Psychological Autopsy of Equivocal Deaths Research Paper

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Sometimes it is important for legal purposes to determine a decedent’s mental state at the time of death. The psychological autopsy was developed in the late 1950s by mental health professionals associated with the Los Angeles Suicide Prevention Center (SPC) to assist with clarifying the mode of death in equivocal cases (Litman et al. 1970; Shneidman 1981; Shneidman and Farberow 1970). An equivocal death is one in which the cause of death may be known – but the mode of death is unclear (Shneidman 1981). The mode of death is classified by way of the NASH acronym: natural causes, accident, suicide, or homicide. For example, if an individual is found floating in a river, the cause of death may be asphyxiation due to drowning, but the mode of death may be unknown with three possibilities arising: an accidental drowning, a suicide, or even a homicide. Another example would be someone found dead at the base of a building; the cause of death is multiple crushing injuries, but was this an accidental fall, a suicidal jump, or a case of the deceased being pushed? Shneidman (1981), who coined the term psychological autopsy, noted that as many as 20 % of all deaths may initially be deemed equivocal. In such deaths, the mode of death cannot be determined by conventional medical or investigative procedures. What is needed is a retrospective evaluation of the decedent’s mental state and the surrounding facts in the case to help determine the mode of death. This research paper begins with a historical summary of the psychological autopsy and an examination of its relationship with other forms of analysis, its legal admissibility, and its criticisms of the technique. This will be followed by a discussion of guidelines for conducting psychological autopsies, including appropriate qualifications for practitioners, decision-making frameworks, and the reporting of results. Finally, future directions for the psychological autopsy will be outlined.

Historical Foundations

The psychological autopsy was developed when Drs. Edwin Shneidman, Norman Farberow, and Robert Litman from the SPC were invited by then Los Angeles County Coroner, Dr. Theodore Curphey, to assist in cases of equivocal suicide. The coroner named this group the Death Investigation Team. Shneidman and Farberow (1970) reported that the team

focused primarily on the personality elements associated with suicide, such as suicidal intention, subtle communications relating to suicidal intent, reactive or psychotic depression, and schizophrenia… the approach of the team was to reconstruct the life style and personality of the deceased, mainly by interviewing the spouse, grown children, parents, physician, and others who knew him well. On the basis of these psychological data, and any other physical evidence of suicide, accident, homicide, or natural death that might be found, the Death Investigation Team attempted to make informed extrapolations over the last days of the victim’s life and then to report these conclusions and recommendations to the coroner for final integration with his other findings (p. 497).

It should be noted that Dr. Avery Weisman subsequently adapted the psychological autopsy for use in helping to understand the precipitating causes related to unequivocal deaths. To this end, Shneidman (1974) wrote that “Dr. Weisman has creatively extended the reach of the psychological autopsy to deaths that are unequivocal as to mode, pursuing such additional piercing questions as: why did this (clearly physically, accidental, or suicidal) death occur at this time? What psychological events preceding the dying period might be related to the death itself? How can we understand this death better?” (p. xi). Weisman (1974) described the application of the “Omega Version” of the psychological autopsy within hospitals, which included information obtained from “actual contact with the patient” (p. 35).

In contemporary times, the psychological autopsy is frequently used as an approach to help understand suicides. In fact, a database search of the term psychological autopsy will invariably result in more references referring to the use of the technique in unequivocal cases than the equivocal cases for which it was originally developed. Accordingly, LaFon (1999) sensibly suggested that the equivocal death psychological autopsy be differentiated from the suicide psychological autopsy. The focus of this research paper will be on the equivocal death psychological autopsy, although invariably some literature and research pertaining to the suicide psychological autopsy are still relevant to the investigation of equivocal deaths as the two variants of the technique are clearly conceptually and practically related.

It should also be noted that since the introduction of psychological autopsies, a variety of terms have been used to describe the use of the psychological autopsy in equivocal deaths. For example, some authors have used the term psychiatric autopsy, although this has usually been used as a synonym for the same technique. Bendheim (1979) attempted to differentiate the psychiatric autopsy from the psychological autopsy based on the differences in training between the two types of mental health professionals. However, Ogloff and Otto (1993) cogently noted that “this distinction appears strained and smacks of guild interests more than significant differences in technique” (p. 608). Accordingly, the broader term, psychological autopsy, seems to have been used by most mental health professionals who research or carry out this type of work.

