Accident and suicide

A:&.

Anal.

& Pwc.

Vol.

3, pp. X9-276.

Perp~mon

Press

1971.

Prmed

RESEARCH ACCIDENT

I” Great

Br~tnm

NOTE

AND SUICIDE”

AN ONGOING STUDY OF ~O~~PARABLE ~OSPIT.~LIZED GROUPS OF DRIVERS INJURED IN ONE-CAR ACCIDENTS AND SURVIVORS OF SERIOUS SUICKDE ATTEMPTS J. GUSSEN University of Southern California, The Suicide Trevention Center, Los Angeles, California (Receioed 12 March 1971) IN RECENT years, problems inherent in man’s physical environment, the vast impact of modern technology and its unwanted and harmful by-products have become an increasing concern of scientists the world over. This concern is now, at long last, beginning to spread to the general public, as the pervasive problems of human ecology and the potential threat to the very survival of the species are increasingly recognized. Motor vehicles are an integral part of man’s environment. Injury and death resulting from motor vehicle accidents rank high amongst their harmful by-products and must be given the same attention and study as all other ecological and public health problems. The research group at the Los Angeles Suicide Prevention Center, long interested in the psychological issues involved in suicidal and destructive behavior in general, some time ago became interested in the study of automobile accidents, particularly in regard to similarities and differences between automobile accidents and suicide (Tabschnick, 1967; Tabachnick and Litman, 1966). Tabachnick ef a!. (1966) compared 15 male drivers, killed in one-car accidents, with 1.5 age-matched fatal suicides as a result of self-inflicted gunshot wounds. In the accident cases, organic causes of illness and death which might have preceded or produced the accident were excluded by the Coroner’s evaluation. The method of study used was the so-called “psychological autopsy”, developed by this group for the study of suicides, and consisting of interviews with persons who knew or had contact with the deceased. From these interviews, an attempt was made to reconstruct thi: individual’s personality and life situation in order to develop an understanding of possibie causes of the incidents and how they possibfy might have been prevented. Their findings in regard to similarities and differences between the two groups were as foliows: the two groups were similar in that about one half of both groups had been drinking prior to their deaths, and often had used alcohol to deal with upsetting situations. Increased motor and verbal activity was another frequent reaction to upset in both categories. About half of both groups showed impulsivity as a character trait, and both groups tended to be conscientious and concerned with “good performance”.

* Supported by USPHS Grant MH 155-10 269

On the other hand. the two groups differed in several regards. Members of the accident group had not encountered a clear, traumatic situation prior to death, but, interestingly enough, about t\vo thirds of them had, Lvithin the preceding year, contemplated moving or had. actually, moved into situations of greater responsibility. The accident group, further, \ias easily upset by slights or criticism, nere relatively active and exhibitionistic, and. compared to the suicide group, were more distantly integrated with the significant others in the en\,ironment. Members of the suicide group had encountered the loss of an important person, or a feeling of failure, or being unloved prior to death. They had demonstrated a number of depressive and self-punitive features in their life style, and they tended to be more c!oselv integrated with significant others. As i practical application of these findings, the investigators proposed that counselling techniques might be of value if individuals do rnoi’e into “accident” prone situations under the pressure of specific stresses. In a more psychoanalytic evaluation of the members of the “accident prone” and ‘-suicide prone” groups in the above mentioned stud:;. the same authors concluded that the latter group tended to be depressl\,e, dependent, passike, immobilized, and constricted, with basic fantasies of losing love or the love object. The “accident prone” men, in contrast, were active, counterphobic, counterdepressive, impulsive, quick, decisive, independent, adventurous, and rebellious with a strong need to prove themselves invulnerable (Litman and Tabachnick, 1967). Osman (1965) reported on a psychoanalytic study of 11 critically injured male survivors of one-car accidents where mechanical defects and external conditions did not seem to be decisive. These patients were seen in from 2 to 30 intervie\v sessions, each lasting from 1 to 2 hr. Interviews tvith next of kin were often included. The aim \vas to obtain a grasp of the total person including his lifelong pattern of interpersonal relationships and his intrapsychic functioning before and after the accident. The author drew the conclusion that accident \lctims are individuals likely to be undergoing an imminent transition in their lives. He postulated that the accident occurs as one incident in a psychic process involving susceptible individuals with impaired ego functionin g. These individuals are likely to have a certain type of personality configuratron which includes a tendency to cherish their psychic autonomy, a tendency to withdraw from conflictin, 0 life situations by utilizing denial, manic defense. and action oriented behavior. They have an affinity for counterphobic mechanisms to obtain spurious mastery and counter ego-dystonic temptations to rely on others. There \vas a high incidence of alcohol intake prior to the accident, and a tendency to nonchalant acceptance of the accident, as a manifestation of a general tendency to remain emotionally uninvolved. There was a preoccupation \+ith automobiles and racing. The ongoing, extensive 3 year study now to be described is concerned with the individual driver’s role in the accident situation, as it relates to his general personality type and life style, as MelI as his current life situation and his psychological reactions to it. HYPOTHESES X

