Introduction
From time to time incidents of suspicious death occur in which the mental state of deceased persons needs to be assessed. If some evaluation can be made of the sort of person they were, their personality and thought processes, especially as that may throw light on any involvement they themselves had in their death, then it may assist the investigation of what is sometimes referred to as ‘equivocal death’. Such an evaluation, known as a psychological autopsy, is an attempt to reconstruct a person’s psychological state prior to death.
The typical case for which a psychological autopsy may be of value is one in which there is some doubt as to whether death was accidental, self-inflicted or malicious, and whether the deceased played an active role in his or her own demise. Such matters can be especially important in life insurance claims that are void if the death were suicide. They are, of course, also of potentially great significance in murder inquiries, such as those in which there is a question as to whether the deceased contributed to his or her own death in some way. Fatal accident investigations, in which the technicalities of what actually led to the accident are difficult to resolve, are other forms of equivocal death in which psychological examination of aspects of the main actors/victims may be essential.
Virtually all attempts to use psychological procedures to throw light on a person’s thoughts and feelings prior to their death have taken place in the USA, most of them in civil and criminal litigation rather than as part of an investigation. It has been claimed, for example, that ‘the drawing of a psychological picture of a dead person whom the expert has never met’ can be a ‘tool for criminal defense attorneys’. The expert who draws such a picture can be used in court to argue, for example, that a person accused of murder was acting in self-defence, or whether a gift is in contemplation of death and therefore of relevance in considerations of taxes due on death.
Many equivocal death examinations, however, have been part of civil proceedings in which a worker’s compensation case makes it necessary to establish that certain events affected the deceased in a particular manner, or that work-related injuries contributed to the eventual suicide of an individual. Another example would be where a will is contested, so the mental state of the deceased is the major legal battle ground. In the case of Howard Hughes, for instance, a psychologist concluded that ‘psychological problems, numerous head injuries, and drug misuse had changed a vibrant millionaire into an emaciated recluse’. The possibly psychotic basis of his reclusiveness, rather than mere eccentricity, posed challenges to the probity of his estate.
A possibly less obvious circumstance in which the characteristics of a person may be usefully inferred, even though that person is not available to answer personal questions, is an inquiry into the report of a missing person. Another example is when it is necessary to understand the decisions made, and actions taken, by people who are no longer able to answer for themselves. For example, in the planning of care routines for demented patients it is inevitable that some inference will be made about the mental state of the people in question. Making those inferences as systematically as possible, drawing on whatever psychological information is available, is likely to improve the decisions being taken.
Psychological Autopsies
Attempts to assess the mental state and characteristics of a person who is not available for direct examination contrast with the task that usually faces mental health professionals: effective mental health assessments typically require the participation and cooperation of the examinee. Although in some circumstances the examinee may choose not to cooperate, it is considered essential that the examinee be available for evaluation. Furthermore, the current mental state and adjustment of the individual concerned is the focus of attention, notably in competency and capacity evaluations such as child custody, competency to plead and competency to testify examinations. For even if subjects of assessments are not willing to participate they can be directly observed, their demeanour considered and their transactions with others noted and other aspects of their daily lives recorded directly. If they are not present, all these aspects of them, which can assist in assessing their mental state, have to be inferred at second or third hand.
Even though evaluations conducted in the absence of the examinee are fraught with challenges and problems, this has not stopped a number of clinical psychologists, psychiatrists and law enforcement agents in the USA from producing such assessments. They have given them a variety of terms, including ‘psychological autopsies’, ‘psychiatric autopsies’, ‘reconstructive psychological evaluations’ or ‘equivocal death analyses’, even ‘offender profiles’ in some cases.
Useful distinctions can be drawn between these different activities, depending on whether the target of the examination is actually known. In the case of the examination of a crime scene to infer characteristics of the offender, often referred to as ‘profiling’, the main quest is to determine the identity of the perpetrator. But where the identity of the subject is known, as in the attempt to determine whether the death was by accident or suicide, the objective is to reconstruct the mental state of the deceased. If this can be based upon information obtained from people who had direct or indirect contact with the subject of the examination, then it is most likely to be called a ‘psychological autopsy’. In cases where the investigation 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, it may be called an ‘equivocal death analysis’ or EDA. Clearly an EDA is open to many more biases and distortions than a ‘full’ psychological autopsy. What little experience there is about EDAs casts grave doubts on their validity.