Equivocal death analysis (EDA) was a term coined by behavioral scientists at the Federal Bureau of Investigation to describe their analyses of equivocal deaths for law enforcement (Ault et al. 1994; Poythress et al. 1993). Canter (1999) noted that an EDA “is carried out by law enforcement officers, usually FBI agents, who only examine the crime scene material and other information directly available to the police inquiry” and suggested that “an EDA is open to many more biases and distortions than a ‘full’ psychological autopsy” (p. 128). However, recent literature from EDA practitioners suggests that there is perhaps little actual difference between the two terms (Lacks et al. 2008), although assessors may not always conduct the required interviews themselves. Given the variety of terms in use and the various permutations of the technique, Ogloff and Otto (2003) suggested the umbrella term reconstructive mental state evaluation to “include techniques or a group of techniques whereby a mental health professional attempts to describe or discern the mental state of a deceased or missing person at some prior point in time” (p. 1186). It should be noted that they stressed this definition and did not suggest that nonmental health professionals were unqualified to conduct such analyses in certain circumstances.

Relationship To Other Forms Of Analysis

While seemingly esoteric, psychological autopsies clearly have some parallels with other forms of behavioral and psychological analysis. As the prior mental state of the person is one of the key considerations, clinical assessments for the purposes of an insanity or mental impairment defense are conceptually related. While both techniques involve the retrospective analysis of collateral information, insanity evaluations generally involve knowledge of the behavioral outcome and are concerned with determining the person’s mental state and intent at the time of the offense (Ogloff et al. 1993). In comparison, while psychological autopsies also require a retrospective assessment of the individual’s mental state and intent, an opinion is also required regarding the person’s actions (i.e., to determine the mode of death). Indeed, in the case of the mental state at the time of the offense evaluation, the mode of death is known. Furthermore, the major difference is obviously that for insanity evaluations the person being assessed is available for examination, although his or her mental state may well have changed from what it was at the time of the offense.

Some authors have made a conceptual link between the psychological autopsy and offender profiling, a technique in which the likely characteristics of a person are inferred from their offense behaviors. This link likely reflects the fact that some authors and practitioners have been engaged in both activities (e.g., Ault et al. 1994; Canter 1999). However, these are considerably different techniques. Offender profiling is essentially a form of retro-classification that provides the broad characteristics of an unknown offender. In contrast, the psychological autopsy provides more fine-grained and definitive opinions regarding the intentions of a known individual, right down to classifying their death into one of four nominal categories. Where the two activities do overlap is in regard to their basic rationale. According to Shneidman (1970), psychological autopsies are theoretically based on the principle that dying behaviors are an integral part of the lifestyle of the individual. In this way, a detailed examination of the individual’s life will shed light on their death. Similarly, offender profiling is often based on the premise that behavior reflects personality (Douglas et al. 1992), such that aspects of offence behavior will reflect behavior in other aspects of the offender’s life. Thus, both activities can be conceptualized as elaborations of routine activity theory (see Canter 2000) but from different directions and with very different levels of focus.

Perhaps the most closely related technique to the psychology autopsy is that of indirect personality assessment. As the name suggests, this involves an assessment of an individual’s personality without actually meeting the person. These include “psychiatric profiles” of world leaders used by governments for intelligence purposes, such as the well-known psychiatric analyses of Adolf Hitler conducted in the 1940s (e.g., Langer 1972). A seemingly more common application is in criminal investigations, where evaluations of an individual suspect and their likely reaction to questioning or other investigative approaches are discerned from collateral information (Ault and Hazelwood 1995). This is similar to a psychological autopsy, except for the fact that the person is still alive, although, as with the psychological autopsy, the person conducting the assessment does not have the benefit of directly accessing the subject of the evaluation. The other difference lies again in the focus, which is on likely future behavior rather than likely past behavior (i.e., reason and cause of death).

