Psychological autopsy of a person who died by suicide: inquiring about his life, emotions and thoughts to prevent other deaths

• Psychology How to help a person who has thought about taking his own life:
• Survivors The complicated grief after a death by suicide, fight against pain, stigma and loneliness

A death by suicide is always followed by immense pain and multiple whys. Only the person who has left knew what he suffered and tormented him so much that it made him believe that there was no other way out, but there is a way to better know his emotional state, thoughts and vital circumstances in the days before his death: performing a psychological autopsy. Experts explain in this report the key steps for the "reconstruction" of that inner world with a scientific method still of little application in Spain and that can be key not only to understand the causes of their suffering but to prevent other suicides. Last February a judgment of the Superior Court of Justice of Cantabria included it as evidence in a judicial process.

Its origin dates back to 1958 in Los Angeles, California (USA). The increase in drug overdose cases and the difficulty in establishing with certainty whether they were deaths by suicide, homicide or accident led the coroner Theodore Curphey to request the collaboration of a team of doctors and psychologists, including Robert Litman, Norman Farberow and Edwin Schneidman. The latter is attributed to the creation in 1961 of the term 'psychological autopsy', which sought in its beginnings to clarify deaths with dubious causes. He defined it as "the retrospective reconstruction of the life of a deceased person to gain a better understanding of his death." With the passage of time, its usefulness as a scientific research tool acquired greater weight.

Associations and helplines

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-In case of imminent vital emergency call directly to the emergency number 112.

-If you have suicidal ideation 024

- Telephone of Hope: 717.003.717.

- Suicide prevention telephone (Barcelona): 900.92.55.55.

-Telephone/Chat ANAR of Help to Children and Adolescents 900 20 20 10

- Telephone Against Suicide- La Barandilla Association (Madrid): 911.385.385.

-- RedAIPIS-FAeDS Association

- Papageno 633 169 129 supervivientes@papageno.es

-Association The Yellow Girl

-P81 Social Association

- APSAV. Association for the prevention of suicide. Green hugs. Asturias.

- AFASIB (Familiars i Amics Supervivents per suïcidi de Les Illes Balears (Balearic Islands)

-AIDATU. Basque Association of Suicideology

- APSAS: Association for Suicide Prevention and Survivor Aid. (Girona)

- APSU: Association for the prevention and support affected by suicide (Cdad. Valenciana)

- ASAM: (Burgos).

- BESARKADA-Abrazo: Navarra.

- BIZIRAUN: Basque Country

-BIDEGUIN: Basque Country

- After Suicide: (Barcelona)

- Alaia Foundation (Madrid)

- Metta-Hospice Foundation (Valencia)

- Goizargi: Navarre

- Survivors of León Group.

- There is Exit, Suicide and Duel: (Cantabria)

- Ubuntu (Seville)

- Light in the Dark Association (Tenerife)

-Back to Live Association (Tenerife)

The aim is to shed light on suicidal behaviour, which involves biological, psychological and/or social factors. There is never a single cause. In this process it is essential to analyze the biography of that person and especially his last month of life, draw a psychological profile that helps identify traits and aspects of his personality (such as his reactivity to stress, resilience, emotionality, aggressiveness or impulsivity); risk and protective factors; possible precipitants, motivations or whether or not there was intentionality. The professional who investigates with the necessary rigor and respect in the inner world of a person who has died by suicide is the psychologist or forensic psychiatrist.

The expert conducts a thorough investigation of documents to know your medical, psychiatric, family, financial, academic or legal situation. The results of forensic autopsy, letters and notes, diaries, e-mail messages, social networks and internet searches are also examined because they can offer very relevant information. In this 'post mortem' evaluation of the life, thoughts and emotions of a deceased person it is essential to have the testimony of those around him and therefore interviews are conducted with family members and other people with whom he had a significant relationship such as friends, colleagues, his family doctor or therapist. In some cases, the spaces in which he spent his last moments are also investigated.

Eleven lives

Protect your life from suicidal ideation.

"Seek help before distress blocks you, you're not alone"

• Writing: YAIZA PERERA Madrid

"Seek help before distress blocks you, you're not alone"

Prevention.