The difference between a literary autopsy, or a military character analysis, and a psychological one are likely to be differences of degree rather than kind. A psychologist would be expected to provide more systematic detail and to give clearer evidence for the conclusions reached. It might also be expected that the psychologist would more confidently express views on the motivations and personality of the target than would other authorities. However, the contribution of psychologists to the investigation of equivocal deaths is still very limited, and probably not as different from the work of a literary biographer as some psychologists would like to think.
Perhaps the most obvious difference to hope for, between the literary recreation of a bygone celebrity and a psychological autopsy, is that the psychologist would draw upon what is known of people and processes similar to that demonstrated in the actions at the centre of the inquiry. The individual being considered would be taken as an illustration of people and processes who are known to have carried out similar actions. In this way, the expert opinion would be clarified and bolstered by the empirical evidence of other known cases. For example, knowledge of how adolescent suicides prepare to take their own life, or what is typically contained in a suicide note, may be drawn upon to develop the account of the individual and his or her actions, before death.
Unfortunately, there is still very little detailed empirical evidence available on many topics that are relevant to contributing to equivocal death investigations. Perusal of the literature also indicates a lack of a comprehensive assessment and evaluation of the nature and validity of those psychological autopsies that have been carried out. It is therefore most appropriate to consider the psychological autopsy as a relatively unstructured technique, in which mental health professionals attempt to describe the thought processes and personality of a deceased person prior to death, and in some cases to comment on their likely participation in their own death. Its contribution to equivocal death investigations may therefore be best regarded as the development of an organized framework for indicating the issues to be considered when forming a view about the deceased.
The most common equivocal death scenarios that are examined in the USA are those in which suicide is suspected but is not absolutely certain. The first people to contribute to such examinations are generally regarded as being Shneidman and Farberow at the Los Angeles Suicide Prevention Center during the 1950s. They responded to requests from the coroner that they assist in determining the cause of death in equivocal suicides. Information from persons related to the deceased was combined with the coroner’s (i.e. pathological) findings to determine the cause of death as either suicide or accident. Shneidman and Far-berow gave technical definition of the psychological autopsies that they carried out for the coroner: ‘A retrospective reconstruction of an individual’s life that focuses on lethality, that is, those features of his life that illuminate his intentions in relation to his own death, clues as to the type of death it was, the degree (if any) of his participation in his own death, and why the death occurred at that time’.
The Technique
As has been indicated, contributions to equivocal death investigations can range from an essentially informal attempt to reconstruct the thoughts of the deceased to a much more thorough exploration of everything that is known about him or her. For, although such contributions have been made over a period of approximately 40 years, there are still no standardized procedures that have been agreed upon for making them. However, where more systematic methods are employed, they have commonly involved obtaining information from interviews with survivors of the deceased and archival sources. Shneidman and his colleagues interviewed relatives, friends, employers, physicians and others, including teachers and in some cases even bartenders, who could provide relevant information in an attempt to reconstruct the deceased’s background, personal relationships, personality traits and lifestyle. They sought significant details of the events immediately preceding the death. All of this information was subsequently reviewed by the death investigation team in the coroner’s office, resulting in a determination of the mode of death.
Shneidman subsequently developed an outline for conducting a psychological autopsy, which essentially consisted of a 16-point check list (Appendix I) that is not that dissimilar to the framework that might be used by any physician in preparing a medical case history. The major differences from other forms of medical case history are the focus on what is known about the deceased’s typical actions, especially reactions to stress, what might be known of the person’s interpersonal relationships, thought processes and experiences surrounding the death. The procedure is based on the assumption that people close to the deceased can provide accounts of both historical and recent developments and behaviors of the deceased. Likewise, historical and recent archival information, such as physicians’ records, may contribute to a determination of the individual’s mental state at a particular point in time. The procedure also implies a form of corroboration in which as wide a range and variety of sources of information are collected to ensure that the bias inherent in any one source of information does not distort the whole picture.
The problem of bias is an especially important one, given the importance that may be given to the psychologist’s opinion about the cause of death. Yet few writers on this process discuss it in any depth. Litman and coworkers are possibly the most direct in drawing attention to recurring problems. They point out that there is often a lack of information about the individual, particularly information that could be used for a reliable inference regarding his or her psychological state. Secondly, the information may be distorted by the informants. They cite instances of evasion, denial, concealment and even direct suppression of evidence. Indeed it may be expected that expert advice is required precisely in those situations in which there are doubts and ambiguities surrounding the events of the death. That, after all, is what makes it ‘equivocal’, so the problems described are part of the reason why an expert is called in to help.