number of hypotheses were generated from the above mentioned studies, from psychoanalytic theory and findings, and from other sources. These hypotheses were arrived at by concensus in the research group and expanded upon as the project progressed. Thus, they necessarily reflect the theoretical orientation and particular aims of this group. They relate to the study of a number of life-long personality characteristics and life styles as well as emotional states in life situations relative to the incident. The basic general hypothesis

Accident and Suicide

371

of the study is that the accident victims as a group are going to be more like a comparable suicide group than a control group of appendectomy patients on a number of characteristics chosen to test 14 additional, more detailed hypotheses. These hypotheses are not mutually exclusive and are concerned with the finding in the different experimental groups regarding the following: (a) Whether in the case of accidents, the accident represented a deliberate suicide attempt. (b) Past suicide attempts, communications of suicidal pre-occupation and suicidal thoughts. (c) Manifestation of depressive symptoms. (d) Manifestation of counter-depressive attitudes. (e) Patterns of drinking and drug abuse. (f) Tendencies to self-injuriously not seek and/or not follow medical advice. (g) Behavior risking injury to themselves or others. (h) New responsibilities and emotional reactions to them. (i) Tendency to utilization of impulsive actions with self-destructi\-e implications. (j) Lack of integration between passive and inactive styles of life on the one hand, and counter-depressive, active, energetic styles of life on the other hand. (k) Loss of self-esteem prior to the incident. (I) Change or transition of any kind preceding the event, whether perceived as positive, negative or neutral. (m) Frequency of contact with mental health professionals. (n) The occurrence of early or late loss of persons important in the individual’s life. Hypotheses (l-n) were not formulated during the design of the project, but were formulated during the course of data collection. Further hypotheses may develop as the evaluation of data progresses after completion of the study. THE

SAMPLE

The main thrust of the study is to compare surviving drivers injured in automobile accidents with survivors of serious suicide attempts. It was clear from the outset that if \\e wished to study patients in some depth and to investigate enough cases to permit evaluation of significance, our resources would force us to limit our sample and procedures in certain ways. The sample was designated as follows: (a) Males, 18-48. (b) One-car accidents. (c) Drivers only. (d) Subjects limited to patients hospitalized at the Los Angeles County-University of Southern California Medical Center; however, to be followed after discharge, if necessary. The goal is to study patients in the following four categories with the desired number of 30 in each: 1. Critical Accident Group, critical being defined according to certain criteria concerning severity of the injury sustained. 2. Intermediate Accident Group, with less severe injuries. Although this is designed as a separate group, we are not convinced that the severity of the injury is necessarily a differentiating variable. 3. A group of survivors of serious suicide attempt. 4. An appendicitis control group, the presence of appendicitis to be confirmed by gross inspection at the time of appendectomy. This group was chosen as control after preliminary