The national plan against suicide that never came: "Among the ruling class there has been no conscience or will"

• Writing: SANTIAGO SAIZ Madrid
• Writing: ILLUSTRATION: EVA CERDÁ SANCHO

The national plan against suicide that never came: "Among the ruling class there has been no conscience or will"

On February 27, the Superior Court of Justice of Cantabria included the psychological autopsy as evidence in a sentence that considered a suicide at work accident. The worker took his own life on April 12, 2021 at the age of 53. His widow wanted to know and put in writing the reasons that dragged him to such a devastating emotional distress. He asked a psychiatrist to try to find out what he thought and felt in the days leading up to his passing. Their findings have helped demonstrate that the suicide trigger was related to problems in their work and has been key to resolution.

The expert who investigated the case collected information from 2011, the year he started working at the company in Vitoria, and until the moment of his death after being sanctioned for workplace harassment, he made a questionnaire of 123 questions to his widow, brothers, colleagues and former co-workers and reviewed audio and WhatsApp recordings of his superiors and extensive documentary material. The 'trace' ruled out the existence of a diagnosed mental disorder and found that the deceased felt like a "scapegoat for the conflict generated by the union elections in the supermarket", that he suffered intense concern about the consequences of a possible criminal complaint and that the transfer of his job and the rejection of his colleagues had complicated his personal life and led to suicide planning, It includes the judgment. That enormous concern was corroborated by the searches he made on the internet in the hours before his suicide and in the "emotional" farewell note written to his wife and daughter on his mobile phone.

The resolution includes the psychological autopsy as a "proven fact" and points out the "valuable information" it offers. The court ruled against a previous resolution of the Court number 3 of Santander and emphasizes "that the problems of a labor nature have a clear temporal connection with the suicidal act, since they begin just three months before the fatal outcome and are very present the days before the decision to take his own life "and that "there is no other triggering factor, neither identifiable personal nor intra-family context".

"It helps to know why you have done it"

In Spain, a psychological autopsy is always carried out when those who died by suicide are members of the Civil Guard or National Police. Javier Jiménez Pietropaolo was one of those in charge in 2000 of developing a specific model for these State Security Forces and Bodies and underlines the importance of this methodology to discover the reasons why an official wants to take his own life, not so much the cause of death, which is not usually doubtful. "We know that in almost all cases it has been a suicide but the psychological autopsy helps us to know why it has done it and to improve the Suicide Prevention Program." This clinical psychologist, honorary president of the Association of Research, Prevention and Intervention of Suicide, and Relatives and Relatives in Grief by Suicide (RedAIPIS-FAeDS) highlights the need to extend in the public sphere the use of this tool to know "why people commit suicide in Spain".

Risk and protective factors

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Risk factors

• Mental disorders (Depression, schizophrenia, anxiety disorder)
• Drug or alcohol abuse
• Physical health (chronic pain or terminal illness)
• Psychological dimensions (hopelessness, perfectionism, personality traits such as aggression, impulsivity, anger, irritability, hostility and anxiety)
• Gender (men have higher rates of completed suicides and women have higher suicide attempts)
• Age (adolescence and old age)
• Marital status (A statistically significant association has been observed between having no spouse or partner and suicidal behavior)
• Employment and economic status (Loss of employment and poverty; high-stress professions; low educational attainment)
• Lack of social support
• Antecedentes familiares de suicidio
• Conducta suicida previa
• Historia de maltrato físico o abuso sexual
• Acoso por parte de iguales en adolescentes

Factores protectores (aquellos que disminuyen la probabilidad de un suicidio)

• Habilidad en la resolución de conflictos o problemas
• Tener confianza en uno mismo
• Habilidad para las relaciones sociales e interpersonales
• Presentar flexibilidad cognitiva
• Tener hijos, más concretamente en las mujeres
• Apoyo familiar y social, no sólo la existencia del apoyo sino su fuerza y calidad
• Integración social
• Poseer creencias y prácticas religiosas, espiritualidad o valores positivos
• Adoptar valores culturales y tradicionales
• Tratamiento integral, permanente y a largo plazo en pacientes con trastornos mentales, con enfermedad física o con abuso de alcohol.

