Psychosocial Autopsy of Mass Suicides: Changing Patterns in Contemporary Times

Incidents of mass suicides have been reported since ancient times wherein a large number of people killed themselves at the same time. These suicides occur for different reasons and goals. Historical perspective has revealed the presence of religious inspiration, death pacts and cults. Out of the various methods adopted for deciphering the psychological state of a person prior to committing suicide, plus a host of emotional, social, economic and cultural reasons, psychosocial autopsy is a promising one. It helps in investigating and analyzing the relevance of these interacting factors in self-inflicted deaths and provides an answer to the family members and friends of individuals who have died this way. A look into the literature reveals that there has been a change in pattern and motive of mass suicides across genera-tions. An understanding of the decedent’s personality, behavior patterns, motives, presence or absence of mental illness helps researchers in unearthing the suicidal risk factors that mitigate or aggravate suicidal behavior in masses. The present chapter discusses the change in pattern of mass suicide with the advent of comput-ers and social media by citing some case studies from India and abroad.


Introduction
India recently witnessed two unnerving suicide events. In 2018, 10 family members of the Chundawat family from Burari were found hanged, while the oldest family member, the grandmother, was strangled. The Burari deaths are infamously known as the "Burari case" or "Burari Kand." In another wave of suicides, in 2019, over 20 students killed themselves in a span of 1 week since Telangana Intermediate Examination results were announced. These two events, even though isolated in space and time, can be categorized under the phenomenon of mass or cluster suicides. While the major underlying cause of Telangana deaths was identified as failure of students in examination, it is the Burari case that perplexed one and all. This case was beyond the scrutiny of logic as it could not be explained by the usual causes of suicide in India, such as health concerns (mental and physical), bankruptcy and indebtedness. [1] Thus, Burari and Telangana point towards two different motives for suicide. With the help of these two examples, the authors wish to highlight the complexity and diversity prevalent in suicidal behavior.
The phenomenon of suicide can be viewed as a spectrum and the only way to arrive at any meaningful suicide prevention strategy is to first understand this psycho-social phenomenon in its different expressions. At a time when India is grappling with issues of mental health, this chapter aims to draw attention to the emerging trend of clustering and contagion in suicidal behavior, its nature as well as its manifestation, as witnessed in the contemporary Indian social cultural set-up.

From mass to cluster: Emerging trends in suicidal behavior in India
Recently, the rate of cluster suicides in India has been growing rapidly since the last decade. It is a matter of deep concern as it became a massive social problem and thus, effective interventions and solution for suicide prevention need to be developed at the earliest.
There is a shift in the predominance of the number of suicides from the elderly to the younger people all over the world. India is labeled as "Suicide Capital of South-East Asia' as it has recorded the highest number of suicides in South-East Asia in 2012, according to a WHO report [2] also in 2016 the number of suicides in India had increased to 230,314 and suicide was the most common cause of death in both the age groups of 15-29 years and 15-39 years. India has a major contribution to global suicide deaths as it increased from 25·3% in 1990 to 36·6% in 2016 among women, and from 18·7 to 24·3% among men.
There are several different types of mass suicide events that can occur, each for a different reason and for different goals. Form historical perspective the most infamous events of mass suicides are those that are related to religious groups or cults.

