BURGESS ET AL. HOMICIDE-SUICIDE AND DUTY TO WARN

Homicide-Suicide and Duty to Warn Ann W. Burgess, L. Kathleen Sekula, and Carrie M. Carretta Abstract: This retrospective study of medical examiner records from three counties reported on 252 persons who killed 302 victims before killing themselves and reviews the Tarasoff ruling that set the standard for duty to warn and/ or protect third parties whose lives are threatened by a patient. The three sites varied significantly for the perpetrator in terms of race, employment, cause of death, and motive. Female offenders killed more children under the age of 10 and adolescents than did male offenders. Evidence of premeditation included suicide notes and weapon brought to the crime scene, while strangulation indicated a spontaneous domestic homicide. Implications for practice are discussed including the importance of evaluating violent thoughts, fantasies, and behaviors in acute emergency settings and recommendations include second opinion consultation for Tarasoff-type cases and psychological autopsy review for completed homicide-suicide cases.

While homicide-suicide cases make sensational headlines, they leave many unanswered questions. Police and emergency services staff ask, “Why did this happen?” Friends and associates ask, “What did we miss?” Family asks, “What could we have done?” The co-occurrence of two divergent forms of lethal violence, one directed against other persons and one against the self, write Liem and Oberwitter (2012), has long puzzled clinicians and researchers, since there is a tradition to regard homicide and suicide as antagonistic expressions of human aggression.

Ann W. Burgess, R.N., D.N.Sc, F.A.A.N., is Professor of Psychiatric Nursing, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. L. Kathleen Sekula, Ph.D., A.P.R.N., F.A.A.N., is Professor of Nursing and Director, Forensic Nursing Graduate Programs, School of Nursing, Duquesne University, Pittsburgh, PA. Carrie M. Carretta, Ph.D., A.P.N., A.H.N.-B.C., F.P.M.H.N.P., is Assistant Professor/ Research Faculty, School of Nursing, Rutgers The State University of New Jersey, Newark, NJ. Psychodynamic Psychiatry, 43(1) 67–90, 2015 © 2015 The American Academy of Psychoanalysis and Dynamic Psychiatry

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Violent death is a critical concern in psychiatry, as mental health practitioners are required to evaluate and treat patients who threaten to kill others as well as themselves. Homicide-suicide, an event in which an individual commits a homicide and subsequently (usually within 24 hours) commits suicide (Felthous & Hempel, 1995), has some unique features. It is a rare event, estimated to occur between 0.2 and 0.38 per 100,000 persons annually, is a distinct category of homicide, and is usually carefully planned by the perpetrator as a two-stage sequential act (Knoll, 2012). Both suicidal and homicidal ideations are major criteria in a mental status examination and assume a larger component in forensic evaluations for dangerous risk assessments (Gellerman & Suddath, 2005). A forensic issue connected to suicide and homicide-suicide relates to warning others when a clinician has knowledge of a patient’s harmful intent to self or others. Few court rulings have had the impact on clinicians as has the 1976 case of Tarasoff v. California Board of Regents decision (Mason, 1998). In the United States, some states impose an actual duty to warn based on the Tarasoff case. However, Herbert’s analysis (2002) notes that no two states approach the issue exactly the same way, and the legal statutes of many may impose a serious burden of guesswork for the clinician. This article reports findings from a study of medical examiner cases from three counties to try to answer statistical questions about causes and motives and suggests factors that psychiatric clinicians may consider when assessing and treating persons with suicidal and/or homicidal ideation that could give rise to a duty to warn. Background Constructs of Homicide-Suicide Cases Contemporary theories perceive homicide-suicide to be a variation of the two behaviors. One model of homicide and suicide developed by Henry and Short (1954) links both suicide and homicide to aggression that stems from frustration. In a study of 148 cases in England between 1946 and 1962, West (1965) characterized homicide-suicide as a single act based on the minimal time between acts and the close relationship of the two persons. Stack (1997) suggests the self becomes a legitimate target of aggression in the form of suicide and the homicide-suicide and is characterized by a high degree of frustration, showing patterns of discord and

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physical abuse—a notion corroborated by previous empirical research (Morton, Runyan, Moracco, & Butts, 1998; Rosenbaum, 1990). Thus, aggression toward others and aggression toward the self are determined by either external or internal attribution styles. Liam, Hengeveld, and Koenraadt (2009) question if homicide is outwardly directed and suicide is inwardly directed, why does someone commit homicide and then commit a suicide? The research related to homicide-suicide addresses age of victim (from infanticide to eldercide), number of victims (double, triple, mass, serial), type of victim (familicide), and co-dependent crimes (felony, sexual). Since the late 1960s, the re-emergence of the women’s movement called attention to violence against women primarily in the areas of rape and domestic violence (Crowell & Burgess, 1996). In addition, Cohen’s (Cohen, Lorente, & Eisdorfer, 1998) study of homicide-suicide emphasized older persons, Safarik and colleagues studied the investigative aspects of elderly female homicide (Safarik, Jarvis, & Nussbaum, 2000), and Campbell’s (2007) work assessed dangerousness in domestic violence and child abuse situations. The Violence Policy Center (2012) reports that although there are no national statistics for homicide-suicides, the Center has been collecting their own statistics since 2002. The VPC analysis reveals that in the first half of 2011 there were 313 murder-suicide events resulting in 691 murder-suicide deaths, of which 313 were suicides and 378 were homicides. By doubling the total number of fatalities during the six-month period for a yearly estimate, there were an estimated 1,382 murder-suicide deaths in 2011. Homicide-suicide cases have been difficult to study for several reasons. First, until recently, there has been no centralized database for analysis; second, because there is no medico-legal distinction of homicide-suicide and cases typically do not result in a criminal charge or trial to provide in-depth analysis of the perpetrator; third, researchers often have had to rely on newspaper accounts of cases and thus cannot report on prevalence or incidence; fourth, the research community arrives separately at suicide from a clinical orientation or homicide from a forensic orientation rather than exploring the combination of lethal behaviors; and fifth, with the death of the perpetrator, classifying a case based on assumed psychopathology or motive is particularly prone to speculation. As a result, there is no theoretical foundation within which to understand motivation in specific subcategories of homicide-suicide that, in turn, could direct prevention strategies. For example, the psychoanalytical literature has a long history of proposing a link between homicidal and suicidal tendencies, characterized by Freud’s notion of the death instinct. This notion was further elaborated upon by Men-