Apenas existen referencias a la autopsia psicológica en los 13 planes específicos de prevención autonómicos que existen actualmente y tampoco se alude a ella en la Estrategia de Salud Mental del Sistema Nacional de Salud (2022-2026) (España aún carece de plan nacional), no obstante, algunas CCAA ya comienzan a dar los primeros pasos para potenciar su uso. País Vasco está actualmente en proceso de formación de profesionales y La Rioja y Castilla y León la contemplan en sus diferentes programas para disponer de más datos sobre las circunstancias y factores asociados a los suicidios y facilitar la consulta recíproca de la información clínica y forense de los casos consumados. También Cataluña trabaja para compartir información de forma más directa entre el Instituto de Medicina Legal y el Código Riesgo Suicidio (CRS)

Cuando muere un policía nacional acuden de inmediato al lugar al menos dos Psicólogos Facultativos del Equipo de Intervención Psicosocial del que Jiménez Pietropaolo es el responsable no solo para recabar información ( informe del médico forense, sanitario, disciplinario, lugares de destino o documentos personales) sino para brindar asistencia psicológica a los familiares y allegados: "Por tu ser querido no podemos hacer ya nada, pero podemos hacer por ti y porque otros no pasen por lo mismo". A los supervivientes, las personas que han perdido a alguien cercano por suicidio, "les ayuda muchísimo" recibir ese apoyo, que les digan "pregúntame y cuéntame lo que quieras", asegura este experto.

Les ayudan a entender que una persona que muere por suicidio "está sufriendo muchísimo, no ve otra salida y sienten que son una carga" y tratan de liberarles de la culpa que sume a la mayoría en una profunda angustia. El pasado día 20 de marzo fue el cumpleaños de Pietropaolo y recibió emocionado el mensaje de una mujer agradecida por el consuelo que recibió por teléfono tras perder a su madre: "Fue la primera mano a la que pude agarrarme cuando no paraba de caer".

Es frecuente que los supervivientes tengan ideación suicida especialmente durante el primer año tras la pérdida y la entrevista a familiares para la autopsia psicológica puede servir también para realizar una primera intervención en duelo y que puedan expresar su dolor ante un hecho tan traumático. Hay expertos que plantean que el tiempo ideal para la entrevista es de dos a seis meses después del deceso pero no hay unanimidad al respecto

Jiménez explica que cualquier familiar podría encargar una autopsia a un psicólogo o psiquiatra especializado que ofrezcan ese servicio en el ámbito privado pero que muchos supervivientes no lo hacen porque "creen conocer algunas de las causas". No obstante, una persona que se plantee solicitarla, subraya, debe pensar antes de hacerlo que quizás eso le lleve a averiguar "cosas que son muy dolorosas", asegura.

Indagar sobre una muerte para evitar otras

Acercarse a los motivos o circunstancias que llevaron a una persona a suicidarse puede abrir caminos para proteger otras vidas porque permite conocer posibles factores de riesgo, de protección, señales de alerta y precipitantes.

"En psiquiatría y psicología todas las evaluaciones se centran en una entrevista a la persona y en este caso la persona ha muerto. Aquí es un trabajo de investigación retrospectivo para conocer todas las circunstancias y el contexto en que se ha producido y el papel que ha podido tener la propia persona en esa muerte", resume Anna Mateu, psicóloga forense del Instituto de Medicina Legal de Cataluña. Ella apuesta por el "tándem" psicólogo forense y médico forense como el equipo más adecuado para sacarlo adelante porque además se garantiza metodológicamente lo que se denomina "el consenso entre jueces", que certifica que tras un análisis individual por parte de cada uno de los profesionales hay una puesta en común y una conclusiones compartidas que añaden máxima fiabilidad al proceso. Mateu lleva una década en el organismo y hasta ahora no ha recibido ningún encargo judicial en ese sentido pero sí dispone de la formación adecuada para realizarla si se diera el caso.

Actualmente "como prueba pericial en el marco de investigación judicial no es habitual que se solicite" la realización de la autopsia psicológica aunque los institutos de medicina legal repartidos por toda España sí han participado de forma directa en "todos los estudios dirigidos a la investigación científica, resalta Alexandre Xifró Collsamata, subdirector de este mismo organismo y experto en Psiquiatría forense.

