Further information of note came from Angela’s parents, who revealed that she was about to receive a $500,000 inheritance from an aunt who had recently died. Angela and her husband knew of this bequest. Angela’s husband was a secondary beneficiary of the inheritance as long as the couple remained officially married.
The estranged husband was indicted for second-degree murder, convicted, and sentenced to life in prison.
Did You Intend It?
An individual may have no intention of dying when he or she makes a suicide gesture—the sole purpose of the gesture may be as a cry for help or to bring about a desired result, in a relationship or in the external world.
Friedrich Nietzsche, in Beyond Good and Evil, said, “The thought of suicide is a great consolation: by means of it one gets successfully through many a bad night.” For some very disturbed patients, the freedom to terminate one’s own life is a fundamental solace. It is conservatively estimated that 30,000 people kill themselves each year. In fact, the actual figure is likely much higher. The World Health Organization estimates that nearly a million people around the globe take their lives each year, The same organization also estimates that 10 to 20 million people attempt suicide each year. Almost everyone has thought of suicide at one time or another, usually when seriously depressed or during a difficult personal crisis. Although there is quite a spectrum of intent among those who have contemplated suicide, often only a fine line exists between those who think about suicide and those who actually commit it.
In my clinical experience, patients may be suicidal for just seconds, minutes, or hours. Other patients have been seriously suicidal for days, weeks, months, years, or much of their lives. Sometimes a quirk of fate makes the only difference in whether a person survives a suicide attempt. One of my patients, prior to coming to me for treatment, survived a massive overdose of pills that she took as she lay in a bathtub full of water. It was in the middle of winter. The water rapidly cooled as she lost consciousness, lowering her metabolism enough so that she survived until the next day, when she was discovered by her housekeeper. Having attempted suicide once and failed, she never again had the urge to harm herself. However, of those who do commit suicide, anywhere from 9% to 33% have made previous attempts. It is estimated that 8 to 25 suicide attempts occur for every completed suicide. Between 7% and 12% of patients who make suicide attempts commit suicide within 10 years, which means that attempted suicide is a significant risk factor for suicide.
In the United States, the statistics on suicide provide some hard facts. The rate of suicide in the general population in 2005 was 11 per 100,000 people per year. The rate has remained steady for many years. For persons with schizophrenia, mood disorders, or those who abuse alcohol or drugs, the rate soars to 180 per 100,000. In one study, the leading methods of suicide were
• Firearms, 60% (males 65%, females 40%)
• Hanging, 14% (males 15%, females 12%)
• Gaseous poisons, 10% (males 8%, females 11%)
• Solid/liquid poisons, 9% (males 6%, females 27%)
• All other methods, 7% (males 6%, females 10%)
The family and friends of suicide victims are at increased risk of suicide themselves. They are also more vulnerable to physical and psychological disorders. Suicide intent is frequently an issue in criminal cases in which it must be determined if the victim was murdered or committed suicide. In civil litigation, determination of intent is necessary to recover death benefits under insurance policies, in legal actions involving workers’ compensation benefits, in malpractice claims, and when suicide is alleged to be the result of injurious actions by third parties. The most insidious tangle is in regard to insurance benefits. Insurance companies that suspect suicide may invoke a policy’s exclusionary clause to deny responsibility to pay benefits, whereas the deceased individual’s estate may contend that the death was accidental and not suicide. Stakes regarding suicide intent can be as large as the $36 million riding on the cause of Robert Maxwell’s death.
Why Naked Suicide?
Legend has it that when Cleopatra committed suicide by allowing the bite of an asp, she was naked. A famous painting of Cleopatra’s death reveals an obvious erotic theme. Both Marilyn Monroe and Robert Maxwell were naked when discovered dead, she in her bed, he floating in the ocean. There is little mystery about Monroe’s naked state, since she was known to sleep in the nude. Why Maxwell was naked when he died is a mystery, and the authorities seemed to take little note of it in their autopsy. They should have. As an expert witness in a number of suicide cases in litigation, I found that in approximately 5% of my cases, the individual committed suicide naked. Even so, attorneys and other experts in most of the cases showed little interest in the fact of the suicide’s nakedness. Only in one case did it make a difference; the attorneys for the defense in a suicide malpractice case postulated that the patient was found hanging naked as the result of an autoerotic asphyxia gone wrong. The case was settled.
Most naked suicides are fraught with psychological meaning, if that meaning can be divined. The professional literature has little data on the topic. Most information is anecdotal, coming from individuals who have attempted suicide naked, but survived. The reasons given reflect highly individual psychodynamics in each instance. I have asked a number of experienced psychiatrists for their interpretation of naked suicide. Many spontaneously recited Job 1:21: “Naked came I out of my mother’s womb, and naked shall I return.” Other psychiatrists postulated that naked suicide symbolizes a new beginning, a rebirth and cleansing or a sloughing off of an intolerable world. Naked suicide challenges the forensic psychiatrist’s sleuthing abilities.
