Suicide by Cop: What Motivates Those Who Choose This Method? Ralph H

Cases That Test Your Skills

Suicide by cop: What motivates those who choose this method? Ralph H. de Similien, MD, MS, MEd, and Adamma Okorafor, MD

Mr. Z, age 25, has a history of suicidality. Recently he attempted How would you to provoke a police officer to shoot him, hoping to be killed in handle this case? Answer the challenge the process. How would you approach this ‘suicide by cop’? questions throughout this article

CASE Unresponsive and suicidal Which characteristics increase the risk of Mr. Z, age 25, an unemployed immigrant “suicide by cop (SBC)”? from Eastern Europe, is found unrespon- a) male sex sive at a subway station. Workup in the b) previous suicide attempt emergency room reveals a positive urine c) untreated psychiatric disorders toxicology for benzodiazepines and a blood d) religiosity alcohol level of 101.6 mg/dL. When Mr. Z e) all of the above regains consciousness the next day, he says that he is suicidal. He recently broke up with his girlfriend and feels worthless, hope- The authors’ observations less, and depressed. As a suicide attempt, The means of suicide differ among indi- he took quetiapine and diazepam chased viduals. Some attempt suicide by them- with vodka. selves; others through the involuntary Mr. Z reports a history of suicide attempts. participation of others, such as the police. He says he has been suffering from depres- This is known as SBC. Other terms include sion most of his life and has been diagnosed “suicide by means of victim-precipitated with bipolar I disorder and borderline per- homicide,”1 “hetero-suicide,”2 “suicide by sonality disorder. His medication regimen proxy,”3 “copicide,”4 and “law enforcement- consists of quetiapine, 200 mg/d, and dulox- forced-assisted suicide.”5,6 SBC accounts for etine, 20 mg/d. 10%7 to 36%6 of police shootings and can Before immigrating to the United States 5 cause serious stress for the officers involved years ago, he attempted to overdose on his and creates a strain between the police and mother’s prescribed diazepam and was in a the community.8 coma for 2 days. Recently, he stole a bicycle SBC was first mentioned as “suicide by with the intent of provoking the police to kill means of victim-precipitated homicide.” him. When caught, he deliberately disobeyed Wolfgang5 reported 588 cases of police the officer’s order and advanced toward the officer-involved shooting in Philadelphia officer in an aggressive manner. However, Drs. de Similien and Okorafor are PGY-4 Residents in Psychiatry, the officer stopped Mr. Z using a stun gun. Howard University Hospital, Washington, DC. Mr. Z reports that he still feels angry that Disclosures his suicide attempt failed. He is an Orthodox The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers Current Psychiatry Christian and says he is “very religious.” of competing products. Vol. 16, No. 5 47 Cases That Test Your Skills

between January 1948 and December 31, Seventy-seven percent had low socioeco- 1952, and, concluded that 150 of these nomic status,11 with 49.3% unemployed at cases (26%) fit criteria for what the author the time of the SBC incident.1 termed “victim-precipitated homicide” because the victims involved were the Pathological characteristics of SBC and direct precipitants of the situation leading other suicide means are similar. Among to their death. Wolfgang stated: SBC cases, 39% had previously attempted Instead of a murderer performing the act suicide6; 56% have a psychiatric or chronic of suicide by killing another person who medical comorbidity. Alcohol and drug represents the murder’s unconscious, abuse were reported among 56% of indi- and instead of a suicide representing the viduals, and 66% had a criminal history.6 desire to kill turned on [the] self, the vic- Additionally, comorbid psychiatric dis- Clinical Point tim in these victim-precipitated homi- orders, especially those of the impulsive cide cases is considered to be a suicide and emotionally unstable types, such as Suicide by cop has prone [individual] who manifests his borderline and antisocial personality dis- similar psychosocial desire to destroy [him]self by engaging order, have been found to play a major role and pathological another person to perform the act. in SBC incidents.12 characteristics as other The term “SBC” was coined in 1983 by means of suicide Karl Harris, a Los Angeles County medical Individual suicide vs SBC examiner.8 The social repercussions of this Religious beliefs. The term “religiosity” is modality attracts media attention because used to define an individual’s idiosyncratic of its negative social consequences. religious belief or personal religious phi- losophy reconciling the concept of death Characteristics of SBC by suicide and the afterlife. Although there SBC has characteristics similar to other are no studies that specifically reference means of suicide; it is more prevalent the relationship between SBC and religios- among men with psychiatric disorders, ity, religious belief and affiliation appear including major depression, bipolar dis- to be strong motivating factors. SBC vic- orders, schizophrenia, substance use dis- tims might have an idiosyncratic view of orders,9 poor stress response skills, recent religion related death by suicide. Whether stressors, and adverse life events,10 and suicide is performed while under delu- history of suicide attempts. sional belief about God, the devil, or being possessed by demons,13 or to avoid the Psychosocial characteristics include: moral prohibition of most religious faiths • mean age 31.8 years1 in regard to suicide,6 the degree of religios- • male sex (98%) ity in SBC is an important area for future • white (52%) research. • approximately 40% involve some Mr. Z stated that his strong religious faith form of relationship conflict.6 as an Orthodox Christian motivated the In psychological autopsy studies, an attempted SBC. He tried to provoke the offi- Discuss this article at estimated 70.5% of those involved in a cer to kill him, because as a devout Orthodox www.facebook.com/ SBC incident had ≥1 stressful life events,1 Christian, it is against his religious beliefs CurrentPsychiatry including terminal illness, loss of a job, to kill himself. He reasoned that, because a lawsuit, or domestic issues. However, his beliefs preclude him from perform- the reason is unknown for the remaining ing the suicidal act on his own,6,14 having 28% cases.2 Thirty-five percent of those an officer pull the trigger would relieve involved in SBC incidents were mar- him from committing what he perceived as Current Psychiatry 48 May 2017 ried, 13.5% divorced, and 46.7% single.1 a sin.6 Cases That Test Your Skills