Xifró subraya que aunque en España no esté extendido el uso formal de la autopsia psicológica, cuando una persona se quita la vida siempre hay "cierto grado de reconstrucción" de lo ocurrido: "Si hay suicidio consumado hay intervención del médico forense y autopsia judicial. Si se clasifica como suicidio es que se cumplen unas mínimas condiciones, tiene que haber constancia y evidencia suficientemente clara de dos cuestiones: autoinflicción e intencionalidad. Ésta puede ser explícita con alguna manifestación verbal o escrita pero también datos implícitos".

El Instituto de Medicina Legal de Cataluña puso en marcha en 2010 un proyecto de estudio de suicidio y patología mental en el que se realizaron 10 entrevistas a familiares. No eran estrictamente autopsias psicológicas pero se produjo el mismo acercamiento a ese dolor extremo que conlleva una muerte por suicidio. La culpa, angustia, vergüenza, impotencia y negación de la realidad están presentes con frecuencia. Hubo momentos, explica Mateu, que las propias médicos forenses se veían "superadas" por el sufrimiento de los seres queridos y destacaban la importancia de una buena formación y preparación en duelo para desarrollar esa labor correctamente. Son conversaciones para las que hay que encontrar el "momento adecuado", que no coincida, por ejemplo, con el aniversario de la muerte o de la personas fallecida porque "el estado emocional influye mucho en la información".

¿Por qué España no realiza de forma habitual la autopsia psicológica? Es un interrogante aún sin respuesta. Quizás por el "tabú", que aún rodea al suicidio, apunta esta psicóloga catalana, que está "preparada" para cuando haya un encargo judicial en este sentido y "pueda dar respuesta".

The scientific literature also gives psychological autopsy another relevant utility in improving the certification and registration of deaths by suicide.

"To make a good prevention plan, you have to start doing psychological autopsies and you will see that there are more suicides than they say there are," says Javier Jiménez. The latest data from the INE put the number of people who took their own lives in 4 in Spain at 003,2021 but experts estimate that the number may be higher.

"The coding of mortality is exclusively based on the forensic part," explains Alejandro de la Torre, psychologist and coordinator of the National Platform for the Study and Prevention of Suicide. "This has the advantage," he continues, "that we know that those deaths with a very high probability are by suicide but it has the problem of false negatives, there are many cases in which a suicide is coded in another way. In a death due to a road collision, the forensic doctor will possibly be left with the main hypothesis, traffic accident, gives as an example of La Torre, who regrets the lack of awareness of the importance of improving epidemiological surveillance systems and knowing the magnitude of the reality of suicide.

"The psychological autopsy is the other measure that can have weight to validate these data, it serves to make the estimates more reliable," says this expert. Xifró assures, however, that currently in Spain "the judicial mortality data are of a high quality" after the implementation in 2019 of a new notification system that allows the information to pass directly from the institutes of legal medicine to the INE without intermediation of the courts as was previously the case.

Detecting hopelessness and combating loneliness

There is no single model and it is historically debated whether it is more suitable to conduct structured interviews, more closed and that reduce the possibility of bias [the most used in Latin America is the MAPI (Integrated Psychological Autopsy Model) developed by the Cuban psychiatrist Teresita García] or semi-structured, which offer a script about what you want to ask but that allows a certain maneuver.

The keys to the Integrated Psychological Autopsy Model (MAPI)

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Expertise in psychological autopsy. Teresita Garcia Perez (2007)

The MAPI (Integrated Psychological Autopsy Model) developed by Cuban psychiatrist Teresita García with the aim of obtaining the rank of expert evidence is one of the most internationally recognized and the most used in Latin America.

• The professional has a series of questionnaires with closed questions that help to draw a very detailed profile of the person who has died. From personal data (marital status, educational level, occupation, religious beliefs, chronic diseases, psychiatric disorders, accidents, suicide attempts or previous suicides in the family, drug use and frequency ...) to his mental state up to one month before death (degree of consciousness, attention, memory, orientation, whether he was critical of himself or satisfied, whether he lived in harmony with others or suffered conflicts, if it was organized ...), emotional (if it was immersed in sadness or euphoria, anxiety or ambivalence ...) or the type of food (normal, anorexia or bulimia), sex (if you suffered impotence, premature ejaculation ...) or hygienic habits and quality of sleep.