Mysterious Deaths: The Psychological Autopsy
The psychological autopsy originated in 1958, from the Los Angeles Suicide Prevention Center, to assist the Los Angeles County Medical Examiner’s Office in distinguishing drug overdoses from suicides. The basic principles for performing the psychological autopsy were established, as was its goal: the psychological autopsy is a procedure that assists in the classification of equivocal deaths, where the manner of death is unclear. A lack of standardization of the psychological autopsy procedures is a significant limitation on the practice, raising admissibility issues in criminal and civil cases.
Forensic psychiatrists are experts who understand the pertinent legal issues as they apply to psychiatric cases before the court. They translate psychiatric principles into the language of intent as it is defined by the legal system. Forensic psychiatry is a recognized subspecialty of psychiatry, and specialists can earn board certification. Years ago, forensic psychiatrists were known primarily for their work with criminals. Today, they also consult on a wide variety of administrative, legislative, and civil law matters, some of them involving suicide.
The forensic psychiatrist is frequently called upon in insurance litigation to evaluate suicide intent, sometimes by the plaintiff—the estate that is bringing the suit—and sometimes by the defendant—the insurance company. Although, as Oliver Wendell Holmes once observed, “Even a dog knows the difference between being tripped over and being kicked,” the forensic psychiatrist’s job in establishing suicide intent can be a complex, daunting task. The basic problem comes from the fact that psychiatry and law have views that differ in trying to understand the conundrum of suicide intent. Psychiatric theories of behavior tend to be deterministic; that is, they say that the individual contends with psychological forces that are often beyond his or her control. On the other hand, legal theories are based on the belief that humans have free will—that they are not deterministic. In evaluating suicide intent, therefore, the forensic psychiatrist must keep both understandings in mind, adapt psychiatric principles to the legal framework, and perform what is, in essence, a psychological autopsy.
The intentional injury exclusion of insurance policies is designed to prevent enrichment for immoral or illegal acts that have been performed by a competent individual. Competency itself is vague and complicated. When is someon
e competent, and when not? It is necessary in individual suicide cases to determine whether the victim intended to end his or her life. Approximately 90% to 95% of all those who commit suicide are suffering from a mental disorder. In a given case, did the individual understand that the self-destructive act would end his or her physical existence or was he or she not able to understand that?
One factor affecting the legal definition of intent is the presumption against suicide that is maintained in many jurisdictions. This presumption is a legal restatement of the common belief that the instinct for self-preservation in a rational person renders suicide improbable. This, of course, is not always true. So-called rational suicides occur, for example, among individuals who have terminal illnesses.
In elderly persons or persons suffering from chronic or terminal illnesses, deciding when a contemplated suicide is rational can be a very tricky business. I have been asked to assess elderly persons who were refusing food, water, and essential medications. In a number of instances, the elderly person’s caretaker assumed that the patient had decided that he or she has lived long enough and has made a rational decision to die. Yet a majority of these persons were depressed and, in reality, were committing silent suicide. Their response to antidepressant medications was often rapid and gratifying.
Evidence of intent is generally derived from two basic sources. The first is from the persons who knew the individual’s behavior and desires for some time prior to the moment of death—such as family members, friends, neighbors, coworkers, and treating physicians. The second source is forensic, and is provided by experts and based on the development of all relevant information about the individual at or around the time of death. In an insurance claim contest, this latter information will be given by forensic psychiatrists, who attempt to determine the most likely psychological reason or cause for the insured person’s death.
In doing our forensic psychiatric work in an equivocal suicide case, we attempt to reach a detailed understanding of the deceased person’s life because the way a person lived has a bearing on how and why he or she died. The key to the establishment of intent, then, depends on the establishment of motive. What could have been the reasons for wanting to die, that is, to have an intent to commit suicide? A terminally ill patient who refuses further medical treatment may seem to be, but is not necessarily, committing suicide. He or she may not intend to die, but rather, to live free of useless, burdensome, or painful medical treatments. Especially in regard to the elderly and chronically ill, the forensic psychiatrist must distinguish between suicide and the desire not to prolong the process of dying. Suicide notes may establish a motive, but such notes are found in only about one-third of all cases.
To reconstruct the psychological life of an individual who is suspected of having committed suicide is to perform a psychological autopsy. In systemic risk assessment, forensic psychiatrists thoroughly examine the person’s lifestyle, circumstances, and the feelings, thoughts, and behaviors that existed during the days and weeks prior to death. This permits a better understanding of the psychological events of those last weeks and the circumstances that might have contributed to the death, considering both suicide risk and protective factors. Table 9–1 is a conceptual model of suicide risk assessment used in assessing suicidal patients and in determining whether a person committed suicide or died of other causes. Other models of suicide risk assessment are available, but none have been tested for reliability and validity.