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ninger (1938), who posited that suicide involved the wish to kill, be killed, and to die. However, there is minimal empirical evidence to support or refute this link. Early literature focuses on classifying homicide-suicides into subgroups. Marzuk, Tardiff, and Hirsch’s (1992) classification system was based on a 4-type victim-offender relationship: uxoricide (killing an intimate partner followed by suicide), filicide-suicide (killing of a child followed by suicide), familicide-suicide (killing of a partner, children), and non-family homicide-suicide. Later classifications are based on psychopathology (Felthous & Hempel, 1995), motive (Harper & Voigt, 2007), and precipitating stressors (Hanzlick & Kopenen, 1994). Liem, Postulart, and Nieubeerta (2009) added familicide-suicide to include killing family members as well as a partner, and a category of extra familial homicide-suicide for persons who kill outside of the family and whose perpetrator characteristics include having been bullied in childhood, having few friends, perceiving the world as unjust, and building frustration and anger. History of the Tarasoff Liability Decision Although the Tarasoff case involved a homicide, it raises comparable issues related to homicide-suicide cases and our study. The Tarasoff decision has been widely critiqued in the psychiatric and legal literature as an empirical study of private law in action (Givelber, Bowers, & Blitch, 1984), malpractice countersuits (Taub, 1981), a household word in American mental health circles (Wexler, 1979), Tarasoff liability (Mason, 1998), and a reconsideration (Herbert, 2002). We describe the Tarasoff decision and cases related to it. Psychiatrist-lawyer Paul Herbert, clerking at the California Supreme Court at the time Tarasoff was argued and decided provides a clear factual account of the case (Herbert, 2002): Prosenjit Poddar, a native of rural India, was a graduate student studying electronics and naval architecture at the University of California-Berkley in 1967. In 1968, he began pursuing Tatiana Tarasoff, a community-college student who lived with her parents. Poddar made several attempts to start a relationship with her including a March 1969 marriage proposal. Following her rejection, Poddar became humiliated, angry, returned home and expressed to his roommate thoughts of killing Tarasoff. His behavior escalated and he became paranoid, taping telephone conversations with Tarasoff and listening to them over and over. He told coworkers that he would like to blow up Tarasoff’s home.

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He began to show signs of clinical depression and lost interest in his studies. A friend urged him to seek mental health counseling. In June 1969, Poddar, persuaded by his roommate to seek counseling at a university health service, told the psychiatrist of his thoughts of killing an unnamed young woman with whom he was obsessed. He was given weekly therapy sessions with a psychologist and antipsychotic and sleep medication. While Poddar was in therapy for 8 weeks, he continued repeating his homicidal thoughts. In response, the psychologist told Poddar he would have to restrain him if he continued such talk which prompted Poddar to stop therapy. At this point, the therapist conferred with the treating psychiatrist and another university psychiatrist and a letter was written to the university police. The letter noted that Poddar was threatening to kill an unnamed female, that he had informed his roommate that he intended to buy a gun, and that he planned to kill the woman. The psychiatrists recommended Poddar be committed for observation to a mental hospital and requested the assistance of the university police. The campus police interviewed Poddar whose new roommate was Tarasoff’s brother. Poddar acknowledged the troubled relationship but denied any death threats. The brother knew the threats were against his sister but was said to have dismissed them as being serious threats (Winslade & Ross, 1983, p. 63). The police, satisfied that Poddar was rational, released him on the promise to stay away from Tatiana (Tarasoff v. The Regents of the University of California). The chief of psychiatry at the university health service then asked the police to return the psychotherapist’s letter, directed all copies of the letter and notes he had taken as therapist be destroyed and ordered no action to be taken against Poddar (Tarasoff v. The Regents of the University of California, p. 341). Two months after his interview with campus police, Poddar began stalking Tarasoff, purchased a gun and on October 27, 1969 went to her home, found her alone, and shot and killed her. He then called the police and waited to be arrested. Tarasoff’s parents sued the university health services chief of psychiatry, the psychiatrist who initially saw Poddar, the psychologist who saw him for 8 sessions, along with one other campus psychiatrist who had taken part in one discussion, and the campus police. They alleged that defendant therapists did in fact predict that Poddar would kill and were negligent in failing to warn (Tarasoff v. The Regents of the University of California, p. 345). The lower court, the Superior Court of Alameda County, dismissed the lawsuit, finding that there was not a valid cause of action against