In an attempt to reduce these inherent difficulties Brent proposed that particular attention be paid to the choice of informants, the manner of approach to informants, the effect of the time period between death and the interview on the quality of the information obtained, and the integration of the various data sources. He suggested broadening the range of informants, particularly to include peers in the case of adolescent suicides. He also provided guidelines for approaching informants, emphasizing professional distance and the avoidance of platitudinous commiseration. Brent also reports that he found no simple or consistent relationship between timing of the interview and the quality and quantity of the data obtained. He further recognized that, although the integration of various data sources is a common problem in psychiatry, it is a particularly salient issue in the administration and interpretation of the psychological autopsy. Brent reviewed the relationship between direct and indirect interviews as methods of obtaining family history, suggesting that both sensitivity and specificity of data may be enhanced by increasing the number of informants and including more female informants.
Thus, one of the contributions of behavioral scientists to the formulation of opinions on a suspicious death is the greater care and systematization that they bring to the process, drawing on sources that might not normally be considered by legal professionals or physicians. The most comprehensive set of guidelines, intended to enhance the systematization and move towards standardization of the psychological autopsy, has been provided by Ebert (Appendix II).
Process
In keeping with a procedure that has evolved in response to practical and legal demands, there is no well-developed conceptual or theoretical basis for deriving conclusions from the various sources of information to provide guidance on equivocal deaths. It appears that the professionals involved draw upon their experience to relate the facts to symptoms or syndromes that they would draw upon in their daily practice, searching, for example, for evidence of psychosis, depression or organic dysfunction.
In an attempt to systematize the basis of any guidance, various authorities have proposed some principles, especially for determining if a death was suicide. Perhaps the most clearly stated principle is that expressed by Faberow and Schneidman, that most suicide victims communicate their intentions to others in some way. These principles have been converted into a standardized assessment protocol by Jobes and coworkers. They provide a 55-item Death Investigation Checklist that can be used by medical examiners. On the basis of a successful test of the validity of this checklist they developed 16 criteria that they called the Empirical Criteria for the Determination of Suicide (ECDS). This process enabled them to clarify determination of suicide as being based on the concepts of ‘self-infliction’ and ‘intention’. This allowed them to derive a score from the ECDS for each of these aspects. By comparing the scores obtained in 35 known accidental deaths and 28 known suicides they were able to show that ‘self-infliction’ and ‘intention’ scores both had to be greater than 3 for the death to be declared a suicide.
Although this procedure adds a rare level of precision to what are often difficult medicolegal decisions, the authors emphasize a caveat. Even though, ‘medicolegal judgements may be strengthened through such tools, leading to more objective and scientific determination of suicide as a manner of death. It is critical to note that the ECDS instrument is not meant to be a rigid and definitive standard designed to usurp the professional’s judgement and authority’.
Validity of Psychological Contributions to Equivocal Death Investigations
Given the many difficulties associated with contributing to equivocal death investigations, it might have been expected that there had been many attempts to determine how effective they actually are. Yet there has been very little research that examines the reliability or validity of psychological autopsies or related contributions to inquiries into fatalities. As mentioned, some preliminary work to develop operational criteria for determining suicide as cause of death has been conducted. Fifteen years earlier, in 1976, Shneidman rather disingenuously, referred to the increasing acceptance by coroners of psychologists’ opinions as a measure of the validity of those opinions. One group found a high correlation between rank-ordered types of depressive symptoms in depressed suicide victims and in clinically referred depressed patients. This work in effect demonstrated the capacity of interviewers, using a psychological autopsy format, to elicit such information accurately, albeit across a narrow spectrum. Others used the family history interview process to confirm diagnoses obtained via a psychological autopsy procedure, although recognizing that this study was subject to limitations of possible interviewer bias, interviewee bias and a limited sample.
It has been recognized that, even before the validity of psychologists’ contributions to inquiries can be sensibly explored, it is important to establish whether different psychologists would offer the same opinion if given the same information. This is the issue of ‘reliability’ rather than ‘validity’. If different psychologists form different views when presented with the same material, then there is little hope that, in general terms, the opinions derived from the processes they used would be correct, or valid.