Legal Admissibility Of Psychological Autopsies

Evidence based upon psychological autopsies, or similar reconstructive evaluations, has been admitted by courts in various jurisdictions, although this has primarily been in the civil arena. In the United Kingdom, attempts to admit psychological autopsies in criminal cases have been unsuccessful. For example, in the case of R v. Gilfoyle, a man was convicted of murdering his pregnant wife who died from hanging. A psychological autopsy conducted by a professor of psychology suggested that suicide was a likely mode of death, but this was deemed inadmissible (see Canter 2005). However, evidence of a similar nature was admitted in the unpublished Northern Ireland case of Torney (1996, as cited in Gudjonsson and Haward 1998). In this case a police officer was charged with the murders of his wife, son, and daughter. He claimed that his son had gone “berserk” and killed his mother and sister before committing suicide. A psychologist reviewed the case material and testified that the scene was not consistent with this scenario. Rather, they suggested that a carefully planned execution was more likely. This evidence was admitted and the defendant was convicted of all three murders. While this evidence does not appear to have been described as a psychological autopsy, the parallels with this technique are obvious.

In regard to American courts, Ogloff and Otto (1993, 2003) noted that the technique has been chiefly admitted within civil courts, but added that there has been reluctance to permit testimony regarding mode of death. Rather, testimony limited to the decedent’s state of mind prior to death is more likely to be allowed. Ogloff and Otto also noted that psychological autopsies have been allowed in cases of insurance and workers compensation, but not in regard to testamentary capacity or intestate succession, which suggests that the courts are uncomfortable with psychological autopsies that opine on the ultimate issue. Ogloff and Otto also found that criminal courts have been less willing to admit such evidence, and on the rare occasions in which they have, the ultimate issue is not directly addressed. Indeed, Ormerod (2001) described the 1996 case of USA v. Jean in which a “psychological expert was permitted to testify that none of the indicators of suicide normally associated with a person who commits suicide were present” (p. 22) but was not permitted to state that therefore the deceased was murdered.

Criticisms Of Psychological Autopsies: The USS Iowa Controversy

The use of psychological autopsies in equivocal deaths was soundly criticized following the widely publicized and now infamous USS Iowa incident in 1989. This involved an explosion aboard a US naval ship that killed 47 sailors. A Naval Investigative Service (NIS) investigation initially ruled out the possibility of an accidental explosion. The NIS focused their attention on two sailors: one who died in the explosion and a friend who was set to be the beneficiary of the other’s life insurance policy. They asked behavioral scientists at the FBI’s National Center for the Analysis of Violent Crime to give an opinion, based upon the evidence collected during the investigation, regarding the likelihood of three outcomes:

(a) Mass murder by the surviving sailor

(b) A suicide-homicide attempt by the dead sailor to get revenge on the surviving sailor for getting married

The FBI analysts formed the latter opinion. This caused considerable controversy, with some writers critical that the agents had not considered the possibility of an accident (which was later determined to be the cause of the explosion when the case was reopened; see Lacks et al. 2008). This is perhaps an unfair criticism because an accident had been ruled out by the referring agency at the time of the referral. Nevertheless, a “peer review” panel of 14 psychologists and two psychiatrists was somewhat critical overall. The co-chair of the House Armed Services Committee reportedly commented that “the FBI flunked this peer review” (see Poythress et al. 1993, p. 10). However, a more balanced evaluation of the review panel’s conclusions is provided in an empirical study of their reports (Otto et al. 1993). This revealed that the members of the peer review panel were largely in agreement with the FBI agents’ inferences regarding the dead sailor’s adjustment and psychological functioning, with agreement on 70 % of such information. However, the panel was not in agreement with the agents regarding the dead sailor’s culpability and risk for suicide, with the FBI agents providing what were described as more negative and stronger conclusions than those of the panel members. There was also some suggestion that competing hypotheses were ignored. On the basis of this case, some members of the panel recommended that the users of psychological autopsy techniques “should not assert categorical conclusions about the precise mental state or actions of the deceased” (Poythress et al. 1993, p. 12) and should also make appropriate qualifying statements for any opinions rendered. This is a very sound suggestion that should be followed in psychological autopsies and other equivocal death analyses since they force the person or people conducting the review to explicitly consider and weigh evidence both in favor of and against all reasonable alternatives.