In a psychological autopsy, what we look for are ways to evaluate the ability of the deceased to conceive, plan, and execute suicide, and to evaluate that within the legal concept of intent. A failure in any one of these three basic phases of mental functioning may indicate that the deceased lacked the mental capacity to intend suicide. However, the presence of ability to conceive, plan, and execute suicide does not necessarily ensure that the deceased had sufficient mental capacity to intend suicide. For example, one could conceive and plan violent acts with the greatest diligence and execute them with remarkable elegance, and still be mentally deranged by delusions and thereby be considered as lacking the mental capacity to fully intend a violent act. In some jurisdictions, the presence in the deceased of serious mental illness may negate any finding of intent. In other jurisdictions, even if the person has been totally psychotic, he or she can still be determined to have had suicide intent. If the psychotic individual did not understand what he or she was doing, would that mean intent was absent? For example, was there intent to die if a person on LSD was convinced that he or she could fly off a building and not be harmed? In that instance, I would conclude that the intent was not to commit suicide.
Complex and nuanced medical-psychiatric issues are often present in determining intent to commit suicide. The psychiatrist who only treats patients, or who seldom thinks along the lines necessary for forensic evaluation, has a tendency to overidentify with the family of the bereaved and give a judgment that favors the family over the insurer. Forensic psychiatrists, trained in clearly separating the treatment component from the role of evaluator, are more able to minimize or to avoid emotionally biased conclusions in litigation.
It is important to evaluate the person’s state of mind in relation to the legal question at hand, for example, to evaluate intent to commit TABLE 9–1. Systematic suicide risk assessment: a conceptual model
Assessment factorsa Risk Protective
Individual
Distinctive clinical features (prodrome)
Religious beliefs
Reasons for living
Clinical
Current attempt (lethality)
Therapeutic alliance
Treatment adherence
Treatment benefit
Suicidal ideation
Suicidal intent
Suicide plan
Hopelessness
Prior attempts (lethality)
Panic attacks
Psychic anxiety
Loss of pleasure and interest
Alcohol/drug abuse
Depressive turmoil (mixed states)
Diminished concentration
Global insomnia
Psychiatric diagnoses (Axis I and Axis II)
Symptom severity
Comorbidity
Recent discharge from psychiatric hospital
Impulsivity
Agitation (akathisia)
Physical illness
Family history of mental illness (suicide)
Childhood sexual/physical abuse
Mental competency
(continued)
TABLE 9–1. Systematic suicide risk assessment: a conceptual model (continued)
Assessment factorsa Risk Protective Interpersonal relations
Work or school
Family
Spouse or partner
Children
Situational
Living circumstances
Employment or school status
Financial status
Availability of guns
Managed care setting
Demographic
Age
Gender
Marital status
Race
Overall risk ratingsb
a Rate risk and protective factors present as low (L), moderate (M), high (H), nonfactor (0), or range (e.g., L–M, M–H).
bJudge overall suicide risk as low, moderate, high, or a range of risk.
Source. Adapted from Simon and Hales 2006. Used with permission.
suicide as defined in the insurance policy signed by the deceased and by the laws of the jurisdiction. The legal context evaluates motive, intent, and act in regard to a particular happening. In clinical psychiatric contexts, it is conception, planning, and execution that must be assessed, and the two sets of notions are only roughly similar. Here, as in other clinicallegal contexts, an imperfect fit exists between psychiatry and the law.
Conception (Motive)
How, when, and why the idea of attempting or completing suicide aris
es in a person must be critically analyzed, especially in a court case. Was it a sudden and impulsive act, or was it planned in considerable detail? Was the suicide committed in a fit of rage or during a bout of drunkenness? Was the suicide the outgrowth of depression or schizophrenia? Can one find evidence of a plan to commit suicide, say, in the fact that an individual was mired in financial problems and might hope by death to provide for his or her family through insurance death benefits? Consider the following case:
A 57-year-old chairman of the board of a once successful manufacturing company, which he had built up through years of hard work, is facing difficult choices. Business reverses and intense competition have brought on a crisis. Banks are demanding payments on loans that are overdue and are refusing to refinance those loans. The chairman sinks his personal fortune into the company in the fight to keep it afloat. He takes a substantial cut in his own salary. His wife of 28 years is worried, because in all that time, she has never seen him so upset. He seems “panicked” about their personal finances.
The couple’s three children are in college, and he wants to keep them there. He himself never had the benefit of a college education. He cannot bear the thought that if the financial situation continues to worsen, he might not be able to pay the balance of their tuitions. He hints to his wife and friends that he has a plan to improve his financial situation. At work, he seems to function without difficulty. He does not seek out a mental health professional, nor does he seem to coworkers to be depressed.
One morning, the chairman works until 11 A.M. and then departs in his car for a meeting in another part of town. The weather is clear. En route to that meeting, and traveling at 80 miles per hour, his car strikes a bridge abutment. He dies instantly in the crash.
Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior Page 26