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the defendants (that is, that the Tarasoff family had no right to sue) because the university owed no duty of care to Tarasoff. The Supreme Court of California reversed the decision of the lower court, by a split vote of four to three. The majority vote focused on two fundamentals: (1) public policy interest in protecting the public from a known threat required disclosure of the confidential information to avert a preventable injury or death (Herbert &Young, 2002) and, (2) the purported “special relationship” of a psychotherapist and patient. The three dissenting justices were opposed to the finding that a therapist might be held liable for failing to predict a patient’s tendency to violence based on studies focused on the difficulties in forecasting dangerousness, and the potential cost of diminished confidentiality between patient and therapist (Herbert, 2002). As for Poddar himself, he was convicted of second-degree murder at his first trial. He appealed the decision, and the appellate court reduced his sentence to manslaughter. Two years later (in 1974) the California Supreme Court vacated that judgment and ordered a retrial. Five years having elapsed since the original trial, the state, rather than go through a second trial, released Poddar—on condition he return to India and not return to the United States. He has by now, it is said, been happily married to an attorney. In today’s world, the Tarasoff case would be classified as a “breakup” violence case similar to the Wayland, MA case of Nathanial Fujita (CBS Boston, 2013) where a jury found the 20-year-old guilty of first degree murder in the stabbing and strangulation death of his 18-year-old exhigh school girl friend. The prosecutor said the motive was “rage over the breakup.” The father of the victim said he would advise never leaving a young woman alone with someone with whom she had ended a relationship. Method of Study This retrospective record review study was based on the examination of medical examiners’ records pertaining to individuals who killed another person(s) and then themselves. Sample The sample included a total of 252 cases of homicide-suicide: 59 from Orange County, CA, 131 from Los Angeles County, CA, and 62 from Al-

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legheny County, PA. The offices of the County Medical Examiners for Orange County, CA, Los Angeles County, CA, and Allegheny County, PA provided access to archival files of homicide-suicide deaths for persons who underwent autopsy between 2001 and 2011. Permission to conduct the study in CA was obtained from the University of Medicine and Dentistry of New Jersey Institutional Review Board (IRB). Protection of human subjects was achieved through de-identification of data at the time of data collection to ensure anonymity of the subject to anyone other than the data collector. Data were collected by hand onto paper copies of the Homicide-Suicide Assessment Tool developed by two of the article authors. The tool evaluates six major variables: cause (how the person died); mode (circumstances that led to the death or deaths); motive (why the person was killed); intent (resolve to carry out the crime); lethality (explains probability of success of the death); and point of origin (implication for potential for intervention). There are two methodological limitations with the data. First, psychiatric history or on-going mental health treatment of perpetrator or victim was missing from the medical examiner files and crime scene data and photographs were unavailable for review. Second, it was sometimes difficult to establish consistency for coding from three separate medical examiner office records. Statistical Analysis Relationships between the three counties of homicide-suicide cases relative to age-related factors (such as motive for death, life stresses, etc.) or death-related factors (such as location, weapon used, method, cause) were explored. Where distributions were highly skewed, medians and inter-quartile ranges (IQR) were reported, otherwise means were presented. For bivariate comparisons, t-test or odds ratios (OR) with 95% confidence intervals (CI) were reported. All analyses were conducted using SPSS version 21 for Windows. While the three sites varied on some demographic variables, they did not differ on other important variables. The data are presented in the aggregate for variables where the three counties did not differ and explained from the perspective of the clinical significance.

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Homicide-Suicide Classifications For this article, cases from the medical examiners’ offices were coded into one of five categories based on victim-offender relationship (spousal, partner, familial) plus motivation of perpetrator (jealousy, revenge, altruism, etc.; Knoll, 2012). The following major patterns are adapted from Marzuk, Tardiff, and Hirsch (1992) and Knoll (2012). • Consortial-possessive: Relationship characterized by domestic abuse, multiple separations and reunions, or recently estranged. Motives tend to be paranoid or morbid jealousy. For this study, several variables were combined to determine the classification. For example, if the offender killed a partner/spouse and was separated from the partner or lived alone it was classified as consortialpossessive. • Consortial-physically ailing: One partner living with a chronic medical condition including pain and suffering. Poor health typically includes financial difficulties; depression is usually present with despair about the future. Suicide notes often left. • Filicide-suicide: A parent kills a child and then immediately suicides. Motives include psychosis, altruism, and revenge. • Familicide-suicide: Members of a family are killed. The perpetrator is usually depressed and experiencing precipitating stressors such as marital problems, custody disputes, or financial problems. • Adversarial homicide-suicide (extra familial): This type often includes bullied students, a disgruntled ex-employee, client, or resentful paranoid loner. Blame is externalized onto others with the perception of having been wronged and the perpetrator has depressive, paranoid, or narcissistic traits. There may be persecutory delusions and auditory hallucinations. The perpetrator has a fascination with weapons, especially guns, and has no escape planned from the homicide. The event may include “suicide by cop” where he forces police to kill him (Knoll, 2012). Findings Profile Characteristics of the Homicide-Suicide Perpetrators by County Location. Of the three counties, 131 cases (52%) were from Los Angeles County, 62 cases (25%) were from Allegheny County, and Orange

