BRIEF REPORTS ALTRUISTIC MURDER-SUICIDE: A CASE REPORT AND CUNICAL INDICATIONS William
I.,ren
L. Fink
H. Roth
M.D. M.D.,
MPH.
WFhe death of a patient is a cataclysmic event for both the patient’s family and physician. This report is about such a death. A 24-year-old psychiatric patient who manifested great psychological distress was altruistically murdered by her father. He then turned the gun on himself. We report this case to alert psychiatric clinicians to some of the circumstances that might be assodated with murder-suicide (1-3), and to discuss the implications of such a tragedy in relation to the current psychiatric emphasis on patients’ rights, brief hospitalizations, and voluntary care in the community. The case involves a 24-year-old single Caucasian woman who was admitted to a hospital psychiatric ward in March 1975. In the spring of 1973, while a graduate student in mathematics, she had begun to experience angry feelings toward other people. She described those feelings as “seeming not to belong to me.” The patient was briefly seen in individual psychotherapy where a diagnosis of borderline schizophrenia was made. In the fall of 1974 she experienced acute anxiety while teaching. She was hospitalized in Maine for three weeks and was treated with haloperidol and psychotherapy. Ego-alien feelings and depression returned. She was subsequently admitted to the hospital in March of 1975 for evaluation of possible temporal lobe epilepsy and for further psychiatric work-up. (Some features of this case have been changed to disguise the identity of the person involved.) The patient was an only child. She had functioned very well in grade school and high school and had had a number of friends. She achieved a master’s degree in University of Pittsburgh and the Western Clinic, 3811 O’Hara Street, Pittsburgh, Pennsylvania 15261. Dr. Fink is assistant professor in the department of psychiatry of the School of Medicine and assistant program director of the assessment and brief treatment unit. Dr. Roth is associate professor in the department of psychiatry and director of the law and psychiatry program. The
authors
Psychiatric
558
are with the Institute and
HOSPITAL
& COMMUNITY
PSYCHIATRY
mathematics. The family history of psychiatric illness was positive only in the father, who had been treated for alcoholism more than 20 years ago. He had been a successful physicist who was retired at the time of the patient’s hospitalization. The patient’s hospital course in March 1975 was stormy. Multiple EEGs failed to reveal any evidence of temporal lobe seizures. The patient underwent paranoid decompensation while in the hospital. When offered medication, she initially felt that the doctors were trying to poison her. The patient’s parents, who visited regularly, were quite upset by the decompensation. They were seen for a brief family evaluation, which revealed a close bond between the parents and the patient. The patient, however, was never fully explicit with the parents about her fears and worries. The patient’s paranoid ideation responded to perphenazine, and ten days after admission she was discharged. After discharge, the patient was seen weekly. She was noted to be depressed. Because the patient’s diagnosis was still uncertain, it was decided to discontinue her medications and to schedule sleep studies. One week after medications had been stopped, the patient showed increasing anxiety and inability to sleep. She was started on haloperidol, 2 mg. q.i.d. She developed suicidal ideation, which was discussed with the father when he came with her for an outpatient appointment. Both the father and the patient resisted rehospitalization. The father said he would assume responsibility for the patient since he was at home and could watch her closely. It was recommended to the father that he get rid of a gun that was in the home. On subsequent visits, hospitalization was again recornmended. The patient and the father refused on the grounds that she had previously gotten worse in the hospital. The frequency of outpatient visits was then increased. Two days after an outpatient visit, the patient’s mother called to say that the patient was sleeping much better and appeared to be feeling better. Later that same day, however, the mother called again to say that she had arrived home from work to find that her husband had shot and killed the patient, then turned the gun on himself. A diary was found in which the father delineated his
