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 “religios ity” 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 pro- cess (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 confron- tation 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.