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County reported 59 cases (23%). The variables in which the three sites varied significantly for the perpetrator were race, employment, cause of death, and motive. In Los Angeles County the majority of perpetrators were male, Hispanic, lived with a partner, were between the ages of 35 and 64 (X = 47.27), and killed their victim by gunshot. The motive in most cases was domestic conflict. The majority of perpetrators had no prior arrest for violence (73.2%) or prior arrest for substance abuse (90.4%). Suicide notes were left by 22.3% of perpetrators and 96.4% had no reported history of prior suicide attempts. The largest age group of murdered victims was 35–64. The majority of victims were female (78.6%), Hispanic (43.5%), and the victim was the intimate partner in 71% of the cases. The majority of victims (69.5%) were killed in their house by gunshot (86.3%). In Orange County the majority of perpetrators were male, Caucasian, lived with a partner, were between the ages of 35 and 64 (X = 51.36), and killed their victim and themselves by gunshot. Most killed their intimate partners (69.5%) or another family member (13.6%). Domestic conflict accounted for the majority of motives. There were no prior arrests for 78.8% of the perpetrators and no prior drug/alcohol arrests for 79.2%, and 36.8% left a suicide note. There were no reported prior suicide attempts in 89.3% of the cases. In Allegheny County the majority of perpetrators were male, Caucasian, and intimate partners of the victim. The motive in the majority of cases was domestic conflict. Marital status included 37% of perpetrators who were single or in a partner relationship (42%). The majority (80%) used a gun to kill a partner inside a house (79%), did not have a prior arrest for drug/alcohol abuse (88%), or a history of substance abuse (52%), had no history of suicide attempt (98%), and did not leave a suicide note (70%). Racial distribution of perpetrators was significantly different among the sites (F = 88.469, df = 10, p = .000). Los Angeles County had a higher number of African Americans (73.5%) than Allegheny County (19.1%) or Orange County (7.3%). In addition, Orange County and Los Angeles County had a greater number of Hispanics, whereas none were noted in Allegheny County. Racial differences reflected the census data of the three sites: the majority of perpetrators in Orange County (71.2%) were Caucasian, the majority in Allegheny County (77.4%) were Caucasian, while the majority (43.5%) in Los Angeles was Hispanic. The use of a gun was a dominant method of killing by all perpetrators regardless of race. Second leading cause of death for Caucasians was blunt force trauma and for African Americans, Hispanics, and Asians it was a cutting instrument.

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Employment was significantly different. LA had the highest percentage employed either part-time or full-time at 72.5% (with 22 cases with missing data), followed by Orange County at 27.1% (with 25 cases with missing data), and lastly Alleghany County at 19.4% (with 44 cases with missing data; F = 24.537, df = 2, p = .000). Motive for the murder-homicide was gathered in five categories and included mixed findings regarding significance. In cases of uxoricide, the victim-perpetrator relationship differed significantly among the three sites, with Allegheny County having the highest number of intimate partner homicide-suicides at 80.3%, followed by Orange County at 61.1%, and Los Angeles at 59.6% (F = 27.239, df = 14, p = .018). The consortial-physically ailing had no significant differences between the three counties. Los Angeles had 12.3% (n = 13), Orange County was 2.1% (n = 1), and Allegheny County had 11.3% (n = 7). There were no cases of fillicide-suicide in Orange County or Allegheny County, but Los Angeles had 6 or 5.7% total cases. Familicide-suicide differed significantly between the three counties. Orange County had 41.7% (n = 20), Allegheny County had 33.9% (n = 21), and Los Angeles had only 12.3% (n = 13; F = 18.883, df = 2, p = .000). Adversarial-homicide-suicide (extra familial) was also significantly different for the three counties (F = 25.153, df = 2, p = .000) with 31.3% (n = 15) of Orange County cases. Los Angeles was next lowest with 8.5% (n = 9) and Allegheny County had only 1 case (1.6%). Cause of death was significantly different across sites. The major cause of death for all three counties was gunshot with Orange County at 90.3%, Los Angeles at 91%, and Allegheny County at 71%. The second most frequent cause of death differed with Allegheny County having more deaths by blunt force trauma than the two California counties and with Los Angeles County having more victims dying by a cutting instrument than in Allegheny or Orange County. In cases with data, a history of substance abuse differed between the counties with Allegheny County highest at 48%, Orange County at 21%, and Los Angeles County at 19% (F = 7.091, df = 2, p = .029). A history of prior drug and alcohol related arrest was 7.6% based on the data available and a history of past arrest for violent offense occurred in 15.2% of all cases. There were several variables that did not differ significantly among sites. Aggregate data for marital status indicated 27.6% of perpetrators were single, 54.1% were partnered, and 18.4% were separated or divorced. When looking at age by individual perpetrator age, the mean and median for all sites did not differ significantly: X = 48.51 and Median = 46.0 (p = .088). The victim’s ages did not differ significantly whether analyzed by individual age (X = 40.73, Median = 41.0) or within four

