Mental Disorders and Suicidal Intention

Background

This report continues to explore the use of psychological autopsies to clarify intention in suicide, comparing clinical experience with courtroom experience. In a previous communication (Litman, 1984), I described cases in which courts were asked to decide whether insurance benefits would be paid after a death. These disputes focused on a clause that is found in most life insurance policies, stating that for the first 2 years the face value death benefits will not be paid if the death is due to suicide “sane or insane.” The various states have somewhat differing interpretations of this clause, which has been an element in life insurance policies for almost 100 years. In 1979, an Appeals court in California announced a novel and unique interpretation, ruling in the case of Searle v. Allstate that (by definition) an insane person cannot commit suicide, since an insane person would not be capable of forming a suicidal intention and understanding the nature of the act. In my previous report, I criticized that decision, pointing out that the psychological key to defining suicide is intention, and that “insanity” is not a relevant issue. Subsequently, in April 1985, the California Supreme Court overruled the Appeals Court (Searle v. Allstate, L.A. 31703 Sup. Ct. No. 405535), stating that insane people have committed suicide throughout history and that what is essential in defining suicide is that the victim intended to end his or her life. The Court specifically ruled out the concept of “irrisistible impulse” as a factor that would negate or supersede intention. What was essential, the court repeated, was that the person understood that the self-destructive act would end his or her physical existence. Finally, the Court held that the burden of proof was on the insurance company to show, by a preponderance of the evidence, that the person intended his or her own death.

The Meaning of “Intention”

The verb “to intend” is derived from the Latin verb intendere, which means “to stretch out toward, or to end at.” In English, “to intend” means “to have in mind as something to be accomplished; to contemplate; to plan; to design; to purpose.” The noun “intention” indicates stretching out of the mind, or psychological exertion for a purpose, to an end.

There are stages in the development of intention, beginning with imagination or contemplation of suicide, continuing through development of a plan or a design, then moving into implementation of the plan through imaginary or realistic rehearsals, and finally culminating in a self-destructive action. The concept of suicide requires that the self-destructive action has, as at least one of its purposes or goals, the death of the person. However, no one can know for certain that a given self-destructive action will result in his or her death. For example, people have survived after shooting themselves in the head or jumping off the Golden Gate Bridge. We may say that suicide certification requires that persons committing self-destructive actions have it in mind that the actions will result in their deaths, within the limits of predictability.

In evaluating the purposes and goals of suicidal actions, we need to understand the motives for suicidal actions. Suicide is always available as an option for persons who have problems in life that they consider to be insoluble by any behavior other than suicide. The purpose in suicide is to resolve problems of living that are causing a great deal of pain and distress. The common statement about suicide in farewell notes is that “this is the only way [to solve my problems].” Additionally, notes often contain the following: “I'm sorry; I love you; please forgive me.” In suicide, a person has it in mind to end a distressing life situation by a self-destructive act, which carries a known predictability for causing death. Death is understood, in the mind of the person, as an end to his or her earthly existence. When one's own death is being used instrumentally to solve life's problems, we are talking about suicide.

With intuitive awareness of this circumstance, family members of a person who has died as a result of a self-destructive action will claim, “This death could not have been suicide because the deceased person had no life problems. The person was perfectly well adjusted, happy, enjoying life, had many plans for the future. We even had tickets for a vacation next week.”

Insanity and Suicide

In my previous paper (Litman, 1984), I dramatized the concept of degrees of intention in suicide, evaluating the amount of planning, deliberation, and special effort required by classifying self-destructive deaths in a manner analogous to the way homicides are classified (first-degree, second-degree, etc.). I want to emphasize, however, that unlike homicide, suicide is not illegal and is not a crime. In California, suicide has never been criminal or illegal. At one time, under the English law, suicide was a criminal act. “Insanity” was a merciful excuse to avoid the punishments of family and corpse that were demanded by the law. But those laws have been abandoned; in Britain, the last of them was repealed in 1961. American states that originally adopted the English common law have also decriminalized the act of suicide.

