Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior (34 page)

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 factors
^a
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 factors
^a
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 ratings
^b

^a
Rate risk and protective factors present as low (L), moderate (M), high (H), nonfactor (0), or range (e.g., L–M, M–H).
^b
Judge 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 arises 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.

Police examination of the scene reveals no skid marks from his car. No other vehicles were involved in the crash. It could not be established that there were any pre-crash mechanical problems with his car. An autopsy finds equivocal evidence that he had had an acute heart attack. No suicide note is found. The death certificate states that the cause of death is natural. The workers’ compensation insurance carrier, however, conducts its own investigation and concludes that the death was a suicide. It refuses to pay out on his policy.

The forensic psychiatrist retained by the family of the deceased, and charged with the task of performing a psychological autopsy, does not automatically accept the death certificate finding, nor does she reject it. Death certificates frequently do not address the matter of suicidal intent or lack of it. The death certificate is a document whose purpose is to provide vital statistical data. It is not based on the totality of evidence that may later become available. The forensic psychiatrist cannot simply accept the postmortem finding of a possible heart attack either, because it is not in keeping with the weight of the other evidence. For instance, it was discovered that shortly before his death, the deceased had put all of his affairs in order.

The forensic psychiatrist’s examination of the chairman’s life reveals a man who was very disciplined and who rarely acted impulsively. He led a quiet life, had conservative habits and tastes. No history of alcohol abuse, drug abuse, or gambling was present. Family, financial stability, and occupational success and gratification are no longer protective factors against suicide.

The workers’ compensation law in the deceased’s state reads that the insurer could refuse to pay compensation “if the injury or death resulted from the person’s intent to injure or kill himself.” The forensic psychiatrist concludes that despite the absence of evidence of a mental disorder such as depression or psychosis, the preponderance of the available evidence (more likely than not) showed that the chairman had intended to kill himself, in a suicide staged as an accident, to provide financially for his family. The chairman’s
conception
or
motive
for killing himself was likely the result of his declining financial status and the perception that further decline would produce dire consequences for his family. His
plan
was to cause his death through a staged accident and thereby enable his family to cash in on his large insurance policy.
Execution
of the plan of suicide was carried out by crashing the car into the bridge. The three conditions required to find intent to suicide were thus met. The forensic psychiatrist presented her findings to the family. They discharged her and decided to seek another expert opinion.

In the matter of conception or motive, there are suicides that are not motivated or not intended. Some people who suffer from brain disorders may be considered unable to conceive or to have a motive for suicide, but they occasionally randomly or impulsively kill themselves—or others. Trauma to the head or drug and alcohol intoxication can cause acute brain dysfunction accompanied by the unleashing of violence. The resulting acts, even when directed against the impaired person, may not meet the legal criteria for intent to commit suicide, in part because it is so obvious that the other two conditions, planning and execution, have not been met.

Certain “suicides” are also just as clearly not intended, although they involve no physical brain disorder. For example, a person may plan a suicide gesture. The motivation may show the intent is only a cry for help or the desire to manipulate a situation or another person, but, through miscalculation, the suicide gesture may result in death. Miscalculations also occur in other kinds of death that initially may appear to be suicides, such as in autoerotic asphyxia. This is an attempt by young men to enhance sexual pleasure by decreasing the flow of oxygen to the brain. If miscalculated, it can result in death by hanging, even though the real motive was only to produce a heightened sexual experience while masturbating.

Planning (Intent)

One can conceive the idea of suicide but fail in the intent or planning of it. Persons driven by impulse, by psychosis that produces a break with reality, or by intoxicants may have lost the ability to plan a violent act, even though they have thought about it for some time. The event may still happen, however, even if it is not actually planned. Intoxicants may destabilize the person and prematurely precipitate a violent act. For example, consider this case:

A 33-year-old minor league baseball player harbors a grudge against a former major league coach. The player has often been heard by other players to threaten physical harm to that coach, who he feels has thwarted the player’s major league career. One evening, while intoxicated with alcohol and cocaine, he takes a baseball bat and bludgeons to death a different person, the coach of an opposing minor league team, and then fatally shoots himself.