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groupings (1 ≤ 20; 2 = 20–34; 3 = 35–64; 4 = 65 and over): the majority (46%) of perpetrators ranged between 35 and 64 years, as did victim ages (46% between 35 and 64). Gender differences varied by site with both Orange and Los Angeles counties reporting more female perpetrators than did Allegheny County. Female offenders killed more children under the age of 10 than did male offenders (31.6% versus 4.3%, respectively; F = 30.539, df = 7, p = .000) and also killed more children between the ages of 10 and 19 than male offenders (5.3% versus 0.9%, respectively). Evidence of Psychodynamic Factors The same forces that influence normal everyday conduct also influence the offender’s actions during an offense (Douglas, Burgess, Burgess, & Ressler, 2013). Behavioral observations relevant to offender thinking and planning are: (a) how the encounter between offender and victim occurred, (b) was the victim blitz-attacked or verbally conned, and (c) what type of weapon was used for both lethal acts. All cases of violent death, whether homicide, suicide, or both, are reportable deaths to law enforcement and to medical examiners for cause of death. Investigators have an opportunity to interview family members in the course of notification of the deaths. As such, information that speaks to the psychodynamics of the death provided insight into the planning of the crimes. Premeditation. A homicide usually involves planning by the perpetrator with the target victim being unaware. Most violent crime has a quiet, isolated beginning in the offender’s imagination where the person fantasizes about the killing. When offenders translate the violent fantasies into action, their emotional needs compel them to exhibit violent behavior during the commission of the crime (Douglas et al., 2013). A violent fantasy, write Gellerman and Suddath, is a thought in which the individual imagines physically harming another person. It is distinguished from either an intention (in that the imagined violence is not aimed at immediate action) or from a delusion (in which the distinction between imagination and reality is lost; Gellerman & Suddath, 2005). Evidence of premeditation in this study consisted of suicide notes, type of weapon, and moving the body after death. Suicide notes indicate planning and were recorded from the ME files. Although not significant (p = .338), Orange County had the highest percentage of suicide notes (21 or 36.8%), followed by Allegheny County (18 or 29.5%), and Los Angeles last (29 or 22.3%). Notes were not always found at the crime scene

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but some were later found at the perpetrator’s home, on the perpetrator at a location different from the victim, or previously mailed to an acquaintance of the perpetrator. Leaving a suicide note was significantly related to illness motive for the murder (p = .000). Seventy percent of the offenders who committed homicide-suicide for health reasons left a suicide note; 68% of those 70 and older left a suicide note and 91% of the offenders 70 and older used a gun. Other documents were found to indicate planning. A divorced, employed woman who killed her biological son and common-law husband before shooting herself left her will and testament on a table. In a mass shooting case of 11 people, several notes in a journal and a suicide note were found stating the perpetrator’s intentions. The perpetrator and two females died at the scene and one female died at the hospital. Detectives found letters of intentions, a video camera, three weapons, and the medical examiner found a gun in the perpetrator’s shorts before starting the autopsy. In a case where court records indicated the children’s parents had been in a custody fight, a 51-year-old grandmother shot and killed her 5-year-old and 5-month-old grandchildren before killing herself. She left two notes in which she indicated depression and stress over family and financial matters. Details of the planning might come from a secondary source as in the case where detectives reported that the husband had long planned the act as the postal service was contacted to hold the mail and instructions for burial arrangements and personal assets were found in a letter typed on his computer The type of weapon can indicate a spontaneous act or advanced planning, if, for example, the weapon is brought to the scene. A spontaneous domestic homicide tends to be triggered by a recent stressful event or a cumulative buildup of stress. The perpetrator would usually not think to move the body especially if the suicide followed within a very short time period. There is one crime scene in that both victim and offender are found in the same location such as inside a house. The crime scene reflects disorder and the impetuous nature of the murder. The weapon will be one of opportunity obtained and left at the crime scene or hands used for strangulation or lethal assault. The crime scene may also reflect an escalation of violence as with a confrontation that starts as an argument, intensifies into hitting or throwing things, and culminates in the victim’s death. There may be indicators of undoing as the offender’s way of expressing remorse or the desire to undo the murder. Undoing is demonstrated by covering up the body. Moving the body from the death scene or repositioning the body are both expressions of undoing (Douglas et al., 2013, p. 171). One example of spontaneous domestic homicide-suicide indicated the victim struggled and tried to resist strangulation as noted by inju-

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ries to the victim’s neck. The partner then moved her body to a second location where he committed suicide rather than leaving her body at their residence. In a second case, an ex-husband was found dead in his garage with the car running and a plastic tube running from the exhaust pipe to the back of the car hatch which was sealed with masking tape. The victim had numerous abrasions and contusions on her neck. Police reported the ex-husband killed his wife at their residence and then transported her to his father’s house where he killed himself. One theory for a suicide has been labeled the “Othello syndrome” (Sukru, Huner, & Yerlikaya, 2004) where, referring to Shakespeare’s play, Othello killed Desdemona while under the belief she had betrayed him, realizes her death was unjust, and kills himself out of shame and guilt. This theory suggests the suicide is reactive rather than premeditated, as it stems from a feeling of remorse for the homicidal act (Guttmacher, 1960; Henry & Short, 1954). Other Evidence. The criminal actions of a perpetrator can provide evidence of mood. Extreme anger was noted when one perpetrator went far beyond what was physically necessary to kill his ex-partner. The victim was dismembered and there were towels and an extension cord tied around the victim’s neck. Immediate cause of death was determined to be blunt force trauma of the head and strangulation. Sometimes an offender’s narcissism is displayed as in the case where the police found a camcorder in the “on” position on the living room table and a VCR running documenting the deaths. Psychotic Symptoms. In one case the perpetrator’s step-mother told detectives the perpetrator told her that, “The devil said to me that if I kill Timmy I will get Tara back.” In another case, the perpetrator’s father said his son had a mental health history but would not tell the family anything other than he suffered from “major depression.” The father offered to get the son help on numerous occasions but he always refused. There may be prior threats as a warning sign of the pending violence as in the case where a wife hid her partner’s guns. The week prior to the homicide-suicide, the victim checked for the hidden guns, found them missing, and told a family member. Or there may be verbal notification where a perpetrator had told his family he could not live without his wife who was terminally ill and would commit suicide. In this case, the family had representatives from the local hospice talk with the husband two days before the homicide-suicide. And there may be witnesses to abuse as in the case where four caregivers had resigned due to the son’s abuse, neglect, and harassment of his mother. The incidents had been

