The principle of psychological autopsy is based on the meticulous collection of data that are likely to help reconstitute the psychosocial environment of individuals who have committed suicide and thus understand better the circumstances of their death.
The first authors to use this method did so for medical and legal reasons, particularly when the causes of death were ill-defined. The method was later applied to suicide prevention, crisis intervention, or research both to improve existing knowledge and identify subjects “at risk” of committing suicide. Thus, among studies using the method of psychological autopsy, it is important to distinguish those that are aimed at studying individual cases from wider-scope studies designed to pursue particular research goals.
In a research-specific context, psychological autopsy appears to be a useful tool first of all to shed light on suicidal behavior and thus develop prevention. The design of such research therefore depends on the specific questions and hypotheses it is meant to address.
From the methodological point of view, psychological autopsy appears to be a complex and multidimensional strategy. In the first place, “cases” must be defined with a great deal of care to constitute homogeneous samples made up of verified suicide cases, particularly in view of the fact that in many countries suicide is not recorded as such.
For the most part, the method is based on collecting information by interviewing people connected with the subject who committed suicide. In this type of approach, it is obviously useful to have a great variety of information sources. The methods involved take into account the circumstances of death as well as the medical data obtained from the family doctor and other official sources.
Being the most likely to provide accurate and reliable information, the suicidee’s friends and relatives are a crucial source. However, contacting such people, who are naturally bereaved, to collect information can raise a large number of questions from a methodological, practical, and ethical point of view.
It appears increasingly necessary to standardize the methods by which such data are collected. A sketchy standardization already exists in the form of various methodological items such as a letter followed by a telephone call. This is the most frequently used approach in research studies. The best time to contact friends and relatives has been established to be between 2 and 6 months after the suicide event. The time lapse to be observed should allow the more painful mourning period to have past while not letting interviewees’ memories become exceedingly altered.
This type of working procedure must definitely be validated by competent ethical committees. It is also highly important that the informants feel at ease with the investigators, that they know they are being respected and understand why their contribution is of particular interest for research. When using the results, it is important to respect the informants’ anonymous status, their right to interrupt their participation at any time and have the possibility to destroy the recorded information that involves the informant to optimize the interviewing process and ensure result quality.
As rigorous as such data collection might be, this type of methodology depends on getting indirect information from a third party and is consequently exposed to structural bias. This introduces some degree of subjectivity, which may influence the validity and reliability of the information gathered by interview. One way of reducing such bias is to interview a number of friends and relatives for each suicide case.
In the future, one should ensure that the studies are tightly controlled in spite of the difficulties such methodology might raise. Control groups should be specifically set up in terms of the working hypothesis. Under certain circumstances, setting up more than one control group might be useful or even indispensable. Interviewees should always be people that are closely connected with the control subject, because using the latter as an informant seems inappropriate. Regarding methodological procedure, it is important to consider that the control group is made up of people who are alive, which introduces a built-in bias. It is therefore highly desirable to set up a control group of people that have committed suicide—but do not obey the criteria to be included as “cases” in a given study—and run research interviews of their friends and relatives.
Studies involving psychological autopsy gather information on a large number of parameters including details about the person’s death, family background, social context, life trajectory, social interaction, working conditions, physical/mental health and history, previous suicidal behavior if any, negative elements in the person’s life, contact if any with help line services before committing suicide, and reaction of friends and relatives to the suicide. The different systems that can be used to achieve this are not necessarily based on strict guidelines. Indeed, studies have revealed significant differences in the way interviews are conducted in the absence of a prevailing standard, although pioneering studies often serve as templates for the more recent studies. Studies based on evaluation naturally structure interviews and allow full coverage of various clearly formulated issues. However, here again, standardization is lacking when it is in fact crucial.
Nonetheless, while collecting data demands a rigorous approach, a degree of flexibility in the interviewing process is desirable to take into account the psychological needs of bereaved friends and relatives. Beyond serving the immediate goals of the study, it is necessary to find a suitable compromise between the investigators’ need for rigorous methodology and a necessary adaptability on the part of the clinical personnel involved. Besides the general principles of “good clinical practice” that normally prevail in this type of research, additional principles must be respected because of the psychological nature of such clinical practice. Indeed, the psychological autopsy technique is a special case in that it is not only a research tool, but also a psychological intervention and therefore belongs to the therapeutic field. The interview undeniably has an impact on the mourning process of the people close to the dead person, which can reactivate the trauma and elicit emotional upset.
Interviewers are usually psychologists or psychiatrists. It is recommended that they have clinical training, good knowledge of social work, and a good capacity for empathy without being overwhelmed by their own emotions. Supervision appears to be necessary with regard to both research and the psychodynamic aspect. Research work should be associated with a center where the interviewed person can be referred if specific treatment turns out to be necessary.
Thus far, the available data on psychological autopsy enables one to define a few guidelines to produce quality studies in the future. These guidelines include the necessity to constitute samples of more than 60 cases in order to be able to draw general conclusions and thus test the primary hypotheses of a research program. In this respect, it is crucial to define clearly the initial hypotheses, protocol, and diagnostic criteria as well as the precise characteristics of the sample. Case definition, the constitution of control groups, and the qualifications of intervening personnel are all important elements. Finally, a cautious evaluation of the quality of the data collected is essential.
Original Article: Suicide: Psychological autopsy, a research tool for prevention
Authors: Agnès Batt, Frank Bellivier, Benoît Delatte, Odile Spreux-Varoquaux