studies OFthe patient population in the four groups indicated that the age distribution in this group was relatively similar to the three experimental ones. Exact age matching in the four groups was not considered possible because of the limitations of time and case material. METHODOI_OGY All data are elicited through direct interviews with patients in and out of the hospital. In order to make the study feasible, and because it was felt that this amount of time represented a suitable compromise for our purposes, interviews ivere limited to a total of G-5 hr maximum. As the research group consists primarily of psychoanalysts and psychoanalytically oriented behavioral scientists, it was decided to use only psychoanalytically trained investigators. Tabachnick (in press), in summarizin, 0 the reasons for this choice, states that it is hoped that investigators with this type of trainin, 0 would be better able to establish rapport Lvith the patient, to identify and overcome conscious and unconscious resistances and distortions, thus obtaining more reliable data. Through their familiarity with psychodynamic concepts, they would be able to utiiize the material obtained for psychodynamic hypotheses regarding the patient’s personality, life-style, and life-situation at the time of the event. He also, hobvever, outlined some of the problems which might be experienced by psychoanalysts in the utilization of an unfamiliar method and with a primarily nonpsychiatric poputation. Studies to test the validity of the above assumption regarding this category of interviewers as compared to others are being proposed. Case finding is done by continuous survey of all pertinent hospital wards. AI1 interviews are taped, and all records are coded so as to assure complete confidentiality. Interviewers are instructed not to use a pure questionnaire approach, but to employ a freer, open-ended associative technique in addition to obtaining the desired answers. Within this framework, they are encouraged to develop their own personal techniques. Each investigator has to commit himself to a minimum of four cases, one in each category, and to another group of four if he wishes to continue in the project. This is done in order to, as much as possible, minimize the risk of a given investigator developing psychological “sets” through seeing too many cases in any one category. Data are collected in the following forms: 1. The data sheet

Investigators are asked to fill out a measuring instrument in questionnaire form, designed to test the various hypotheses mentioned above. The 205 questions are constructed so that answers them aliow the such as chi-square, analysis of variance, factor analysis, on a variety data data groups. A computer read-out is obtained for item each case. Different the Data the following categories and, if relevant, time relation the event: acts

communications

273

Accident and Suicide

E. F. G. H. I. J. K. L. !. 0.

Alcohol history Drug ingestion Self-destructively not seeking or following medical advice Increased risk taking Adjustment to change Violence Lack of integration between depressive and counterdepressive Loss of seif-esteem Driving history Events of the accident itself Dynamics of the interview

styles of life

The questions are phrased so that they can be answered by a simple “yes”, “no” or “no or by checking off one item in a series or graded quantity such as time, information”, frequency or amount. The following are a few examples of the type and form of questions asked: Under section A: In the 7 days prior to the accident, suicide attempt dicitis, subject had suicidal thoughts.

The same question the event.

is repeated

Under section B: During the last month, subject have?

for the period of 6 months-l

how many traffic accidents

1. Yes 2. No 3. NI

or appen-

yr, or 1 yr or longer prior to

did the

1. 2. 3. 4.

None One More than one NI

This question is repeated Moving violations-during

Attitudes

toward

for the periods of the most recent 6 months, 3 yr, and lifetime. 1. O-l the last year: 2. 2-3 3. 4-5 4. Over 5 5. NI Much concern driving violations. 2. Moderate concern 3. Little or no concern 4. NI

Under section H: In the 7 days prior to the accident, suicide attempt or appendicitis, approximately how many times did the subject injure himself and/or have a “narrow escape” from injuring himself or killing himself by taking unnecessary risk? This question is repeated longer prior to the event.

for the periods

of 7 days-6

months,

1. 2. 3. 4.

None l-2 times 3-10 times Over 10 times NI

6 months-l

yr, 1 yr or

27-t

J.

GUSEN

Under section I: Advance at Lvork, school or finanically:

If yes, subject reports

If yes. interviewer as predominantly:

his feelings predominantly:

(or rater) evaluates

advance for the subject

If yes, the most recent occurred:

1. 2. 3. 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. 5.

Yes No NI Positive (Pleasant) Mixed Negative (Unpleasant) NI Positive (Pleasant) Mixed Negative (Unpleasant) NI 7 days-l month l-6 months 6 months-l yr 1 yr NI

2. The narrative

In order to derive the full benefit of the skills of the interviewers and the investigative technique chosen, investigators are asked to provide, in narrative form, a description and psychodynamic formulation of the patient’s character, life-style, major defenses and data of importance in the past history, as well as of the individual’s current life-situation. They are, in addition, asked for a psychodynamic hypothesis regarding the incident under investigation and a description of the dynamics and circumstances of the interviews. These narratives produce less well-defined descriptive data which will, whenever possible, be collated both for the possible coding of information for formulations of new hypotheses, and for crosschecking with findings from the data sheet. RELIABILITY