hopeless feelings about the daughter’s condition. He believed that she was incurably mentally ill, possibly “genetically tainted,” and that she would never be able to live a normal life. He reported her pleading with him to put her out of her misery. It was apparently in response to those hopeless feelings about his daughter’s illness that he killed her and himself. In a subsequent meeting with the mother, it was learned that family friends were not surprised at the father’s action. Knowing the closeness between father and daughter, they viewed the father’s act as a gift of love. Murder-suicide is an unusual occurrence, but it happens. Therefore, psychiatric clinicians should be alerted to the possibility of it under certain circumstances. A review of the literature reveals that such crimes almost always occur in domestic settings. They are more often committed by a man than a woman. And 15 per cent of those who commit murder-suicide have themselves made previous suicide attempts. West divided persons who commit murder-suicide into two groups-the “sane” and the “insane.” Among the “sane” offenders, the most common motivation is altruism. The victims are almost always relatives; and occasionally the victims are willing participants who are in some way sick or disabled. Depression in a parent, coupled with real or imagined physical or emotional defects in a child, is a clinical constellation associated with child murder by parents (3). The case reported here certainly matches the clinical circumstances associated with murder-suicide. Unfortunately, the patient’s initial psychopathology and then her marked suicidal ideation overshadowed the depth of her father’s distress. During her initial brief hospitalization, one family session was held, but the focus was principally upon the problems of the patient and not on the family dynamics or the family’s response to her illness. After hospitalization, the patient was seers with her father, but the focus was again upon the patient’s syrnptomatology. The father’s willingness to provide personal support and home supervision seemed to provide the least restrictive alternative to hospitalization. In considering preventive measures, the current philosophy of psychiatric care bears mention. There is increasing emphasis today on brief hospitalization following the medical model and emphasizing neuromedical work-ups and aggressive use of psychotropic medications. The duration of hospitalization is often dependent upon the patient’s willingness to be hospitalized. With such an orientation, the patient’s family situation, the psychodynamics of the family members, and the stresses attendant upon them may receive less attention than was formerly the norm when hospitalizations were longer. Respect for the privacy of an adult patient may also contribute to decreased communication with the family about the nature of the patient’s illness. It is clear from the case presented here that the current emphasis on brief hospitalization and home treatment can put a tremendous burden upon a patient’s caretakers. Even if a family is willing to assume the responsibility of caring for an actively disturbed patient
at home, their ability to handle the stress requires both a thorough initial evaluation and continued monitoring and information exchange with the patient’s therapist. There has been much recent emphasis on the harm that families may do patients by involuntarily cornmitting them to mental institutions. Possible problems, including murder-suicide, that may arise when families are permitted or encouraged to take too much responsibility for severely ill patients have, perhaps, received too little attention. REFERENCES
1) D. J. West, Murder Press, Cambridge, 1987. 2) P. J. Resnick, “Child
Followed
by
Suicide,
Harvard
University
Murder by Parents: A Psychiatric Review of Filicide,” American Journal of Psychiatry, Vol. 126, September 1969, pp. 325-334. 3) M. Rodenburg, “Child Murder by Depressed Parents,” Casiothan Psychiatric Association Journal Vol. 16, February 1971, pp. 41-
48.
NIGHT COURT: OF LEGAL AND James Jeffrey
It P. Fraser, E. Froelich,
A COLLABORATION MENTAL
HEALTH
SYSTEMS
Ph.D. J.D.
#{149}While the cases seen in a municipal courtroom and in a mental health center’s crisis department often are nearly identical, the description of the problem and the actions of the agency differ drastically. Too frequently, the invo!ved parties either are inducted into the roles and processes of the criminal justice or mental health system to their detriment, or are refused help with a problem because it is outside the range of one system or the other. What has been needed for some time is a model tlat meshes the elements of both systems. In Dayton, Ohio, such a model has been developed through the collaboration of the City Prosecutor’s Office, the University of Dayton Law School, and the Good Samaritan Community Mental Health Center. Potential misdemeanor charges involving generally predetermined classifications of statutoly offenses, such as intrafamily, inteipersonal, or neighborhood disputes, are referred to a nonlegal hearing for negotiation of a resolution and a plan to avoid future problems without court proceedings. Parties to interpersonal difficulties who have filed complaints are channeled into the program. All cornplaints must first be made to police who, in the district covered by the Good Samaritan Community Mental Health Center, have the option of calling a mental health crisis therapist to the site to try to solve the problem immediately. If this option is not chosen, or in Dr. Fraser is director of the crisis and brief therapy department of the Coed Samaritan Community Mental Health Center, 2222 Philadelphia Drive, Dayton, Ohio 45408. He is also an assistant clinical professor University
director
VOLUME
of psychiatry in Dayton.
in
the
School
of
MedICine
Mr. Froelich is an assistant of the law school clinic at the University
30 NUMBER
8 AUGUST
1979
at professor
Wright State of law and
of Dayton.
