Section VII Home

Behavioral Emergencies Update

Volume 3, Issue 2
Spring 2002
Section on Clinical Emergenices and Crises
American Psychological Assn.
Section VII Contact Info

In this issue...

Posttraumatic Growth and Crisis (DeBrule & Range)

Integrated Assessment (Hillbrand)

Suicidal Patient Age and Critical Risk Factors (Bongar)

Section VII 2002 APA Convention Program

Task Force Update

Section VII Considerations

Minutes from the Section VII Business Meeting

Publication Highlights

Special Offer for Section VII Members



Integrated Assessment of Suicide
and Homicide Risk

Marc Hillbrand
Connecticut Valley Hospital and
Yale University School of Medicine

Homicide-suicide denotes one or more homicides followed by the perpetrator's suicide. To many people the term conjures images of politically motivated acts such as the Palestinian suicide bombers, the Japanese kamikaze pilots of World War II, or the World Trade Center bombers. The 15 deaths at Columbine High School and 13 deaths caused by a disgruntled Atlanta day trader illustrate the fact that most homicide-suicides are in fact private tragedies with enormous psychological impact on all the people they affect, including witnesses, survivors, friends and relatives, and emergency personnel.

Just as suicidal ideation is more common than suicide, homicidal ideation is more common than homicide. Similarly, coexisting homicidal and suicidal ideation, which may be jointly present in about 5% of visits to emergency departments (Feinstein & Plutchik, 1990) is more common than homicide-suicide. Section VII members are undoubtedly well acquainted with the various guidelines for the assessment of suicide and violence potential (e.g., Kleespies, Deleppo, Gallagher, & Niles, 1999; VandeCreek, & Knapp,1999). These assessment guidelines focus solely on suicide risk or on violence risk, but not jointly. Yet there is a dynamic relationship between the two types of risk that current guidelines ignore. Individuals at risk for homicide-suicide are typically so distraught and hopeless that they want to die and also rageful at others whom they perceive as victimizers. Assessing both risks are thus clinical activities that need to go hand in hand. In such assessments, clinicians need to be mindful of the fact that risk of harm to self and risk of harm to others share some etiological factors (e.g., impulsivity) as well as protective factors (e.g., good peer relations). The following briefly reviews current knowledge on homicide-suicide. Interested readers are referred to more extensive reviews by Coid (1983) for a cross-cultural perspective, Hillbrand (2001) for theoretical and practical considerations, and Marzuk, Tardiff, and Hirsch (1992) for nosological considerations.

Homicide-suicides account for .03% of all deaths in the US. Rates are similar in many other countries, though outside the US homicide-suicide account for a much higher proportion of all homicides because homicide rates are much lower. Most homicide-suicides involve one killer (typically a man) and one victim (typically a woman), who are usually acquainted. Homicide-suicides are more similar to suicides than to homicides, in that there is usually no history of lifelong impulsivity or violence towards others. Previous suicide ideation and attempts are common, as are hopelessness, despair, and clinical depression. Both homicide and suicide are usually planned events.

Aggression against self and against others coexist on a continuum of severity. At one end of the continuum lie coexisting fantasies of homicide and suicide without intent to harm. Next on the continuum lie non-lethal acts of interpersonal violence and parasucidal behaviors, which frequently coexist in violent individuals (Hillbrand, 1995). Suicide by victim-precipitated homicide entails the use of lethal force in order to get someone else (e.g., a police officer in "suicide by cop") to kill the suicidal person. In attempted homicide-suicides, one or both violent acts are thwarted. In the most common type of homicide-suicide, a jealous individual kills his or her spouse or consort, then suicides. At the other end of the continuum lie mass murders, killing sprees causing three of more deaths, which typically end in suicide (Dietz, 1986).

Clinicians cannot rely on spontaneously uttered threats of violence in their assessments. Regardless of the referral issue, they need to probe actively for suicidal and homicidal ideation, keeping in mind the fact that reporting suicidal ideation has become acceptable in our culture, but that reporting homicidal ideation is much less acceptable. Bertram Karon (personal communication,1987) said it most judiciously: "First deal with homicide risk. Then deal with suicide risk. Then deal with anything else".



Coid, J. (1983). The epidemiology of abnormal homicide and murder followed by suicide. Psychological Medicine, 13, 855-860.

Dietz, P. E. (1986). Mass, serial and sensational homicides. Bulletin of the New York Academy of Medicine, 62, 477-491.

Feinstein, R., & Plutchik, R. (1990). Violence and suicide risk assessment in the psychiatric emergency room. Comprehensive Psychiatry, 21, 337-343.

Hillbrand, M. (1995). Aggression against self and aggression against others in violent psychiatric patients. Journal of Consulting and Clinical Psychology, 63, 668-671.

Hillbrand, M. (2001). Homicide-suicide and other forms of co-occuring aggression against self and against others. Professional Psychology: Research and Practice, 32, 626-635.

Kleespies, P. M., Deleppo, J. D., Gallagher, P. L., & Niles, B. L. (1999). Managing suicidal emergencies: Recommendations for the practitioner. Professional Psychology: Research and Practice, 30, 454-463.

Marzuk, P. M., Tardiff, K., Hirsch, C. S. (1992). The epidemiology of murder-suicide. Journal of the American Medical Association, 267, 3179-3183.

VandeCreek, L., & Knapp, S. (1999). Risk management and life-threatening patient behaviors. Journal of Clinical Psychology, 56, 1335-1351.