One study examined the agreement between reports completed by 12 psychologists and two psychiatrists, who reviewed materials that addressed the adjustment and psychological functioning of Clayton Hartwig, suspected of causing an explosion aboard the USS Iowa in 1989, resulting in his own death and that of 46 other sailors. Although broad criteria were adopted, only moderate agreement was found between the findings of the 14 professionals conducting the assessment.
This study was initiated as a reaction against an EDA carried out by FBI agents into the USS Iowa tragedy. The agents had formed the conclusion that Clayton Hartwig had deliberately caused the explosion in an act of suicide. Their opinion was upheld by the initial Navy inquiry. However, a number of psychologists were highly critical of the EDA and the way it was carried out. Their examination of the facts indicated that the explosion was indeed an accident, a conclusion later supported by the technical evidence and accepted by a US Congress investigation. It was suggested that the FBI used scientific terms for a process lacking significant scientific methodology, and compounded that problem by failing to delineate sufficiently between ‘opinions’ and ‘facts’.
Two critical points must be made. Firstly, as emphasized earlier, the EDA technique was characterized by the examiners not conducting any interviews but relying on information provided to them based on interviews conducted by other parties. Secondly, given the nature of the initial inquiry and the subsequent review, the persons conducting the review had available to them a quantity of information significantly greater than would normally be present for most assessments. Even with this additional information, though, all panellists would have preferred more information regarding Hartwig.
Subsequent to this review, FBI agents who provided the testimony agreed with the view that ‘perceived utility and anecdotal evidence are mere proxies for validation, not validation itself’. Yet they rather confused the issue by asserting that EDA was an investigative technique and not a clinical investigative method, somehow implying that the sort of detailed evidence that a ‘clinician’ might use in helping an investigation was irrelevant to FBI agents trying to achieve the same objectives.
The FBI agents further asserted that EDA is not a clinical but a professional opinion, based on years of law enforcement experience with indirect assessment of violent death, and the demands of law enforcement require that opinions be provided that do not equivocate. In other words, they are advocating opinions based merely on previous experience without any scientific support for those opinions, or even any possibility for demonstrating that hypotheses alternative to their opinions had been available for test. That they have provided a ‘conclusive’ opinion in 42 or 45 EDAs, as they claim, is of considerable concern when viewed in the context of the technique’s lack of even demonstrated reliability, and the opinion that ‘to provide the validity is an exercise in futility’.
In contrast to the surprisingly cavalier view of some FBI agents, the use of blind studies to obtain an estimate of the validity of the psychological assessments of equivocal death victims has been suggested. In relation to the determination of the mode of death, identification of cases in which the ‘correct’ answer to the question is known has been proposed. Ideally, a group of mental health professionals should be provided with all the information, except for one or two key pieces that clearly identify the correct answer (e.g. a suicide note). The subsequent opinions could then be compared to the ‘correct’ outcome to provide an estimate of validity. Alternatively, evaluation of ‘available’ persons and then provision for assessment of all information, except that which is based on the ‘availability’ of the examinee, has been proposed. Opinions could be compared to those based on comprehensive assessment (including psychometric data) of the individual. Such approaches to address the issues of reliability and validity would seem to be the minimum necessary, but do not yet seem to have been conducted. This suggests mental health professionals should be cautious when using reconstructive psychological evaluations, particularly in legal and quasilegal contexts and those major inquiries, like that in the USS Iowa tragedy, in which much of significance to many people may result from the expert’s opinion. Professionals are ethically obliged not to mislead their clients about the accuracy of the conclusions they draw.
Admissibility
Despite the many weaknesses of the evidence and procedures used in psychological autopsies and the lack of definitive research to support its validity, it is clear that opinions from psychologists and other mental health professionals, about the mental state of the deceased, have been drawn upon in many courts in the USA and can strongly influence the judgements of those who read them. One experiment showed that 95 medical examiners who received reports containing only physical and circumstantial evidence about a fatality gave distinctly different judgments from 100 who had the same reports augmented with psychological opinion. Given such potential impact, it is perhaps not surprising that many jurisdictions have admitted them.