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reported to the Department of Aging prior to the son killing his mother and then himself. Discussion There are two areas for discussion. First, this study reported statistical findings on 252 persons who killed 302 victims before killing themselves and suggests implications for clinical practice when assessing patients about thoughts and plans for violent behavior. Second, it makes two recommendations for dealing with Tarasoff-type cases and advocates for further research to advance the psychiatric science of depression and aggression. Implications for Psychiatric Practice How do the data from this study inform psychiatrists and mental health clinicians who practice psychodynamic psychiatry? We do know the data collected in this population are consistent with the literature in that the majority of homicide-suicides involved guns, the perpetrator and victim were known to each other, both the majority of victims and perpetrators fell between the ages of 35 and 64, the primary motive in the majority of cases involved family conflicts, a small number of suicide notes were left behind, and past history of arrests for drugs/ alcohol or violent acts were low. In addition, most perpetrators were usually male, most victims were female, and race of the majority of perpetrators was Caucasian. The differences by location of the three counties speak to the importance of local, county, and community influences: specifically on cause of death, type of weapon, planning or spontaneous act, and motive. These findings alert the clinician to the sensitivity of the demographics in the practice location. For example, certain regions are more prone to extra-familial cases involving peers (gang shootings) than to domestic partner killings. Violence in the elderly is an increasing concern. Although fatalities for murder-suicide in the elderly in our study were reported to be illness-related in 13 of 22 cases age 70 and over, committed by the male partner and by gunshot, it was not known how many cases involved prior domestic abuse. Salari (2007) in her study of 225 murder-suicide events among dyads with at least one member 60 or older argues that suicidal men in this age range must be recognized as a potential threat

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to their female partner and labels the men as “intimate terrorists,” given that the victims were often terrorized before the murder. Parental murder of their children was a significant concern. More mothers, in our study, killed younger children than did fathers—a finding dissimilar from other studies. Filicide homicides, argue Friedman, Hrouda, Holden, Noffsinger, and Resnick (2005), are different from other types of child murder. The researchers reviewed parental motives for filicide-suicide from 30 county coroner files and classified altruistic and acutely psychotic motives. Twice as many fathers as mothers committed filicide, and older children were more often victims than infants. Records indicated that parents frequently showed evidence of depression or psychosis and had prior mental health care. Tarasoff-Type Cases Although there was no information as to whether (or not) any of the cases in this study had a potential Tarasoff liability issue, in homicidesuicide cases with multiple victims, the forensic issue is usually raised as to whether there was a “duty to warn.” For example, before the shooting, James Holmes, accused of killing 12 and injuring 70 in a July 2012 attack at an Aurora movie theater, was treated by a therapist at the University of Colorado Health Services while studying in a Ph.D. neuroscience program. Documents state the psychotherapist told a campus police officer about her concerns June 12, 2013, the day after she met with Holmes for their only session and that after she stopped seeing Holmes he “threatened and harassed her via email and text messages” (Associated Press, 2013). Despite telling campus police, the media reports lawsuits have been filed stating the psychiatrist’s duty to protect [the public] did not go far enough. In another high profile case termed The Navy Yard Shooting of September 16, 2013, violence, guns, and mental health issues came sharply into focus. Media indicated the shooter, Aaron Alexis, who killed 12 people, had, in recent months, received treatment for paranoia and a sleep disorder. Alexis reported hearing voices in his head and believed people living above him were sending vibrations through his apartment ceiling that were keeping him awake. On August 7, 2013, Alexis called Rhode Island police and told them that he believed three people were following him and trying to hurt him. He also told police that three people communicated with him through the walls, floors, and ceilings of his room using microwaves to send vibrations. In retrospect, it is clear that Alexis was experiencing severe mental health problems