In these times of social changes, the legal guidelines concerning who is responsible and who is financially liable for a suicide death are undergoing considerable transition. The legal definitions of “insanity” have varied greatly, in different times and different jurisdictions. A common forensic standard is that an insane person is one who, because of a mental disorder, is unable to conform his or her behavior to the requirements of the law. Usually this is because of some combination of the following elements: The person does not understand the meaning or consequences of his or her behavior; the person suffers from an irrisistible impulse; the person does not realize or understand that the behavior is illegal or criminal. Because suicide is not against the law, it is difficult to apply the legal concept of “sane or insane” to suicide. I would agree with the California Supreme Court's opinion, with its emphasis on whether the person understood that the self-destructive act would end his or her physical existence. Even when the patient is alive and able to communicate, the question of “insanity” in relationship to suicide risk is complex and difficult; it constitutes a challenge to the judgment and experience of every psychiatrist, because it is a problem of politics and social outlook more than of therapeutics. In civil life, an insane person is one who has been confined involuntarily in a mental hospital on the order of a court. “Sane or insane” is defined not by doctors, but by judges, according to their own standards. I am reminded of the baseball umpire who was asked if he had ever made a mistake, calling a strike a ball, or a ball a strike. He replies, “they ain't nothin’ till I call ‘em.” Similarly, a person is not insane until a judge makes the ruling.

In my experience, even persons who have been judged by a court to be “insane,” in the sense that they have been committed involuntarily for incarceration in a security ward of a mental hospital, still understand the meaning of their own deaths and can therefore commit suicide. We would not certify as suicides, however, the deaths of persons who, because of mental disorders, committed acts that they themselves felt would not result in death. An example is the case of a man who climbed into the lion's area of a zoo under the delusion that he was a Biblical prophet with lion-taming powers, but the lion killed him. Another patient, a nonswimmer, jumped into a reservoir believing that the water had magical powers of rejuvenation, and that therefore he could not die but could only be purified. This individual survived his experience, but if he had drowned, it would not have been a suicide.

The Role of the Psychological Autopsy

In judging whether a self-destructive act was intentional, it is helpful to develop a biography of the person that reviews his or her history, life style, stresses, communications, and behaviors, with special attention to the last days and hours of the person's life. This information, which is gathered through sensitive interviews with family members, friends, work and school associates, and physicians, and is reviewed in association with the physical evidence and the anatomical autopsy, has been termed a “psychological autopsy” (Shneidman, 1981).

Bereaved family members sometimes ask, “How can you reach an opinion about what was in the mind of a person who is now dead?” They are right in the sense that one cannot reach an opinion with absolute certainty. Unfortunately, absolute certainty about human intentions is seldom possible even with the living, including our patients, colleagues, and families. We constantly act upon our own evaluations of others' intentions, based upon their verbal communications, their behaviors, their previous track records, and the social context. The psychological autopsy provides just such information (indeed, more than is usually available), and thus constitutes an excellent window for viewing and understanding intention, focusing especially on the time sequence preceding the death.

Clues to suicide include previous verbal and nonverbal expressions of a wish to die or an intent to kill oneself. We look for preparations for death, farewell gifts and statements, expressions of hopelessness, and pain and illness; we also look for stresses such as losses of money, health, and love. We ask about previous suicide attempts or threats and explore the history of mental disorder. In evaluating whether a death was due to suicide or accident, the past personality is quite important. People who have a history of responsibility, stability, autonomy, and self-care are more apt to die purposely (by events such as a gunshot wound to the head or an overdose of prescription medicine) as opposed to carelessly or accidentally.

The biographies of suicide victims reveal that most of those persons have been suffering from diagnosable mental disorders. In all psychiatric disorders, of course, there can be impairment of perception, volition, and cognition. It is important, however, to keep in mind that mental illness, even when it is present, is only a part of the suicide constellation—one element of many. Other important elements in suicide are precipitating stresses; the individual's values and philosophy; the available support network of people and institutions; and factors connected with age, sex, religion, and occupation. A crucial factor is the willingness of the person to accept help. All of these elements are interactive. Each case must be examined individually on its merits through a psychological autopsy or its equivalent, to determine what we can judge from a preponderance of the evidence about whether the person had it in mind to end his or her earthly existence.