Lethal vs danger. Another difference is Table the level of urgency that individuals cre- Behavioral evolution of a suicide ate around them when attempting SBC. by cop incident Homant and Kennedy15 see this in terms of 2 ideas: lethal and danger. Lethal refers The suicidal individual creates an event to ensure police response to the degree of harm posed toward the Once officers arrive at the scene, the suicidal individual. Danger is the degree subject initiates aggressive actions forcing of harm posed by the suicidal individual a confrontation with the officers toward others (ie, police officers, bystand- The subject has a weapon and indicates so to ers, hostages, family members, a spouse, the officers present etc.). SBC often is more dangerous and The subject threatens the officers with a weapon, sometimes injures officers or citizens more lethal than other methods of suicide. to increase the lethality and urgency of the SBC individuals might threaten the lives situation Clinical Point of others to provoke the police into using The subject refuses to surrender and may deadly force, such as aiming or brandish- express his desire to be killed by officers SBC individuals ing a gun or weapon at police officers The subject advances toward the officers and might threaten the refuses to drop his weapon forcing the officers or bystanders, increasing the lethality to engage lives of other to and dangerousness of the situation. Source: Adapted from reference 16 provoke the police Individuals engaging in SBC might shoot into using deadly or kill others to create a confrontation with force the police in order to be killed in the process (Table16). • their need to “save face” by dying or being forcibly overwhelmed rather Instrumental vs expressive goals than surrendering Mohandie and Meloy6 identified 2 primary • their intense power needs, rage, and goals of those involved in SBC events: revenge instrumental and expressive. Individuals • their need to draw attention to an impor- in the instrumental category are: tant personal issue. • attempting to escape or avoid the con- Mr. Z chose what he believed to be an sequences of criminal or shameful actions efficiently lethal way of dying in accord • using the forced confrontation with with his religious faith, knowing that a police to reconcile a failed relationship confrontation with the police could have • hoping to avoid the exclusion clauses a fatal ending. This case represents an of life insurance policies instrumental motivation to die by SBC that • rationalizing that while it may be was religiously motivated. morally wrong to commit suicide, being killed resolves the spiritual problem of Which experimental treatment has been suicide found to rapidly reduce suicidal ideation? • seeking what they believe to be a very a) lithium effective and lethal means of accomplish- b) clozapine ing death. c) ketamine An expressive goal is more personal and d) electroconvulsive therapy (ECT) includes individuals who use the confrontation with the police to communicate: • hopelessness, depression, and The authors’ observations desperation SBC presents a specific and serious chal- • a statement about their ultimate iden- lenge for law enforcement personnel, and Current Psychiatry tification as victims should be approached in a manner differ- Vol. 16, No. 5 49 Cases That Test Your Skills