Qualifications Necessary For Conducting Psychological Autopsies

Those conducting psychological autopsies would appear to require a high degree of expertise and knowledge from a variety of disciplines and areas. Given the nature of the practice, it is recommended that the assessor be a registered mental health professional (i.e., a psychologist or psychiatrist is most likely), that they have training and experience in the assessment of suicide and risk factors for suicide, and that they have some familiarity with viewing and interpreting death scene materials and photographs. As noted above, a deficit in one of these areas would not necessarily obviate an individual from conducting psychological autopsies, so long as the person benefitted from the expertise of colleagues who have the requisite level of expertise in a complimentary area. Indeed, FBI behavioral analysts and detectives trained in the FBI’s methods conduct such analyses without being registered mental health professionals; ideally, however, they have access to psychological or psychiatric experts with whom they can discuss the case and obtain the necessary assistance and support. Regardless, these proposed skills suggest that some degree of specialist multidisciplinary knowledge is required. Similarly, Ritchie and Gelles (2002) suggested that mental health professionals conducting psychological autopsies should receive “basic didactic information” in the areas of crime scene investigation, toxicology, and forensic pathology. This advice would seem particularly necessary for psychologists who need not be medically trained and may not have a background in biology or chemistry.

Lack Of Standard Guidelines

Despite the fact that psychological autopsies have been conducted in cases of equivocal death since the late 1950s – and likely long before without being recognized as such – there is a remarkable lack of standard guidelines for the technique. Shneidman (1981), one of the originators of the technique, advocated a flexible procedure but noted that there were 16 areas of information which “might be included” in a psychological autopsy. These were extended and greatly elaborated by Ebert (1987) to 26 categories of applicable information regarding the deceased individual. Ebert’s list of information has been deservedly influential, as subsequent guides have essentially modified and slightly extended his initial list. All of these approaches provide useful information for ensuring that data collection is thorough. However, none describe how one should subsequently use the information to make a final conclusion (Otto et al.1993). Ogloff and Otto (1993) argued that without a standard technique, terms such as psychological autopsy “are really describing a goal of an inquiry as much as a particular technique” (p. 611). This is concerning because opinions expressed in psychological autopsies can ultimately form the basis of very important decisions. For example, Jobes et al. (1986) reported that, in an experimental paradigm, the inclusion of brief psychological autopsies had a statistically significant impact on medical examiners’ subsequent opinions regarding mode of death.

An attempt at providing an actuarial (i.e., mechanical and algorithmic) approach to one of the decisions involved in psychological autopsies is the Empirical Criteria for the Determination of Suicide (ECDS; Jobes et al. 1991). This is a 16-item tool, derived from an earlier 55-item Death Investigation Checklist, which can provide an indication as to whether a death is likely to be a suicide or an accident. The ECDS involves three sections. Section A refers to self-infliction and intention and consists of 13 items (e.g., toxicological evidence indicates self-inflicted death, decedent had suicidal thoughts). Section B refers to self-infliction only and includes two items (i.e., decedent had experienced general instability in immediate family, decedent had recent interpersonal conflict). Section C includes one item relating to intention only (i.e., decedent had history of generally poor physical health). A total self-infliction score is obtained by adding sections A and B, and a total intention score is obtained by adding sections A and C. The case is determined to be a suicide if the score on both totals is three or more. The case is determined to be an accident if at least one of the total scores is two or fewer.

The ECDS was found to correctly classify 100 % of suicides and 83 % of accidents in the cases reviewed, producing an overall level of correspondence with the professional medicolegal judgment of death 92 % of the time. However, and perhaps appropriately, the authors cautioned that “it must be emphasized that the ECDS do not provide absolute and definitive determinations of the manner of death independent of professional medicolegal judgment. Indeed, the ECDS should only be understood (and used) as a tool for investigation which augments professional judgment” (Jobes et al. 1991, p. 254). Similarly, Simon (2002) described the ECDS as “useful as an adjunctive tool to professional clinical judgment” (p. 150).

It should also be noted that the ECDS was developed to differentiate between suicide and accident modes of death, so it is not applicable in cases of potential homicide.