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(Tucker, Gillum, & Baldor, 2013). A lawsuit for 37.5 million dollars was filed by the sister of one of Alexis’s victims and the U.S. Department of Justice has joined in a lawsuit against the company that conducted background checks on Alexis. The evaluation of dangerousness usually includes asking persons about violent fantasies that have a physical or sexual content, when they first noticed such thoughts, and how close they have come to acting on those fantasies. Gellerman and Suddath (2005) review the circumstances in which the violent fantasies a patient revealed were worrisome enough to warrant, on the part of a therapist, a duty to warn or to protect a third party. They strongly recommended that clinicians do a thorough assessment of risk factors for dangerousness, the nature of the fantasy, and the attitudes and behaviors related to the fantasy—all with the goal in mind to help differentiate whether the fantasy appeared to represent, as best as one could determine, a truly serious danger (Gellerman & Suddath, 2005). Assessment in the Emergency Room. Psychiatrists and mental health clinicians often assess or consult on acute cases involving dangerous intent seen in an emergency setting. Thienhaus and Piasecki (1998) outline 12 basic guidelines for evaluating homicidal patients in the emergency department. 1. Make safety a priority. Patients need to be searched for weapons and security personnel must be available. 2. Evaluate the patient’s situational context specifically identifying the prevailing stressors. 3. Expand the patient database to include a detailed history of past acts of violence. Obtain, where possible, prior medical, police, family, and victim reports. 4. Assess psychopathology, specifically loss of reality testing, mental status changes, and a reduction in impulse control, such as mania, delirium, or intoxication. 5. Consider the patient’s suicide risk. 6. Operationalize deterrents such as a religious belief or fear of the legal consequences that may mitigate against homicidal behavior. 7. Review the situation awaiting the discharged patient. Will the patient return to an unchanged situation. Will drugs, alcohol, or weapons be readily available? 8. Avoid a “no-homicide” contract. Clinical contracts are not legal contracts and falsely reassure the clinician that a risk has disappeared. 9. Seek a second opinion. It corrects distortions and countertransference attitudes.

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10. Order a urine drug screen, and do not discharge an intoxicated patient. 11. Document the dispositional decision and its rationale for forensic reasons. Provide clear directions about what to do if the patient reexperiences homicidal thoughts. 12. Fulfill legal duties. ER staff must know their state’s case law in advance of their being faced with a Tarasoff-type situation. Staff need to be aware that violence toward others constitutes a tort. Patients manifesting such violent tendencies or intentions should be informed that the consequences of their violent behavior would include criminal sanctions. When guidelines are not followed, clinicians are exposed to legal suits. In the following case, psychiatric staff only met criteria 1 and 5 prior to discharge of the patient and failed to warn the ex-wife of his homicidal thoughts. In Charlotte, NC (2010) 35-year-old Kenneth Chapman committed suicide as police arrived at his door. In the preceding two weeks, he had killed his wife and two of his four children. He had been seen by mental health professionals three times in an emergency department for depression in the days and weeks prior to the murders and he left a videotape of his confession. Chapman’s two surviving children sued in 2011, claiming that the healthcare system had not adequately treated Chapman and had violated its own policy by failing to warn Chapman’s family of his threats against them. The policy said, in part, that in the case of a “clear, imminent and reasonably foreseeable danger of harm by a patient to a known victim,” personnel should, “if appropriate,” contact police and the targets of the threats. The case was reported in the media to have settled for 11.5 million dollars (Gordon & Leland, 2013). Brief and/or Long-Term Treatment Treatment of suicidal and homicidal patients requires specific skills and an evidence-based foundation to guide practice. Psychodynamic psychotherapies have a long and distinguished history of carrying out studies of relevant variables, such as: levels of consciousness, the structure of personality, governing principles of the pleasure and reality constructs, defense mechanisms, and stages of psychosexual development. According to Gunderson and Gabbard (1999), psychodynamic psychiatry therapies operate on an interpretive-supportive continuum

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with an emphasis placed on more interpretive or supportive interventions depending on the patient’s needs. There are clinical studies that address levels of consciousness. For example, Busch and colleagues (Busch, Milrod, & Sandberg, 2009) have developed an evidence-based psychodynamic therapy for anxiety, concentrating particularly on the role of unconscious unexpressed anger, demonstrating good outcomes in 21 sessions compared with controls. Ursano, Sonnenberg, and Lazar (2004) emphasize that the classification of wishes into the libidinal versus the aggressive, and the balance between such wishes, may be a reflection of the patient’s contemporary experiences. The clinician’s skill now comes into play in assessing the balance of these thoughts vis-àvis the aggressive, as opposed to the libidinal, wishes. In the following case, the psychiatrist tragically failed to fully understand and interpret the homicidal and suicidal wishes and intent of a patient in the context of a dismissal from a group therapy setting. In Oakland County, Michigan (Grant, 2006), Mr. A., a 57-year-old man, attended group therapy led by a psychiatrist. Another patient, Mr. B., was dismissed from the group by the psychiatrist, but returned to the office with a gun during one of the regular sessions. Mr. B. shot and killed the psychiatrist. He then entered the group meeting room where he fired his gun several times more, fatally injuring another patient and wounding Mr. A. Mr. B. then turned the gun on himself and committed suicide. Mr. A. then had to be away from work for six weeks, having suffered wounds to the lower leg, foot, and hand. In a civil suit, Mr. A. testified that the psychiatrist, his daughter—who was also a psychiatrist at the office, and their associates, all knew Mr. B. was dangerous and should not have been included in group therapy. Mr. A. claimed that Mr. B. had a history of questionable psychotic behavior and that the other patients should not have been exposed to him. The psychiatrist’s associates, in their defense, contended that they had no way to anticipate this event and had used due care and caution in their practice. A jury, nevertheless, returned a guilty verdict (meaning that the psychiatrist was held responsible), awarding the plaintiff 2 million dollars (Grant, 2006). Recommendations and Future Research Two recommendations, if implemented prior to a potentially lethal act, could advance our understanding of the dynamics of perpetrators who kill and then suicide. The first recommendation is to have a second opinion consultation team available for clinicians evaluating Tarasoff-type