ent than other crisis situations. Because and other affective disorders, lithium has many individuals engaging in SBC have evidence of reducing suicidality. Studies a history of mental illness, officers with have shown a 5.5-fold reduction in sui- training in handling individuals with cide risk and a >13-fold reduction in com- psychiatric disorders—known as Crisis pleted suicides with lithium treatment.19 Intervention Team (CIT) in many areas— In patients with schizophrenia, clozapine should be deployed as first responders. has been shown to reduce suicide risk and CITs have been shown to: is the only FDA-approved agent for this • reduce arrest rates of individuals with indication.19 Although antidepressants can psychiatric disorders effectively treat depression, there are no • increase referral rates to appropriate studies that show that 1 antidepressant treatment is more effective than others in reducing Clinical Point • decrease police injuries when respond- suicidality. This might be because of the ing to calls long latency period between treatment ini- Similar to other • decrease the need for escalation with tiation and symptom relief. Ketamine, an suicide modalities, specialized tactical response teams, N-methyl-d-aspartate glutamate receptor the primary risk such as Special Weapons And Tactics.17 antagonist, has shown promising results factor for SBC Identification of SBC behavior is crucial because of its acute effect on depression.20 is untreated or during police response. Indicators of a SBC Because of its rapid symptom relief, ECT include: remains the standard for treating suicidal- inadequately treated • refusal to comply with police order ity related to treatment-resistant depres- psychiatric illness • refusal to surrender sion, psychosis, or mania.21 • lack of interest in getting out of a bar- ricade or hostage situation alive.18 In approaching a SBC incident, respond- OUTCOME Medication adjustment ing officers should be non-confrontational After Mr. Z is medically stable, he is volun- and try to talk to the suicidal individual.8 tarily transferred to the inpatient psychiatric If force is needed to resolve the crisis, non- unit where he is stabilized on quetiapine, lethal measures should be used first.8 Law 200 mg/d, and duloxetine, 60 mg/d, and enforcement and mental health profession- attends daily group activity, milieu, and indi- als should suspect a SBC situation in individual therapy. Because of Mr. Z’s chronic viduals who have had prior police contact affective instability and suicidality, we con- and are exhibiting behaviors outlined in sider lithium for its anti-suicide effects, but the Table (page 49).16 decide against it because of lithium’s high Once suicidality is identified, it should lethality in an overdose and Mr. Z’s history of be treated promptly. Patients who are poor compliance and alcohol use. at imminent risk to themselves or Because of Mr. Z’s socioeconomic chal- others should be hospitalized to main- lenges, it is necessary to contact his extended tain their safety. Similar to other sui- family and social support system to be part of cide modalities, the primary risk factor treatment and safety planning. After a week for SBC is untreated or inadequately treated on the psychiatric unit, his mood symptoms psychiatric illness. Therefore, the crux of stabilize and he is discharged to his family managing SBC involves identifying and and friends in the area, with a short supply of treating the underlying mental disorder. quetiapine and duloxetine, and free follow- Pharmacological treatment should be up care within 3 days of discharge. His mood guided by the patient’s symptoms and is euthymic; his affect is broad range; his psychiatric diagnosis. For suicidal behav- thought process is coherent and logical; he Current Psychiatry 50 May 2017 ior associated with bipolar depression denies suicidal ideation; and can verbalize a Cases That Test Your Skills