STUDY

AND

CONTROL

In order to construct a reliable measuring instrument and to make possible a continuing test of reliability, all interviews are taped. A pilot study was conducted in which the data sheet was filled out not only by the interviewer, but based on the tapes also, by three different groups of reliability checkers, consisting of three psychoanalysts, threepsychologists and three trained lay workers. An item is considered reliable if three out of four raters agree on the answer, the interviewer simply being one of four raters. Based on the findings of the first pilot study, the majority of items showed high reliability except for a series of items all pertaining to time relationships of certain phenomena in regard to the etent under investigation. This seemed to be due to lack of clarity in the phrasing, and ivhen this was corrected by rephrasing the questions, a second pilot study was conducted. In this study, the instrument showed a very high degree of reliability throughout, and the cases could be used as the first cases of the study proper. An interesting finding which emerged from this pilot study was that the three groups of raters essentially performed equally well, as there was excellent intra- as well as intergroup agreement. It was decided to use the trained volunteer group, which made it practically possible to keep a continuous check on each item on the data sheet of each patient.

Accident

Thus,

and Suicide

275

sheet is rated by three

significant other study

In a number of cases, one or several individuals to whom the patient is well known have been interviewed in order to both check on the data provided by the patient and to shed further light on the individual’s personality, relationship to others, life situation and sequences of events leading up to the incident. 2. A bias or psychological “set “stud,v designed to investigate possible preconceived ideas which various investigators might have in regard to the dynamics of the experimental groups and how this might affect the data collected. DISCUSSION

The question of what constitutes psychoanalytic research, the nature of the data elicited in psychoanalysis and studies derived from it, and how they can be tested for reliability and validity has long been a subject for extensive, sometimes heated, dlscussion. Without entering upon this controversy, it is, in the author’s opinion, important to distinguish the following two major categories of the research use of theoretical and clinical psychoanalytic knowledge, each presenting different methodological and design problems. 1. Research into the reliability and validity of concepts of psychoanalytic theory and therapy, utilizing data directly derived from psychoanalyses of patients. 2. The testing of hypotheses generated from psychoanalytic theory and experience pertaining to selected events or sequences of events in the life of an individual or a group of individuals through the study of a patient or non-patient population, utilizing a variety of techniques other than psychoanalysis itself. The study described above falls into the second category and has as an explicit aim the collection of data lending themselves, to a significant extent, to the development of a reliable measuring instrument and to statistical testing of hypotheses. In a sense, this project involves a study within a study. Not only are we investigating the field, as outlined, but we are also studying a particular technique of investigation, a technique which, however, requires much further evaluation and validation.

276

J. GIBEX

It is our hope that the methodology utilized, with its many possible modifications, wil1 lend itself to expanded possibilities for psychodynamic research into a variety of individual and social phenomena, and that psychoanalysts kvith their particular training and experience can fruitfully, alone or in collaboration with other behavioral scientists contribute to the understanding of such phenomena and to the development of methods for preventing or solving potentially grave indicidual and social problems. We are well aware of defects and limitations in the design and methodology of the study. It is, nevertheless, hoped that it will contribute to the understanding of the problem, generate further hypotheses for research, and, above all, hold out hope for methods of prevention and/or treatment. Tillmann and Hobbs (1949) once wrote, “A person drives as he lives”. Life situations change, however, and an individual may well move in and out of shorter or longer periods of accident-proneness, possibly ranging from minutes and hours to months and years. To the elucidation of these problems, this study is dedicated. REFERENCES

LITMAN,R. E. and TABACHXICK,N. (1967). Fatal one-car accidents. Psychoanalyt. Quart. 36, 218-259. OS.MAN, M. P. (1968). A psychoanalytic study of auto accident victims. Contemp. Psychoanal. 5, 62-84. TABACHNICK,N. (1967). The psycholo,oy of fatal accident. Essays in Self-Destruction. Science House, Inc. New York. TABACHNICK,N. (1970). The psychoanalyst as accident investigator. Behavioral Res. in Highway Safirl 1, 18-25. TABACHNICK,N. and Lrr~.~s, R. E. (1966). Character and life circumstance in fatal accident. Psychoanalyt. Forum

1, 65-74.

TABACHNICK,N., LITMAN,R. E., OSMAN,kl., JOMS, W. J., COHN, J., KASPER, A. and IMOFFAT,J. (1966). Comparative psychiatric study of accidental and suicidal death. Archs gen. Psychiatry 11, 60-65. TILLMANN,W. A. and HOBBS,G. E. (1939). The accident-prone automobile driver. AI?!. J. Psychdry 106, 321-331.