A Decision-Making Framework For Psychological Autopsies

As noted above, the various published lists of information required to inform a psychological autopsy vary in the degree and nature of information required, and they do not describe how one should subsequently use the information to make a final conclusion of accident, suicide, homicide, or natural causes. Shneidman (1981) provided a rare example in which a widow revealed to him her late husband’s suicide note that she had not shown the police, but such “smoking gun” variables are likely to be very rare in equivocal death cases. Ebert’s (1987) pioneering guidelines suggested that practitioners make a chart divided into the four nominal categories (natural causes, accident, suicide, homicide) and record data that supports each mode of death. Analysts were also encouraged to consider the possible reasons why the deceased may have committed suicide and the possible reasons why they may have been murdered. The listing of evidence for and against the four modes of death (or three, as some authors focus only on accident, suicide, and homicide where appropriate) has also been advocated by subsequent authors (e.g., Napier and Baker 2005; Ritchie and Gelles 2002). However, this process should not simply result in an additive procedure wherein the person counts the number of items in each category and chooses the one with the highest frequency count. Rather, Napier and Baker (2005) stated that “the goal is to arrive at a preponderance of factors listed under one of the headings” but added that “from this listing it becomes evident that some factors weight more heavily than others” (p. 624). The final determination is made therefore by the evaluator by some unknown weighting of the various pieces of evidence adduced.

Given the paucity of guidelines for assisting practitioners in making the inferential leap of determining accident, suicide, or homicide in psychological autopsies, Davis (2004, 2010) proposed that a scenario-based hypothesis-testing approach that forms part of a structured decision-making and report-writing framework may be useful. The first section of these guidelines is the Checklist of Equivocal Death Information. This brings together more than 30 areas of information included in previous psychological autopsy publications, as well as other potentially useful information, and is loosely divided into six domains: Personal, Health, Family, Relationships, Preceding Months and Days, and Death Scene. The assessor conducting a psychological autopsy is interested in the longitudinal status of information within each of these domains as well as any recent changes. The Personal domain covers the deceased’s education and employment history, military service, religious beliefs, legal history, victimization, writing, language, reading material, feelings regarding death, familiarity with methods of death, and hobbies and interests. The Health domain covers physical health, alcohol and substance use, and mental health (including general psychological history, mood, and personality). The Family domain addresses the quality of relationships with family members, any familial history of substance use or mental illness, conflicts within the family, and any history of suicides or recent deaths in the family, along with the deceased’s reaction to any such deaths. The Relationships domain covers the deceased’s history of intimate and non-intimate relationships, as well as the details of any current romantic relationships. The Preceding Months and Days domain draws the assessor’s attention to psychosocial stressors, any pre-suicidal behavior, recent changes in habits or routine, and any evidence of future life plans. An estimation of the mental status examination prior to death (i.e., orientation, mood, affect, psychotic symptoms, and judgment) is made, and the events of the day prior to death are reconstructed with particular focus on any departures from the deceased’s usual routine. The final domain is the Death Scene. This involves an examination of the police report, death scene photographs, pathology and other forensic reports, any suicide notes, and the significance of the death scene to the victim. Particular attention is paid to any evidence of other people at the death scene, any signs of a struggle, the possibility of a staged crime scene, or evidence of sexual activity.

There is some unavoidable overlap between these various domains. However, the grouping into six categories facilitates consideration of the deceased’s personality, behavior, mental state, and interpersonal environment over time, with the final two domains providing an eventual focus on the preceding days and the death itself. The checklist, like other previously published psychological autopsy checklists, provides an aidememoire for the assessor to ensure that a comprehensive assessment takes place, thereby reducing errors of omission. However, a thorough assessment will also be sensitive to the idiographic features of the case. For example, if the death potentially involved dangerous autoerotic practices, more information regarding the deceased’s history of such behavior would undoubtedly be required. Hazelwood et al. (1981) identified five characteristics of the autoerotic death scene which assessors should consider in such situations: evidence of a physiological mechanism for obtaining sexual arousal that is dependent upon a self-rescue mechanism or the victim’s judgment to discontinue its effect, evidence of solo sexual activity, evidence of sexual fantasy aids, evidence of prior dangerous autoerotic practice, and no apparent suicidal intent.

To use this wealth of information to answer the questions required of a psychological autopsy, Davis (2004, 2010) has argued that it is important to adopt a method in which the totality of the data is considered in context. While not a case of equivocal death, Canter (1999) alluded to the use of a hypothesis-testing approach in investigating the cause of a fire. This is not unlike the “scenario”-based approach advocated for the assessment and management of recidivism risk in offenders and sex offenders (Hart et al. 2003), although that approach is used to speculate about the future rather than the past. Nonetheless, such an approach appears relevant to the analysis of equivocal deaths, as it promotes consideration of multiple variables in context, rather than simply adding variables together in an abstract mechanical fashion.

