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Ciênc. saúde coletiva vol.17 n.8 Rio de Janeiro Aug. 2012
Psychological Autopsy: an important strategy for retrospective evaluation
Blanca Susana Guevara Werlang
Graduate Program in Psychology, Pontifícia Universidade do Rio Grande do Sul PUCRS. firstname.lastname@example.org
Programa de Pós-Graduação em Psicologia, Pontifícia Universidade do Rio Grande do Sul (PUCRS). email@example.com
Thinking about and addressing the issue of death as a natural consequence of life is often a situation that is difficult to handle and that involves a level of difficulty. This difficulty is amplified substantially when the specific topic one addresses with respect to death is suicide. It is difficult to understand and explain why some people decide to commit suicide, while others in a similar or worse situation do not. This behavior undoubtedly results from a complex interaction of biological, psychological, social, cultural and environmental factors.
Therefore, studies about this issue are clearly important and relevant as Werlang et al.1 emphasize, suicidal behavior includes a central aspect related to suffering, regardless of the point of view according to which it is analyzed. One can think about the suffering that leads an individual to a suicidal act, of the suffering endured by the family who have seen one of their members commit suicide, as well as the social consequences of that act.
In that direction, it is believed that the basic predominant idea among healthcare professionals is that one should do whatever possible or even what is impossible to help people who are suffering, with an objective to preserve the well being of every human. It is my understanding that certainly this is what motivates Fátima Cavalcante and Maria Cecília Minayo to get involved with the issue of suicide and to coordinate a multi-center study aiming to identify and understand the variables that interact and feed the association between the suicide event and elderly.
The article Psychological and Psychosocial Autopsies of Individuals who Died by Suicide in Brazil describes a study that is scientifically, clinically and socially relevant. The text provides very important information related to risk and protection factors that may enable implementing actions to prevent suicide among the elderly. Several aspects of the article are worth commenting; however, I will address only some of them.
It is my understanding that the article's main point is the strategy used to collect data. I have been studying problems related with suicide for over a decade and I use psychological autopsies because I believe that this retrospective examination resource enables us to obtain important elements to comprehend suicide. This type of evaluation has been making it possible to identify direct or indirect clues related to this deadly behavior, shedding some light on the deceased's intention and their role in relation to their own death. Through the method that is conventionally called "psychological autopsy", an expression coined by Shneidman in the late 1950's2, we can understand the psychological aspects involved in a specific death. Psychological autopsy appears as a procedure that will support forensic pathologists classify suicides (the act of intentionally killing oneself) more precisely in death certificates. It quickly becomes an accepted and widely used procedure. However, because it entailed a complex evaluation strategy that lacked a structured procedure model, and in the absence of the object being studied, namely the victim, a few scholars believed that both the informant (family members, friends, physicians, etc.) and the interviewer could be potentially vulnerable to bias3,4. While aware of this problem and exploring an aspect of my professional education I developed a Semi-Structured Interview for Psychological Autopsies (ESAP) as part of my doctoral thesis 5. My proposal was to allow conducting a study6,7 to decrease bias produced by subjectivity when using this evaluation tool, by investigating the tool's applicability in psychological autopsies, whose data demonstrated allowing a reasonable level of agreement between assessors. Other production8-10 has been generated by this Thesis and the ESAP has already been adapted into Spanish11 in a study conducted in Spain.
Therefore, psychological autopsy is a strategy that is used to outline the psychological features of victims who died a violent death; it is used during a death investigation to help determine how an individual died, especially in suspect cases. With time this resource provided substantial help to forensic pathologists and professionals within the field of criminal and civil law3,4 and also started contributing to confirm and/or identify new risk and sociodemographic correlated factors linked to suicide. Fátima Cavalcante and Maria Cecília Minayo developed and used the "Semi-Structured Interview Guide for Psychological and Psychosocial Autopsies" with this intent. Based on scientific literature they organized an interview guide with 43 questions that evaluate social aspects, lifestyle, mental state, description of the suicide and family-related aspects. I am very happy to see that qualified professionals who can relate with the concern and need to help promote health are committed to qualifying the strategy of psychological autopsy. Scientific work such as this will contribute to qualify the strategy of psychological autopsy so that it may cease to be regarded as a subjective tool that is unreliable and unlikely to achieve the status of an appropriately validated tool.
I believe that one of the issues faced by healthcare professionals is knowing how to predict that potentially suicidal individuals will transform their fantasies and/or ideations into concrete actions5. However, studies such as the one conducted by Fátima Cavalcante and Maria Cecília Minayo make a significant contribution to flag the signs that professionals should look for in life stories and behavior of people as indicative of risk of fatal self-inflicted acts.
Another important aspect of the text is the issue of understanding death by suicide at a certain stage of the life cycle. We know that death can befall us at any moment; however most people wish and expect to achieve and enjoy longevity. Science has made progress and this progress in all areas of knowledge has been contributing to increasing the average duration of life. Therefore, in today's society the number of elderly people has been increasing significantly. There is no more room for the idea that an elderly individual has no future. People are living longer and healthcare has been making it possible to minimize limitations and disabilities typical of that moment in life. Old age is no longer regarded only as an unfavorable process of physiological, psychological and social losses that quickly leads to death.
Although scientific progress is evident and it has contributed to adding more years to people's lives, both worldwide and in national terms, risk of suicide has been increasing with age. Suicide in any age group is a tragic and painful phenomenon that leaves a mark, shocks and places an individual at a point of no return. In fact, it emotionally affects everyone connected12, whether directly or indirectly. When self-destructive behavior occurs in old age, its repercussions and the questions it raises are very unsettling and reinforce the ancient view of old age as one where only predominant context is that of decline and loss. Why would an elderly individual who achieves the possibility of longevity decide to take their own life? Has all experience gathered throughout the years not been enough help face difficulties?