559
I.,ren
L. Fink
H. Roth
M.D. M.D.,
MPH.
WFhe death of a patient is a cataclysmic event for both the patient’s family and physician. This report is about such a death. A 24-year-old psychiatric patient who manifested great psychological distress was altruistically murdered by her father. He then turned the gun on himself. We report this case to alert psychiatric clinicians to some of the circumstances that might be assodated with murder-suicide (1-3), and to discuss the implications of such a tragedy in relation to the current psychiatric emphasis on patients’ rights, brief hospitalizations, and voluntary care in the community. The case involves a 24-year-old single Caucasian woman who was admitted to a hospital psychiatric ward in March 1975. In the spring of 1973, while a graduate student in mathematics, she had begun to experience angry feelings toward other people. She described those feelings as “seeming not to belong to me.” The patient was briefly seen in individual psychotherapy where a diagnosis of borderline schizophrenia was made. In the fall of 1974 she experienced acute anxiety while teaching. She was hospitalized in Maine for three weeks and was treated with haloperidol and psychotherapy. Ego-alien feelings and depression returned. She was subsequently admitted to the hospital in March of 1975 for evaluation of possible temporal lobe epilepsy and for further psychiatric work-up. (Some features of this case have been changed to disguise the identity of the person involved.) The patient was an only child. She had functioned very well in grade school and high school and had had a number of friends. She achieved a master’s degree in University of Pittsburgh and the Western Clinic, 3811 O’Hara Street, Pittsburgh, Pennsylvania 15261. Dr. Fink is assistant professor in the department of psychiatry of the School of Medicine and assistant program director of the assessment and brief treatment unit. Dr. Roth is associate professor in the department of psychiatry and director of the law and psychiatry program. The
authors
Psychiatric
558
are with the Institute and
HOSPITAL
& COMMUNITY
PSYCHIATRY
mathematics. The family history of psychiatric illness was positive only in the father, who had been treated for alcoholism more than 20 years ago. He had been a successful physicist who was retired at the time of the patient’s hospitalization. The patient’s hospital course in March 1975 was stormy. Multiple EEGs failed to reveal any evidence of temporal lobe seizures. The patient underwent paranoid decompensation while in the hospital. When offered medication, she initially felt that the doctors were trying to poison her. The patient’s parents, who visited regularly, were quite upset by the decompensation. They were seen for a brief family evaluation, which revealed a close bond between the parents and the patient. The patient, however, was never fully explicit with the parents about her fears and worries. The patient’s paranoid ideation responded to perphenazine, and ten days after admission she was discharged. After discharge, the patient was seen weekly. She was noted to be depressed. Because the patient’s diagnosis was still uncertain, it was decided to discontinue her medications and to schedule sleep studies. One week after medications had been stopped, the patient showed increasing anxiety and inability to sleep. She was started on haloperidol, 2 mg. q.i.d. She developed suicidal ideation, which was discussed with the father when he came with her for an outpatient appointment. Both the father and the patient resisted rehospitalization. The father said he would assume responsibility for the patient since he was at home and could watch her closely. It was recommended to the father that he get rid of a gun that was in the home. On subsequent visits, hospitalization was again recornmended. The patient and the father refused on the grounds that she had previously gotten worse in the hospital. The frequency of outpatient visits was then increased. Two days after an outpatient visit, the patient’s mother called to say that the patient was sleeping much better and appeared to be feeling better. Later that same day, however, the mother called again to say that she had arrived home from work to find that her husband had shot and killed the patient, then turned the gun on himself. A diary was found in which the father delineated his
hopeless feelings about the daughter’s condition. He believed that she was incurably mentally ill, possibly “genetically tainted,” and that she would never be able to live a normal life. He reported her pleading with him to put her out of her misery. It was apparently in response to those hopeless feelings about his daughter’s illness that he killed her and himself. In a subsequent meeting with the mother, it was learned that family friends were not surprised at the father’s action. Knowing the closeness between father and daughter, they viewed the father’s act as a gift of love. Murder-suicide is an unusual occurrence, but it happens. Therefore, psychiatric clinicians should be alerted to the possibility of it under certain circumstances. A review of the literature reveals that such crimes almost always