Using the above approach, Davis (2004, 2010) proposed that assessors develop a series of scenarios that may explain the death in each modality (accident, suicide, and homicide). The assessor then lists the evidence for and against each competing scenario. It is important to explicitly list and evaluate evidence that does not support one’s preferred scenario, as failing to acknowledge conflicting information may contribute to the bias of the assessor and has been a previous criticism of psychological autopsies (Poythress et al. 1993). In essence, each scenario is conceptualized as a hypothesis that has to be subjected to systematic critical scrutiny and potential falsification.

In evaluating these scenarios, relevant empirical information should be consulted where appropriate. For example, significant changes in routine are an important consideration in suicide cases (Litman et al. 1970). When formulating homicide scenarios, it is important to also consider the deceased’s level of risk for murder and to determine how much their lifestyle and activities placed them at risk of being a victim of violence. When formulating accident scenarios, the lethality of the deceased’s behavior should be taken into account, such as how likely an accident was to result in death.

At the end of this process, Davis (2004, 2010) proposed that assessors rate the likelihood that each scenario occurred. This can be expressed in probabilistic terms, or perhaps more appropriately, using ordinal ratings of low, moderate, or high. This is important, because as mentioned above, making outright conclusive opinions has previously been questioned in the literature (Poythress et al. 1993). It would be prudent to consider relevant crude base rates where possible (although they will presumably all be quite low) and also to consider which is the most parsimonious explanation out of the competing scenarios. When making their final determination as to likely mode of death, it may also be helpful for the assessor to provide an indication of their confidence in the decision being made. Indeed, Douglas and Ogloff (2003) have found that determinations of future risk made by forensic mental health evaluators when they are confident about their decision are more likely to be accurate than when they are less confident about their determinations of risk for violence. The option of “unclear” should always be available, as the assessor should not feel that a conclusive opinion must be made. It is an inevitable reality of this inexact and complex practice that some cases will simply have to remain equivocal.

Communicating Psychological Autopsy Results

The most detailed and prescriptive report-writing guidelines for psychological autopsies have been provided by the United States military. These guidelines involve numerous subheadings in an attempt to carefully avoid speculation in the report. Part of a proposed peer review process is to determine whether the examiner has followed the prescribed structure when writing their reports (see Ritchie and Gelles 2002). Employing a somewhat different approach, Davis (2004, 2010) suggested that the exact format of the report will likely vary from case to case; however, a useful structure should include the following components: sources of information and caveats, case summary, personal history of the deceased, stressors, evaluation of different scenarios in each modality (the core of the report) and a final opinion of which scenario is most likely, and the assessor’s degree of confidence about the opinion.

Future Directions

The psychological autopsy has been in existence for more than 50 years. However, it is still hampered by questions of practically unknown reliability and validity. Indeed, Ogloff and Otto (2003) observed that it is difficult to find another area of psychological expert testimony that has been admitted as evidence with such little empirical foundation. It should be noted that reliability has received some limited research attention in regard to the psychological autopsy of unequivocal suicides. Werlang and Botega (2003) developed a semi-structured interview protocol to assist in conducting such analyses. They found that this resulted in a high level of inter-rater reliability in regard to assessors’ final ratings on each scale of precipitators and stressors, motivation, lethality, and intentionality. Similar studies are needed to determine the inter-rater reliability of psychological autopsies in cases of equivocal death, particularly in regard to the various modes of death. Structured guidelines, such as those described above, have the potential to maximize inter-rater reliability over that of more intuitive approaches.

Establishing the validity of psychological autopsies is extremely difficult, which may explain why it has not yet been accomplished or even attempted. By definition, validity is impossible to determine because the focus of the analysis is deceased. The very factors that make a death equivocal and in need of a psychological autopsy also obviate any knowledge of the “true” mode of death by which to compare the outcome of the analysis. However, Ogloff and Otto (1993) suggested almost two decades ago that researchers could identify cases in which the correct answer is known and then remove the most obvious information, such as a suicide note, prior to presenting the case. Analysts using the psychological autopsy could then be compared to the known “true” outcome to provide some measure of predictive validity. However, such studies have not yet been conducted. Accordingly, the psychological autopsy currently remains a promising, yet unavoidably subjective, form of forensic analysis in cases of equivocal death.

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