In most suicides, the person has been considering suicide for some time and has communicated clues to other persons. However, a sizeable minority of suicides (I estimate about 15%) occur rather suddenly and impulsively, when people feel themselves to be in a crisis and when they are under great stress or great provocation. Often, in these cases, there have been few premonitory clues revealed to other persons about what was going to happen. For example, Peterson, Peterson, O'Shanick, et al. (1985) have described persons who shot themselves rather impulsively and only survived through the miracle of modern emergency care. When interviewed later, most of these persons were glad they survived; yet they then confirmed that when they shot themselves, they intended to die.

The intention to die is usually complex and ambivalent, and only constitutes a portion of what is in the suicidal person's mind, which is focused mainly on solving the person's problems of pain and distress. Sometimes, in attempting to solve problems of personal self-doubt and indecision, people place their lives in jeopardy as an “ordeal.” The concept of an ordeal is derived from ancient ways of thinking in which the decision as to whether a person is right or wrong, guilty or innocent, is placed at hazard; it is left up to God to decide whether the person shall live or die. One model for an ordeal is “Russian roulette,” in which a person places one bullet in a five- or six-chambered revolver, and after revolving the cylinder at random, places the gun against his or her head and pulls the trigger one time, thus taking a chance of one in five or six of dying. In our work, we feel that death by Russian roulette is known and predictable, and we term such death “suicide.”

Suicidal actions that involve deliberate planning are more likely to be fatal than impulsive and unpremeditated suicidal actions. Sequential actions require intention. Examples include driving to the Golden Gate Bridge and jumping; securing a gun, loading it, and placing the gun against one's temple; or securing a private place, making a noose, and suspending oneself so as to die by hanging. Less planning is involved in such actions as running into street traffic, ingesting whatever pills happen to be in the family medicine cabinet, or cutting oneself with glass from a broken bottle.

Mental disorders or developmental deficiencies that reduce the capacity for planning and deliberation, and that prevent the psychological organization of sequential actions, greatly reduce the potential for suicide. Persons with advanced Alzheimer's disease or senile psychosis are too confused and forgetful to carry out suicide, although they may say they wish to die. Suicide is amazingly rare in preteenage children, although there is a great deal of research to indicate that these children have suicidal thoughts and carry out suicidal actions; these are usually not fatal, however, just because these young people are lacking in the ability to form and carry out their plans (intention) and in understanding of themselves and the world. Persons who are extremely depressed are too apathetic or too immobilized to take suicidal actions. In summary, experience indicates that a person must have a certain minimal degree of intact volition and thinking ability, and understanding of cause and effect, in order to produce fatal self-inflicted injuries.

A Case of Major Affective Disorder

About half of suicides are preceded by a specific psychiatric disorder—namely, a major affective disorder with one or more depressive episodes. This brief case vignette is presented to illustrate the psychological impairment due to depression and the effect of this impairment on intention.

A 50-year-old law professor committed suicide by shooting himself in the head while he was alone in his apartment at midday. At the time, he was in psychiatric treatment for depression associated with various stresses. He had failed to receive a tenured appointment, partly because of rumors on campus that he used cocaine, which he did. His wife, a successful physician, had served him with divorce papers. His symptoms included insomnia, weight loss, no joy in life, social withdrawal, general fatigue, and retardation in speech and movement; he had also told several people that he wished he were dead. The psychiatrist suggested hospitalization as a possibility, but the patient rejected this as out of the question. He could not be held involuntarily in a psychiatric hospital. He was not confused or disoriented. He could take care of his personal needs. When confronted, he denied vigorously that he was a danger to himself or others “now.” He owned a revolver, which was kept unloaded. About a year before, he had taken out a large life insurance policy, because, he said, his two children were now in college and the family needed financial protection. He continued to teach his classes, but his exposition was noticeably less clear. He alarmed his daughter in another city by writing to her that he was glad she was away, since his future seemed hopeless and he was afraid the depression could be contagious. However, when he killed himself, everyone (including the psychiatrist) expressed shock and surprise.

The psychiatrist and I agreed that the depressive disorder had impaired the patient in the following ways:

The psychiatrist and I discussed the question of whether the patient understood that unless he postponed his suicide for another 10 months, his family would not collect the proceeds of the insurance policy. It was our opinion that he had once known about the suicide exclusion clause, and probably had forgotten it. In any case, protecting his family financially was no longer an important issue to him.

Clinically, the three symptoms that predicted this man's suicide (in addition to the dream of death as peace and security) were hopelessness, noncompliance with treatment recommendations, and substance abuse.