The issue that requires careful consideration is related to the fact that in addition to significant scientific progress that facilitates greater life expectancy, it is increasingly necessary to provide support that will contribute to ensuring that people's life quality will improve. In that sense, it is my understanding that one cannot comprehend the special features of old age without analyzing its interactions with the social, political and cultural contexts where the elderly individual lives. In Brazil the ageing process is not accompanied by improvements to the healthcare system, housing, labor and food conditions. The context is one of social inequality and lack of structures to respond properly to demands of elderly individuals.
Data gathered by Fátima Cavalcante and Maria Cecília Minayo are clear and expose the vulnerability of 51 elderly individuals across ten Brazilian municipalities. They committed suicide while tormented by financial overburden/personal or family debt, abuse and discredit, death and illness of relatives, physical illnesses/limitations to their functional capacity, mental symptoms/disorders, social isolation/loneliness/lack of support, ideations, suicidal attempts and suicide in the family.
It is necessary to think about health actions and public policies that will enable bringing the benefits of science to elderly individuals of all socioeconomic contexts in our country. We should understand elderly individuals within their life process; we should become familiar with their potentials and weaknesses and help them maintain their position within their family group and society.
A highlight of Fátima Cavalcante and Maria Cecília Minayo's text is the detailed description of six cases, of the 51 studied using the Semi-Structured Interview Guide for Psychological and Psychosocial Autopsies. The psychological autopsy strategy enables rebuilding the biography of the deceased, focusing on their intentions with respect to their own death5. The cases presented by the authors clearly reveal unbearable psychological pain. One may state that suicide is not a random, pointless act; it is quite the contrary, it is experienced as the best available escape from a situation of conflict for an individual and it aims to provide a solution for extremely intense suffering. The goal is to suspend the painful flow of consciousness, terminating the invading feeling of hopelessness that makes someone feel defeated and as if there is no way out in life3,4.
However, we cannot lose sight of the fact that suicide at any age group can be prevented. The factors identified by Fátima Cavalcante and Maria Cecília Minayo are related to: illnesses and disabilities, depression and depressive states, family conflicts and conjugal crises. We agree that efforts to prevent suicidal behavior should be guided by knowledge about those and other risk factors. We must look at the fundamental actions12 that can be changed in order to avoid and prevent any possibility, and to provide intervention. As highlighted by Botega et al.12, thinking about preventive aspects of suicide means believing that individuals may be offered other possibilities of addressing difficulties or conditions that lead them to seek in that final act some kind of solution for their suffering. Likewise, it is my understanding that addressing the issue of suicide prevention entreats all healthcare professionals to study and acknowledge the singularity of factors involved in this complex situation. This is another relevant aspect of the study conducted by the authors: it produced scientific knowledge to be shared with other professionals.
Finally, I would like to thank the opportunity of taking part in this debate and to emphasize that studies as the one being debated are crucial and will contribute to organize prevention and care measures based on scientific evidence.
1. Werlang BSG, Macedo MMK, Krüger LL. Perspectiva psicológica. In: Werlang BG, Botega JN, organizadores. Comportamento Suicida. Porto Alegre: Artmed; 2004. p. 45-58. [ Links ]
2. Jacobs D, Klein ME. The expanding role of psychological autopsies. In: Leenaars AA, organizador. Suicidology essays in honor of Edwin S. Shneidman. Northvale: Jason Aronson; 1993. p. 209-247. [ Links ]
3. Werlang BSG, Botega NJ. Avaliação retrospectiva (autópsia psicológica) de casos de suicídio: considerações metodológicas. Psico 2002; 33(1):97-112. [ Links ]
4. Werlang BSG, Botega NJ. Entrevista semi-estruturada para Autópsia Psicológica (ESAP) em casos de Suicídio. In: Corrêa H, Perez Barrero S, organizadores. Suicídio: uma Morte Evitável. São Paulo: Atheneu; 2006. p. 187-195. [ Links ]
5. Werlang, BSG. Proposta de uma entrevista semi-estruturada para autópsia psicológica em casos de suicídio [tese]. Campinas (SP): Universidade Estadual de Campinas; 2001. [ Links ]
6. Werlang BSG, Botega NJ. A Semi-Structured interview for psychologycal autopsy an inter-rater reliability study. Suicide Life Threat Beh 2003; 33(3):326-331. [ Links ]
7. Werlang BSG, Botega NJ. A semi-strutured interview for psychological autopsy in suicide cases. Revista Brasileira de Psiquiatria 2003; 25(4):212-219. [ Links ]
8. Sperb IW, Werlang BSG. Suicídio em uma população rural e urbana de pequeno porte. Boletim de Psicologia 2002; 117(LII):159-182. [ Links ]
9. Sá SD, Werlang BSG. Homicidio Seguido de Suicidio. Universitas Psychologica 2007; 6(2):231-244. [ Links ]
10. Sá SD, Werlang BSG. Homicídio seguido de Suicídio: na cidade de Porto Alegre. Estudos de Psicologia (Campinas) 2007; 24(2):181-189. [ Links ]
11. García-Caballero A, Recimil MJ, Touriño R, García-Lado I, Alonso MC, Werlang BSG, Jiménez J, Perez de Albéniz MC, Losada A, Bendaña JM. Adaptación y Validación de la Semi-Structured Interview for Psychological Autopsy. Actas Espanõlas de Psiquiatría 2010; 38(6):332-339. [ Links ]
12. Botega NJ, Werlang BSG, Cais CF da S, Macedo MMK. Prevenção do Comportamento Suicida. Psico 2006; 37(3):213-220. [ Links ]