  
  

• Family members and relatives are also asked if they had any conflict in the socioeconomic, family, housing, labor or judicial fields and their psychological features are carefully investigated with a list of 91 adjectives (ambitious, satisfied, apathetic, enthusiastic, sensitive, insensitive, stubborn, aggressive, shy, individualistic, spiteful ...), the topics that most interested him, pharmacological treatment he received and signals. that issued up to two years earlier as suicidal verbalizations, pessimistic comments, decreased emotional support for the family, dejection, sexual disinterest, unusual gifts to friends or relatives, self-neglect, expression of feelings of loneliness, self-hatred, feelings of inadequacy, worthlessness or inadequacy or previous suicide attempts.

  
  

• Garcia suggests that the ideal time for the interview is two to six months after the death and go back to a month before it to reconstruct the psychiatric examination because the sources retain an accurate memory of the mental state of the deceased.

  
  

• From his extensive experience performing psychological autopsies, his team concludes, among other aspects, that loneliness is one of the factors that play a more important role in suicide and that addictions in general and alcoholism in particular, constitute a "kind of chronic suicide" since the individual "deteriorates physically and psychologically, It is socially isolated, being frequent hostility against the environment, irritability, violence and after a period of loss of values and family, work and social ties, depression ensues. "

  
  

• The most important areas of conflict they found in the 140 cases investigated were family, housing and economy and the most frequent psychological traits, impulsivity, stubbornness, reserve, self-confidence, capricious behavior and being active people.

  
  
• Most before they died had left signs that they were often thinking about it with pessimistic comments about the future, hopelessness, feelings of loneliness, worthlessness, inadequacy or incompetence and despondency.

The Institute of Legal Medicine of Catalonia opts for the latter, which offer greater flexibility and during these painful conversations, where cases of blockage or emotional overflow may occur, it is necessary. And specifically by the SSIPA. More than a decade ago, psychiatrist Alejandro García-Caballero, coordinator of Prevention and Mental Health Promotion Programs at the Galician Health Service, adapted and validated in Spanish this methodology developed in Brazil, composed of 69 items structured in four modules (precipitants and stressors, motivation, intentionality and lethality).

After interviewing relatives of 26 people who died from death suspected of suicide, an attempt was made to extract "profiles" for the early detection of risk groups and the implementation of protection measures. These are the three main ones outlined by the study:

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Elderly. 46% of the deceased were over 65 years old. Most had recently worsened their health conditions. They lived it with hopelessness and a feeling of being a burden. Physical illness was compounded by the feeling of lack of belonging or breaking of ties (elderly separated by being cared for by children or admission to residences).

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Middle-aged women (34 and 55 years old). Most suffered from sentimental problems coupled with alcohol abuse or borderline/histrionic personality traits. In several cases there were previous attempts. Several of the deceased had studies and good social position but with pathological sentimental or family relationships.

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Psychiatric patients. All cases were followed up and no imminent risk was detected by professionals. Two of them were women with melancholic depression and good family support and frequent follow-up. Two others were men with schizophrenia and the third case was that of a woman with bipolar disorder who stopped treatment because of a desire to be a mother.

A month before taking their own lives, more than 50 per cent of these people, all with a high degree of suffering, had contacted the health services. The conclusions, aimed especially at health personnel, are clear: "Our target for prevention should be those patients with subjective complaints who, however, do not cause us a perception of seriousness and to whom many times, forced by the pressure of care, we dispatch with a 'has nothing'. The measures to be taken are the early detection of hopelessness, feelings of worthlessness and lack of integration as suicidal risk factors." From her extensive experience performing psychological autopsies, Teresita García's team also concludes that loneliness, together with addictions, has a very important weight in the decision to commit suicide.

The strategy developed by this renowned psychiatrist so that the psychological autopsy has a preventive effect at the community level is that the data it offers on the life and death of a person serve as guidance to the different professionals working in this field to know not only the factors that can lead a person to think about ending their days or the most vulnerable groups but also the possible Failures that may have been committed in the care of the victim (for example, if it could have been detected and intervened in a more appropriate way in the face of a mental disorder or difficulties of a social nature) and focus efforts on correcting them and improving the support network that reduces the risk. Understand better in life so as not to have to do it after death.

This report is part of the project 'Once lives' promoted by EL MUNDO for the prevention of suicide and of which Yaiza Perera, Rafa Álvarez, Rebeca Yanke and Santiago Saiz are part.

• Suicide Prevention

According to The Trust Project criteria

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