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(Nota: Artigo sem Tradução em Português)
According to Shneidman's definition (1981), the psychological autopsy is a retrospective reconstruction of a decedent's life initiated to get a better understanding of his death.
The information collected with the psychological autopsy method is of great value to determine and clarify the equivocal death within the NASH(1) classification. Most of death certificates are inaccurate with respect to the modes and may balance between suicide or homicide, but they also may balance within one of the four categories or between them. For example, a death by asphyxiation due to drowning doesn't specify if it was accidental, homicidal or suicidal. This brings another Shneidman's concept of equivocal death, which means that the exact mode of death is unclear despite the medical autopsy ruled asphyxiation as the cause.
Only through the knowledge of the life and psychological history of the decedent, the mode of death can be clarified. What was the decedent's role in his demise is very important to reach a conclusion. It is then a valuable tool in suicidology.
It is important to define the psychological autopsy concept and compare it with the physical autopsy to understand the differences and the similarities of both processes.
The major difference, points to the fact that the physical autopsy method is limited in its physical context, whether the psychological autopsy comprises a more broadening scope in which the physical autopsy results are part of the evaluation process.
The two definitions are here presented:
"Autopsy - A surgical procedure, postmortem, which involves the examination of body tissues, often to determine cause of death." - There are three major differences from this definition that are very important: surgical procedure, examination of body tissues and cause of death.
Replacing these three terms with: psychological procedure, examination of psychological history and mode of death, the definition for psychological autopsy would appear like:
"Psychological Autopsy - A psychological procedure, which involves the examination of the psychological history, often to determine the mode of death."
But this definition would lack some accuracy and completeness. Instead, a more accurate and accepted standard definition is proposed:
"Psychological Autopsy" - A retrospective reconstruction of the life history of the decedent, which involves the examination of physical, psychological and environmental details of the decedent's life in order to more accurately determine the mode of death and get a better knowledge of the death process and the victim's role in hastening or affecting his own death.
As it comes from the definition, the main purpose of the psychological autopsy is to evaluate more accurately the death process of the decedent and thus clarify the final classification of the death mode in the death certificate.
The method has a variety of applications that goes from forensic to statistical applications, which will be outlined bellow.
The psychological autopsy method
In a brief historical review, the psychological autopsy method was a result of efforts of the Los Angeles County Chief Medical Examiner-Coroner, Theodore J. Curphey, M.D. in 1958. Seeing himself unable to certify the mode of a great amount of drug deaths, the Los Angeles Suicide Prevention Center was then contacted to provide assistance in a multidisciplinary joint study of these deaths.
Conducting a psychological autopsy requires reviewing detailed information of the decedent's life, including health records, professional records, interviewing persons from the decedent's social environment, and all the material that could identify the psychological characteristics of the individual.
Some of the main categories included in the psychological autopsy method that provide valuable information are as follows:
- The victim personal information - name, age, marital status, address, occupation, religious activities, personal interests and any information that can help in the construction of the victim's profile.
- Details of death - date and time of death, cause and or method, place of death, police report and witness (if available), autopsy.
- Victim's history - siblings, marriage, medical illnesses and treatments, prescriptions, suicide attempts, therapies, inpatient and outpatient admission history.
- Stress coping - emotional upsets, disequilibrium, coping style to stressful situations.
- Death history of the victim's family - suicide, cancer, fatal illnesses, ages at death.
- Personality - description of the victim's personality and life styles.
- Precipitant factors - short and long term history of upsets, pressures, tensions and other stressful facts of the victim's life.
- Addictions - alcohol and or drug abuse and its implications in the victim's life.
- Interpersonal relationships - within the family, with physicians, friends, coworkers etc.
- Fantasies, dreams, thoughts, premonitions, fears relating to death, accident or suicide.
- Changes before death - eating, life routines, habits, hobbies, isolation.
- Life events - victim's future plans, successes, swings, other important.