A significant review of the use of the psychological autopsy in both civil and criminal cases cited the case of State v. Jones, CR No. 98666 (Arizona Superior Court, 1978), where the psychiatric autopsy of a murder victim was admitted on behalf of the defendant, who claimed self-defense in the killing. The psychiatric autopsy was deemed to show that the defendant, a repeatedly battered wife, was not unreasonable in her assumption that the victim might have killed her. In another case, that of State v. Carrethers, CR No. 100359 (Arizona Superior Court, 1978), a psychiatric autopsy of the defendant’s deceased father was admitted. [In these criminal cases the term 'psychiatric' rather than 'psychological' autopsy was used. Some authorities assert the terms are interchangeable.] The defendant claimed defense of his mother in the killing of his father. The psychiatric autopsy indicated that the father drank heavily, routinely battered his wife and stepdaughter, and provoked numerous acts of violence at work. Again, the psychiatric autopsy revealed that the son had been reasonable in his reaction to his father’s violence. Nonetheless, the review highlights the difficulties associated with the admissibility of psychological autopsies as evidence in court hearings, both in terms of Federal and State (USA) rules of evidence and the inconclusive debate regarding the scientific basis for the technique.
There has been a very thorough review of the questions that psychological autopsy evidence needs to answer satisfactorily if it is to be admissible in a US court. Does its probative value outweigh its prejudicial impact? Will it directly assist the trier of fact? Are such autopsies reasonably relied on by experts in the field? Does the proposed witness qualify as an expert? These are exactly the same questions that a British court would wish to answer, but a British court would probably look for slightly different emphasis; for example, perhaps being more concerned about possible prejudice and less concerned about the status of the expert.
It has been pointed out that at least one supreme court in the USA, that of Montana, has directly upheld the admissibility of a psychological autopsy against an appeal that the psychologist should have interviewed the deceased prior to his death in order for his expertise to be valid. The court held that the fact that the deceased ‘was not interviewed before his death does not render inadmissible a psychologist’s opinion based on the available data’. However, it was emphasized that, while many courts trying accident claims have accepted psychological evidence concerning the deceased state of mind prior to death, they are more reluctant to permit experts to testify about whether the death was a suicide or an accident.
In applications challenging wills and intestate succession, the courts are reluctant even to accept psychological opinion about the intentions or state of mind of the deceased. This seems to be because such opinion is deemed to intrude too closely into the legal realm. The courts believe that, given the same information available to the expert, they could form a view themselves that would be just as valid. This is not far removed from the opinion that there is indeed much that a layman can do in forming a view about a dead person that will parallel the opinion of a professional psychologist. Furthermore, as was shown in the USS Iowa case, there are definite possibilities of prejudice, whereby an opinion presented by an apparent expert is given more credence than it deserves.
All available accounts of psychological opinion relevant to equivocal death cases, used in court, are drawn from the USA. The examples, in the main, though, tend to be civil cases relating to insurance and worker’s compensation. Even in the USA, criminal cases are rarely likely to admit psychological autopsies as expert evidence. No instances of its use in courts in other English-speaking countries have been identified. This may, partly, be a function of the data-gathering or terms used. There are clearly circumstances where defense cases, for example in England or Australia, rely on evidence regarding the personality and mental state of a deceased victim in order to promote the issue of self-defense or provocation.
Relevance to Criminal Investigations
The potential for misuse of reconstructive psychological evaluation techniques has been highlighted with reference to the paucity of the research literature and the difficulties illustrated in the Gilfoyle case and the USS Iowa inquiries. In using a technique with no well-established reliability or validity, the courts are appropriately cautious about allowing its use in evidence. Without doubt, the value of the procedure can be enhanced by drawing on as many and as varied direct sources of information as possible. A clearly scientific stance, in which alternative hypotheses are tested, would also help to reduce the influence of those agencies or other parties with a biased interest in the outcome of the investigation. Such a stance would require the following:
1. Clear statement of the alternative explanations that are feasible to account for the equivocal death.
2. Clear indication as to the evidence that would be required to support or reject each of these explanations.
3. Full account of the evidence that is available and how it relates to the evidence that would be required.
4. Evaluation of the evidence available and the processes that have been undertaken to test it accuracy and validity.
5. Clear statement of how the evidence has been drawn upon to reach conclusions about each of the explanations offered.
Such a thorough report is very demanding and time-consuming to produce. It also likely to require scholarship and research beyond obtaining the facts of the case and accounts from those close to the deceased. In the pressures of a criminal investigation and the legal process, there may not be all the resources necessary to carry out the task at as high a professional standard as all may wish. In such cases the weaknesses in the psychologist’s activities need to be clearly stated, or the professional should actually refuse to undertake the task.