Suicide in ancient India
An understanding of the historical trends with respect to suicide in India takes us back to the ancient scriptures that emerged in the Indian society. After having reviewed different Indian scriptures such as the Upanishads, the Bhagvad Gita and the Brahma Sutras it was concluded that suicide is not either explicitly condemned or glorified nor is it seen as a crime in these ancient Indian texts [3]. Although suicide does find mention in the great epics of Ramayana and Mahabharata, it appears that whether such behavior was approved or disapproved depended on the intent of killing oneself, which was perhaps more important than the behavior itself. Thus, if suicide was undertaken due to selfish reasons, it was likely to be disapproved, but if it was undertaken for heroic or self-sacrificial reasons, it was seen in a more positive light. Within the Indian context, it is also debatable whether taking one's life to attain self-realization or enlightenment should be considered "suicide" or not. In such instances, a more suitable term seems to be "leaving one's body" rather than "killing oneself." Some Indian philosophical systems have emphasized on the existence of soul or atman, which is eternal and imperishable in nature, therefore death is then considered an end to the body or gross physical matter and not the soul.
In some religions such as Jainism there is provision known as "sallekhana" or "sanyasa-marana." It can be defined as the religious practice of voluntarily fasting to death by gradually reducing the intake of food. It is linked to the attainment of "moksha," the liberation from the cycle of life and death [4]. Sallekhana is sanctified morally and ethically by the Jain community, thus it is not considered an act of suicide. These observations point towards the increasing necessity of a culturally based understanding of suicide. Hinduism condemns suicide, but in specific instances accepts it as a meritorious act of self-sacrifice. It is cited in the Manusmriti that libations of water, which are usually offered to the departed souls, should not be offered to those who commit suicide.
In India's past, there have also been widespread instances of "Sati" and "Jauhar" or "Juhar." These practices were considered courageous and an act to save honor. "Jauhar" or "Juhar" was practiced by Rajput women and involved mass selfimmolation, primarily to avoid capture, enslavement and rape by any foreign invader. While, "Jauhar" happens to be an example of mass suicide in India, when it comes to contemporary times the picture is different. There are growing instances of cluster suicide in India. The Burari deaths and the Telangana student suicides are examples of this growing trend.

Mass suicides in the world
History is replete with unforgettable cases of mass suicides. Mass suicide of Jonestown is perhaps one such haunting example that springs to memory. It is popularly known as "People's temple mass suicide." In the 1970s, Jim Jones, a selfstyled prophet established a "socialist community" in Guyana named Jonestown. Jones was popular for his notorious image and was under the scanner for financial fraud and child abuse. Establishing an isolated community in a remote corner was perhaps one of the best ways to sustain his delusions and escape arrest. However, even after he moved to Guyana investigations against him continued. Moreover, his followers who moved with him soon discovered that the utopian world promised to them i.e. "an agricultural commune rich with food, where there were no mosquitoes or snakes and where temperatures hovered around a perfect 72° every single day" was a big lie. Instead, they were starving, living in hot and humid climate, full of mosquitoes and snakes. Naturally, his followers began looking for ways to flee. It has been reported that distressed by his followers' attempts to run away; he ordered them to consume a cyanide-laced potion, which eventually resulted in the death of over 900 people. Later analysis has revealed it as more appropriately a case of mass homicide rather than suicide, as his followers were surrounded by Jones's armed guards, thus they were left with no other option than to die. Jonestown massacre is a classic example of how one man's delusion can be contagious to a mass of people.
Similar cases of mass suicide have been reported in different areas of the world, including the Heaven's Gate Mass Suicide in California, where 39 people of the eccentric Heaven's Gate cult committed suicide. They were all dressed identically, were lying on their bunk beds with plastic bags around their heads. They were misled by their Marshall that a UFO was following the comet Hale Bopp and leaving the human world was the only way to evacuate this earth and reach a better cosmic world [5].
In Uganda, the Movement of the Restoration of ten Commandments of God (MRTCG) was a Catholic group that was convinced that the world would come to an end when the millennium calendar began. On 17 March 2000, they resorted to self-immolation and poisoning.
In all of these cases, it can be observed that the self-proclaimed cult leaders exploited the vulnerabilities of people to meet their own ends. The fabled utopian land is often based on religious foundation. These cases are also testimony to the failure of reason. People when promised of "ideal land" and "perfect future" are willing to stake everything that they have; blindly following the one "messiah" that promises them a better life or rather a better death.