- Intention - assessment of the victim's intentionality.
- Lethality - assessment and evaluation of the method and process in which the death has occurred.
- Informants - their reaction to the victim's death, coping, relationship with the victim.
The interviews with the informants should be conducted with open ended questions, thus enabling the information to flow naturally without the informant be aware of the specific interests of the interviewer. The method of interview should permit that one question gives permission for another thus excluding the need to force answers or disregard the grieving process in which family members may be.
The results of the interviewing are usually discussed with the chief medical examiner or coroner. It is his responsibility for the amendment or certification of the mode of death and the psychological data available is added to other data relative to the process.
It is a very important process that serves also to increase the accuracy of certification, having for example as result a more reliable source for statistics.
Application in suicidology
Despite its use for other modes of death certification that not suicide, it is in suicide that the psychological autopsy has it's most important application.
The method permits the study of the overall factors that contribute as precipitators in the individual's life and its cessation.
It help us to understand the suicidal process as a multifactor phenomenon and can be a valuable tool in future research activities.
With respect to the bereaved survivors, if properly conducted the interviewing process could have a great therapeutic value. It is primarily a postvention(2) process or its beginning.
When studying the suicidal phenomena, statistical data are very important to understand the evolution of the efforts in suicide prevention. The accuracy of the death certificates are extremely important so that the statistical analysis of suicidality may be reliable and not flawed by the equivocal death certificates. One of our contemporary problems with data on suicide rates is due to some inaccuracy of the death certification process worldwide. Many factors are involved like stigma, family protection, that may contribute to death certification flaws.
Investigators conducting a psychological autopsy should follow an outline where the relevant data from the entire process is recorded. Collected data should be recorded with precision and any relevant data not included should be stated as missing.
Any changes in original findings that may alter the conclusions of the report should be presented in a supplemental report with the explanation on how the new findings changes the original ones and conclusions.
Ethic and legal issues
The investigator should be aware of the ethical concerns resulting from the application of this method of investigation. The confidentiality issues of the decedents and informants should be rigorously taken into account.
Also the investigator should be aware and sensible to the fact that family members may be at different stages on the grieving process and thus conduct the investigation not only taken this fact into account without forcing questions and answers but also being aware for the need of psychological support of the informants.
Country and state laws should be checked regarding the psychological autopsy process and confidentiality, specially if for court room use.
The psychological autopsy is then a valuable tool in suicidology. It may be said that the method is basically pure suicidology. Not only that permits the understanding of all the factors that precipitated death but also the decedent's role in his own demise and his psychological state before his death.
The therapeutic value of this investigation method should also be taken into account as a valuable resource for the victims-survivors in their grieving process. The correct assessment of their needs will work as a guide for the future therapeutic actions.
The achievement of more accurate death certificates will result also in more accurate statistical data for the suicide rates. It may also be used to provide information for the study of self-injurious behaviors or parasuicide.
1) NASH classification of death - is an acronym for Natural, Accidental, Suicidal or Homicidal classification of deaths (Shneidman, 1993)
2) Postvention - Activities which occur after the suicidal event. The post-ventive efforts can be of two types: a) working with an individual after he has made a suicide attempt. b) working with survivor-victims of a suicide to help them with their anguish, guilt, anger, shame, and perplexity. (Shneidman,1969)
_Shneidman, Edwin S., Ph.D.(1993). Suicide As Psychache: A Clinical Approach to Self-Destructive Behavior. New Jersey: Jason Aronson, Inc.
_Shneidman, Edwin S., Ph.D. (1967). The forensic pathologist and the multidisciplinary approach to death. In Essays in Self-Destruction. 1st. Ed. p.p. 463-474. New York: Science House, Inc.
_Shneidman, Edwin S., Ph.D. (1969). On The Nature of Suicide. 1st. Ed. p.p. 21. San Francisco. Jossey-Bass. Inc., Publishers.