occur in domestic settings. They are more often committed by a man than a woman. And 15 per cent of those who commit murder-suicide have themselves made previous suicide attempts. West divided persons who commit murder-suicide into two groups-the “sane” and the “insane.” Among the “sane” offenders, the most common motivation is altruism. The victims are almost always relatives; and occasionally the victims are willing participants who are in some way sick or disabled. Depression in a parent, coupled with real or imagined physical or emotional defects in a child, is a clinical constellation associated with child murder by parents (3). The case reported here certainly matches the clinical circumstances associated with murder-suicide. Unfortunately, the patient’s initial psychopathology and then her marked suicidal ideation overshadowed the depth of her father’s distress. During her initial brief hospitalization, one family session was held, but the focus was principally upon the problems of the patient and not on the family dynamics or the family’s response to her illness. After hospitalization, the patient was seers with her father, but the focus was again upon the patient’s syrnptomatology. The father’s willingness to provide personal support and home supervision seemed to provide the least restrictive alternative to hospitalization. In considering preventive measures, the current philosophy of psychiatric care bears mention. There is increasing emphasis today on brief hospitalization following the medical model and emphasizing neuromedical work-ups and aggressive use of psychotropic medications. The duration of hospitalization is often dependent upon the patient’s willingness to be hospitalized. With such an orientation, the patient’s family situation, the psychodynamics of the family members, and the stresses attendant upon them may receive less attention than was formerly the norm when hospitalizations were longer. Respect for the privacy of an adult patient may also contribute to decreased communication with the family about the nature of the patient’s illness. It is clear from the case presented here that the current emphasis on brief hospitalization and home treatment can put a tremendous burden upon a patient’s caretakers. Even if a family is willing to assume the responsibility of caring for an actively disturbed patient
at home, their ability to handle the stress requires both a thorough initial evaluation and continued monitoring and information exchange with the patient’s therapist. There has been much recent emphasis on the harm that families may do patients by involuntarily cornmitting them to mental institutions. Possible problems, including murder-suicide, that may arise when families are permitted or encouraged to take too much responsibility for severely ill patients have, perhaps, received too little attention. REFERENCES
1) D. J. West, Murder Press, Cambridge, 1987. 2) P. J. Resnick, “Child
Followed
by
Suicide,
Harvard
University
Murder by Parents: A Psychiatric Review of Filicide,” American Journal of Psychiatry, Vol. 126, September 1969, pp. 325-334. 3) M. Rodenburg, “Child Murder by Depressed Parents,” Casiothan Psychiatric Association Journal Vol. 16, February 1971, pp. 41-
48.
NIGHT COURT: OF LEGAL AND James Jeffrey
It P. Fraser, E. Froelich,
A COLLABORATION MENTAL
HEALTH
SYSTEMS
Ph.D. J.D.
#{149}While the cases seen in a municipal courtroom and in a mental health center’s crisis department often are nearly identical, the description of the problem and the actions of the agency differ drastically. Too frequently, the invo!ved parties either are inducted into the roles and processes of the criminal justice or mental health system to their detriment, or are refused help with a problem because it is outside the range of one system or the other. What has been needed for some time is a model tlat meshes the elements of both systems. In Dayton, Ohio, such a model has been developed through the collaboration of the City Prosecutor’s Office, the University of Dayton Law School, and the Good Samaritan Community Mental Health Center. Potential misdemeanor charges involving generally predetermined classifications of statutoly offenses, such as intrafamily, inteipersonal, or neighborhood disputes, are referred to a nonlegal hearing for negotiation of a resolution and a plan to avoid future problems without court proceedings. Parties to interpersonal difficulties who have filed complaints are channeled into the program. All cornplaints must first be made to police who, in the district covered by the Good Samaritan Community Mental Health Center, have the option of calling a mental health crisis therapist to the site to try to solve the problem immediately. If this option is not chosen, or in Dr. Fraser is director of the crisis and brief therapy department of the Coed Samaritan Community Mental Health Center, 2222 Philadelphia Drive, Dayton, Ohio 45408. He is also an assistant clinical professor University
director
VOLUME
of psychiatry in Dayton.
in
the
School
of
MedICine
Mr. Froelich is an assistant of the law school clinic at the University
30 NUMBER
8 AUGUST
1979
at professor
Wright State of law and
of Dayton.
559
