
    3. Note any terminal illnesses or diagnoses
  13. Reflective Mental Status Exam of Deceased’s Condition Before Death
    1. Orientation
    2. Memory
    3. Attention
    4. Concentration
    5. Mood and affect
    6. Hallucinations or delusions
    7. Cognition, IQ
    8. Language
    9. Judgment
  14. Psychological History
    1. Look for previous suicide attempts (type, method)
    2. Assess reason for treatment if involved in therapy
    3. Research evidence of depression, manic depression (bipolar disorder)
    4. Research past psychiatric hospitalizations
    5. Examine diagnoses
    6. Examine evidence of impulsive behavior
    7. Examine any recent or past psychological tests (e.g., was the victim given the Rorschach and was the suicide constellation served via the Exner system?)
  15. Laboratory Studies
    1. Examine ballistics
    2. Evaluate powder burns on hands and body
  16. Coroner’s Report
    1. Conduct complete drug screen
    2. Identify any poisons
    3. Read for detailed description of physical functioning/health of deceased at time of death
  17. Motive Assessment
    1. Make a chart divided four ways: Murder, Suicide, Accident, and Natural, recording data to support each as it is uncovered.
    2. Report the possible reasons for suicide
    3. Report the possible reasons why subject could have been murdered (identify enemies, illicit activities)
  18. Reconstruction of Events Occurring on the Day Before Deceased’s Death
    1. Make a step-by-step chart of subject’s movements and activities
    2. Form a chronological history of the victim that immediately preceded death
  19. Assess Feelings Regarding Death as Well as Preoccupations and Fantasies
  20. Military History
    1. Look for evidence of difficulty adjusting such as letters of counseling (LOC), letters of reprimand (LOR), Article 15 action (A15), or court-martial proceedings [Note: A15 is a form of nonjudicial punishment for offenses not serious enough to warrant a court-martial and include repeated lateness, driving under the influence of alcohol, sleeping on duty, or negligence on duty. Punishment from an A15 can include reduction in rank, fines, or removal from duty.]
    2. Attempt to secure job ratings (airman promotion rating and officer effectiveness rating)
    3. Look for decorations or awards
    4. Notice whether deceased was in a combat zone at any time
    5. Look for evidence of posttraumatic stress disorder in Vietnam veterans
    6. Determine the number of assignments and which were at the request of the victim
  21. Death History of Family
    1. Examine history for suicide by other family members
    2. List immediate deceased family members and their mode of death
  22. Family History
    1. Identify family members and relationships with deceased
    2. Examine the socioeconomic status of family
    3. Identify any conflicts that occurred before death of the victim
  23. Employment History
    1. Identify number and types of jobs (high-risk work may indicate the existence of subintention behavior for quite some time)
    2. Look for repetitive problems
    3. Assess whether any problems existed before death (e.g., co-worker conflict, failure to progress as planned)
    4. Note any disciplinary action
  24. Educational History
    1. Assess educational level
    2. Identify any problems with teachers or subjects
    3. Note special interests or topics (e.g., in particular, look for special interests in death)
  25. Familiarity With Methods of Deaths
    1. Examine belongings for guns, knives (e.g., the deceased may have had five or six loaded weapons around his or her house regularly)
    2. Look for lethal drugs
    3. Note deceased’s interest and knowledge in weapons
  26. Police Report
    1. Critical facts will be obtained by review of the police investigation
    2. Pay special attention to ballistics data

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