logical and concrete safety plan. His support system assures us that Mr. Z will follow up with Related Resources his appointments. • Lindsay M, Lester D. Suicide by cop: committing suicide by provoking police to shoot you. Amityville, NY: Baywood 22 His DSM-5 discharge diagnoses are bor- Publishing Company, Inc; 2004. derline personality disorder, bipolar I disor- • Lord VB. Suicide by cop: a comprehensive examination of the der, and suicidal behavior disorder, current. phenomenon and its aftermath. Flushing, NY: Loose Leaf Law Publications, Inc; 2015. Drug Brand Names Clozapine • Clozaril Ketamine • Ketalar The authors’ observations Diazepam • Valium Lithium • Eskalith SBC increases friction and mistrust Duloxetine • Cymbalta Quetiapine • Seroquel between the police and the public, trau- Acknowledgement matizes officers who are forced to use The authors wish to thank Partam Manalai, MD, and Suneeta Kumari, MD, MPH, for their editorial assistance and advice. deadly measures, and results in the death Clinical Point of the suicidal individual. As mental health professionals, we need to be aware of this Educating officers form of suicide in our screening assess- acquaintance and stranger violence. London, United on behaviors Kingdom: CRC Press; 1999:175-199. ment. Training police to differentiate vio- 3. Keram EA, Farrell BJ. Suicide by cop: issues in outcome indicating a mental lent offenders from psychiatric patients and analysis. In: Sheehan DC, Warren JI, eds. Suicide and law enforcement. Quantico, VA: FBI Academy; 2001: illness could lead 9 could reduce the number of SBCs. As 587-597. to more psychiatric shown by the CIT model, educating 4. Violanti JM, Drylie JJ. Copicide: concepts, cases, and controversies of suicide by cop. Springfield, IL: Charles C admissions than officers on behaviors indicating a men- Thomas Publisher, LTD; 2008. tal illness could lead to more psychiatric 5. Wolfgang ME. Suicide by means of victim-precipitated incarcerations homicide. J Clin Exp Psychopathol Q Rev Psychiatry 17 admissions rather than incarceration Neurol. 1959;20:335-349. or death. We advocate for continuous col- 6. Mohandie K, Meloy JR. Clinical and forensic indicators of “suicide by cop.” J Forensic Sci. 2000;45(2):384-389. laborative work and cross training between 7. Wright RK, Davis JH. Studies in the epidemiology of the police and mental health professionals murder a proposed classification system. J Forensic Sci. 1977;22(2):464-470. and for more research on the link between 8. Miller L. Suicide by cop: causes, reactions, and practical religiosity and the motivation to die by intervention strategies. Int J Emerg Ment Health. 2006; 8(3):165-174. SBC, because there appears to be a not-yet 9. Dewey L, Allwood M, Fava J, et al. Suicide by cop: quantified but strong link between them. clinical risks and subtypes. Arch Suicide Res. 2013;17(4): 448-461. 10. Foster T, Gillespie K, McClelland R, et al. Risk factors for References suicide independent of DSM-III-R Axis I disorder. Case- 1. Hutson HR, Anglin D, Yarbrough J, et al. Suicide by cop. control psychological autopsy study in Northern Ireland. Br Ann Emerg Med. 1998;32(6):665-669. J Psychiatry. 1999;175:175-179. 2. Foote WE. Victim-precipitated homicide. In: Hall HV, 11. Lindsay M, Lester D. Criteria for suicide-by-cop incidents. ed. Lethal violence: a sourcebook on fatal domestic, Psychol Rep. 2008;102(2):603-605. continued

Bottom Line Suicide by cop (SBC) describes an incident where a suicidal individual provokes law enforcement officers to kill him. This method of suicide has risk factors similar to other suicide modalities, including male sex, a psychiatric disorder diagnosis, substance use disorders, poor stress response skills, and recent stressors or adverse life events. Religiosity plays an important role in the motivation to die by SBC, because the individual believes he still can benefit from the fruits of the afterlife because he did not perform the act of committing suicide on his own, thereby Current Psychiatry avoiding a sin. Vol. 16, No. 5 51 Cases That Test Your Skills

12. Cheng AT, Mann AH, Chan KA. Personality disorder and In: Walker LE, Pann JM, Shapiro DL, et al. Best practices suicide. A case-control study. Br J Psychiatry. 1997;170: in law enforcement crisis Interventions with those with 441-446. psychiatric disorder. 2015;11-18. 13. Mohandie K, Meloy JR, Collins PI. Suicide by cop 18. Homant RJ, Kennedy DB, Hupp R. Real and perceived among officer‐involved shooting cases. J Forensic Sci. danger in police officer assisted suicide. J Crim Justice. 2009;54(2):456-462. 2000;28(1):43-52. 14. Falk J, Riepert T, Rothschild MA. A case of suicide-by-cop. 19. Ernst CL, Goldberg JF. Antisuicide properties of Leg Med (Tokyo). 2004;6(3):194-196. psychotropic drugs: a critical review. Harv Review 15. Homant RJ, Kennedy DB. Suicide by police: a proposed Psychiatry. 2004;12(1):14-41. typology of law enforcement officer-assisted suicide. 20. Al Jurdi RK, Swann A, Mathew SJ. Psychopharmacological Policing: An International Journal of Police Strategies & agents and suicide risk reduction: ketamine and other Management. 2000;23(3):339-355. approaches. Curr Psychiatry Rep. 2015;17(10):81. 16. Lester D. Suicide as a staged performance. Comprehensive 21. Fink M, Kellner CH, McCall WV. The role of ECT in suicide Psychology. 2015:4(1):1-6. prevention. Journal ECT. 2014;30(1):5-9. 17. SpringerBriefs in psychology. Best practices for those 22. Diagnostic and statistical manual of mental disorders, 5th ed. with psychiatric disorder in the criminal justice system. Washington, DC: American Psychiatric Association; 2013.

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