Commentary: Addressing Suicidality in the Treatment of Parricidal Offenders

The study by Liettu and colleagues¹ indicates that about one-third of the deaths of Finnish parricidal offenders are suicides, some of which occur sooner than other post-offense suicides. Most remarkable about this finding is what it suggests about those who commit parricide in general. Since most adult parricidal offenders have a severe and persistent mental illness and are typically adjudicated as not criminally responsible,^2–7 they are more apt to receive mental health treatment. The fact that a third of the Finnish deaths were attributable to suicide thus suggests an extremely high level of suicidality in this group, as it is likely that the suicidality of others was mitigated by the treatment they received. These findings have several important treatment implications.

First, they serve to remind us that aggression against others and aggression against self so frequently coexist⁸ that conducting violence risk assessment in any clinical encounter without concurrent suicide risk assessment is unwise.^9,10 The same is true of violence risk management and suicide risk management. Those who commit parricide are similar to many other violent individuals who display comorbid aggression against self and aggression against others.⁸ Some clinicians underestimate the extent to which these two forms of aggression coexist.¹¹ The findings of Liettu et al.¹ alert us to the need to be vigilant and to explore suicidality, even when the presenting clinical picture involves violent behavior.

Second, they highlight the fact that parricidal killings by adults are often desperate acts committed by severely ill individuals. In the prototypical parricidal scenario, a severely ill and inadequately treated individual resorts to violence, not in the context of a life-long propensity toward violence, but rather as an expression of despair. The treatment of adults who commit parricide, therefore, primarily necessitates targeting the psychosis, assessing and managing the suicidal risk they pose, addressing their severe dysphoria, and targeting the drivers of any suicidal ideation. Assessing and managing violence risk is, by contrast, a relatively easy task, as most offenders will not recidivate violently.¹² The ingredients of sound suicide risk management bear repeating. It requires identifying factors that amplify the suicidal risk (e.g., substance abuse, hopelessness) as well as protective factors (e.g., commitment to treatment, spirituality); a strategy for obtaining any missing information necessary to conduct a valid risk assessment (e.g., about past response to treatment); an assessment of the chronic risk of suicide; an assessment of the acute risk of suicide; an immediate intervention to increase safety; an intermediate-term package of interventions to address the drivers of the suicidal ideation; an assessment of commitment to treatment by the individual and his or her family; and proper documentation of all of these, including documentation of any consultation sought.^9,10

Identifying drivers of suicidality and targeting them for treatment means addressing the typical, severe dysphoria of the person who kills a parent. Such persons have been described as more dysphoric and also more difficult to engage in treatment than many other insanity acquittees.¹³ One treatment modality that has been developed to address their unique needs is the Genesis Group,¹³ a treatment based on the observation that many of these persons express the belief that no one can understand their unique existential plight. The benefits of this treatment modality have recently been tested (Gauen E, manuscript in preparation). The major challenges that perpetrators of parricide face are daunting: forgiving themselves and finding meaning and solace in their lives. These objectives are very difficult to achieve without psychotherapy. The process is greatly facilitated by a group therapy intervention such as the Genesis Group. A reason for the effectiveness of group therapy is the fact that members who have been in the group for a long time and are thus further along in their recovery can serve as role models to new members whose offenses occurred more recently and can instill in them the hope that recovery is possible.^13,14

Epistemological frameworks influence how we think about various phenomena. Several descriptors are commonly used to make sense of violence, such as the violent individual as superpredator, as afflicted by a chronic illness, and as needing to be incarcerated for life.¹⁵ An alternative framework consists of the public health ideas of disease prevention, injury prevention, and public education. It is time to educate the general public as well as many clinicians about the importance of prevention (e.g., providing assertive treatment to individuals who are experiencing a first-break episode in situations in which there is severe familial strife) and the fact that most who commit parricide are not chronically dangerous mentally ill individuals but rather mentally ill men and women who have committed an act of desperation and who are at greater risk of killing themselves than of harming others.

• American Academy of Psychiatry and the Law