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cases. The team would include clinicians with particular experience in evaluating dangerous behavior, as well as attorneys knowledgeable in cases of this sort. Their task would be to provide guidance in making the most appropriate decision, and also, where pertinent, in helping to arrange for the best disposition (which might include involuntary hospitalization of the potentially violent patient). À propos of the above, the development of an online database of cases would provide a critical resource for the consultation team. An exemplary model designed by Hendin and colleagues for suicide cases could be replicated for homicide-suicide cases. Hendin, Haas, Maltsberger, Koestner, and Szanto (2006) recruited therapists for 36 patients who died by suicide in treatment. The therapists filled out clinical, medication, and psychological questionnaires and wrote detailed case narratives. They then presented their cases at an all-day workshop, and six recurrent problem areas were identified: poor communication with another therapist involved in the case, permitting patients or relatives to control the therapy, avoidance of issues related to sexuality, ineffective or coercive actions resulting from the therapist’s anxieties about a patient’s potential suicide, not recognizing the meaning of the patient’s communications, and untreated or undertreated symptoms. These cases pointed to common problems therapists face in working with suicidal patients and highlight an unmet need for education of psychiatrists and other mental health professionals who work with this population. A second recommendation involves the referring of completed homicide-suicide cases to a review panel of experienced clinicians for what amounts to a psychological autopsy. This procedure was first used to assist coroners in determining cause of death and has since been used in suicide cases to investigate a person’s death. Important steps in this process include (a) reconstructing what the person thought, felt, and did before death, based on information gathered from personal documents, police reports, medical and coroner’s records, and (b) face-toface interviews with families, friends, and others who had contact with the person before the death. The principle of psychological autopsy is based on the meticulous collection of data that would help re-create the psychosocial environment of individuals who have committed homicide/suicide in the hope that by better understanding the circumstances of their actions, tragic consequences of this sort might be anticipated in the future, and, if possible, prevented (Batt, Bellevier, Delatte, & Spreux-Varoquaux, 2005; Knoll, 2008). Toxicology reports, where relevant, constitute additional evidence that could be collected for psychological autopsy reviews (Carretta, Burgess, & Welner, 2014). Post-mortem toxicology findings pointing to the use of prescription medication may indicate recent contact with a

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physician. Examination for prescribed psychoactive medications may also be useful in estimating the frequency and type of psychiatric treatment before death, and may aid in reconstructing some clinically important events occurring before a murder/suicide (Dhossche, 2007). Interviews with family members could provide data as to whether the perpetrator had been seen by a mental health clinician prior to the episodes; also, whether there had been a prior history of domestic violence either in or out of the legal system. Similarly, one might learn whether the victim, prior to the incident, reported any concerns to a counselor, a friend, a family member, or to someone in the legal system. Collaborating with police officers, medical examiners, and prosecutors to provide information post-incident would require addressing legal issues related to patient-clinician privilege; specifically, to what information it would be permissible to share. Future Research In view of how common incidents of homicide-suicide are in the United States (compared with most other countries), close scrutiny of these cases is an urgent matter. Our data suggest that patients who actually report (as opposed to merely harbor) homicidal intent are particularly dangerous to others and, as shown in this study, to themselves as well. Conversely, persons who report only suicidal intent are of course dangerous to themselves, but often enough may be dangerous to others as well. In such cases, clinicians should consider collecting collateral information from partners or other persons close to the patient, by way of determining if there is measurable risk to the family and, hence, on the clinicians’ part, a duty to warn. We know as yet very little about either the character structure or the underlying dynamics of persons who engage in murder/suicide. We know less than we would like concerning whether persons exemplifying certain psychiatric diagnostic categories are more prone to violent behaviors. Most studies have thus far been shortsighted in this regard (though presumably highly paranoid persons would represent greater risk than, say, purely depressive persons). Promising research on homicide-suicide perpetrators includes the Knoll and Friedman (2009) study of psychological autopsies on 18 homicide-suicide cases. In addition to interviews with key persons and review of police and coroner records, the researchers used a modified MINI (Mini International Neuropsychiatric Interview) instrument to inquire about psychiatric symptoms of the perpetrators, focusing es-

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pecially on suicide and violence risk factors (Knoll, 2008, 2009). Twothirds of perpetrators were classified as Consortial-Possessive. One-third were classified as Consortial-Ailing, Consortial-Psychotic, Filial-Revenge, or Familial-Psychotic. Almost all of the perpetrators met criteria for depression. The majority had an active substance abuse problem. Many had family histories of suicide, and prior attempts at suicide. Three perpetrators met the criteria for antisocial personality disorder and had a history of violent behavior including domestic violence, fights, and assault charges (Knoll & Friedman, 2009). The study of homicide-suicide, paying attention to underlying psychodynamic forces whenever these can be ascertained, could make a major contribution to understanding the structure of the thinking, fantasy, and unconscious motivation of persons at risk for enacting this sort of violent behavior. Although the overall murder rate in the United States has declined noticeably in the past 20 years, the numbers of murder/suicide incidents, albeit uncommon, appear to be holding their own. It falls to the lot of mental health professionals in the various disciplines to learn as much as possible about the characteristics of persons at high risk for the commission of murder/suicide—so as to minimize the occurrence of such acts in the future.

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Dr. Ann W. Burgess Connell School of Nursing Boston College 140 Commonwealth Ave. Chestnut Hill, MA 02465 [email protected]

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Homicide-suicide and duty to warn.

This retrospective study of medical examiner records from three counties reported on 252 persons who killed 302 victims before killing themselves and ...
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