Mass suicides and cluster suicides
Mass suicide can be defined as the simultaneous suicide of all the members of a social group [6]. Mancinelli has subdivided mass suicides into two categories: Firstly, (a) hetero-induced, in which a particular population has reacted to oppression, it is typical of defeated and colonized populations forced to escape from reality that does not acknowledge their human dignity, thus people may choose to kill themselves rather than submit to their oppressors. These deaths are often looked upon as heroic and may find a place among cultural myths and legends. Secondly, (b) self-induced, in which the motivation is related to a distorted evaluation of reality, without there being either an intolerable situation or a real risk of death. The question perhaps is whether these categorizations are enough to encompass the range of suicidal behavior that occurs in the present Indian society.
Suicide cluster has been defined as "a series of three or more closely grouped deaths within three months that can be linked by space or social relationships. In the absence of transparent social connectedness, evidence of space and time linkages are required to define a candidate cluster. In the presence of a strong demonstrated social connection, only temporal significance is required" [7]. Another type of suicide cluster referred to as "mass clusters", has been commonly defined as "a temporary increase in the total frequency of suicides within an entire population relative to the period immediately before and after the cluster, with no spatial clustering" [8].
Cluster suicide can be differentiated from mass suicide as a "pocket" phenomenon. It is defined by its contextual factors. Generally, studying clusters becomes more difficult than studying masses, as both temporality and spatiality of the event takes prime importance in its understanding. Again the Burari deaths and Telangana student suicides prove to be examples of the importance of local factors that played a role in these acts.

Types of suicide cluster
There are two main types of suicide clusters: point and mass [9][10][11].
1. Point cluster-Point clusters are time space clustering close in both location and time, that occurs in small communities, and involve a temporary increase in frequency of suicides above a baseline rate observed in the community and surrounding area [9][10][11][12].
2. Mass clusters-occur when a large amount of people kills themselves at the same time. It involves a temporary increase in suicides across a whole population. The difference between point and mass is that it is close in time but not necessarily location. Mass clusters have been documented following suicides of high-profile celebrities or others who receive considerable media attention [10,12].
A new concept has been introduced recently that is Echo cluster, the occurrence of subsequent, indigenous suicide which takes place in the same location after an initial suicide [7,13].
Most attention has focused until recently on a greater than expected number of suicides in specific locations and time periods ("point clusters"), such as the cluster of suicides that occurred in Burari in Delhi where 11 members of a family committed suicide cumulatively.
It is observed that the mechanisms underlying suicide clusters are unclear. It has been proposed that point clusters may result from a process of "contagion," whereby one person's suicidal thoughts and behaviors are transmitted from one victim to another through social or interpersonal connections [10,12].

Categories of suicide
In India there are several categories of suicide cluster which are related with their area of profession. Some of them are students' suicide, family suicide and farmers' suicide.
Student suicide: Now a day's education is becoming society's most critical responsibility as it is more related with social status. Students have to face many challenges that affect their life directly or indirectly like academic stress caused by the very system of education, acquisition of grades, coping up with peer pressure & parental pressure and the emotional disturbances to secure good marks and position. Poor scholastic performance, rising expectations from parents, getting involved in relationships these are the reasons which prompt a student to commit suicide.
Kota in State of Rajasthan in India is well known for its coaching of students for various admission exams after 12th standard. It has become the suicide city as the number of students committing suicide has increased drastically. By the end of the year 2018 three medical/ IIT students committed suicide within four days which brought unsettling case of students suicides. Total 19 students committed suicide in 2018.
A recent example of student suicide cluster was in Indian state of Telangana where more than 20 students killed themselves within a week after declaration of intermediate examination results. Due to the occurrence of these incidents, India's education system is criticized as a poor one in which students are under heavy pressure not just to pass examinations but to exceed expectations at all costs. The instrumental value of education in India is its potential in generating socio-economic and cultural capital through a promise of decent job opportunities in the future.
Family suicide: takes place when a whole family is unanimously agreeing to take the critical step to commit suicide together. There has been a vast increase in the family suicide cases in last 2-3 years. This phenomenon came in light after the death of 11 members of family in the mysterious Burari case' . After few days of Burari case, seven members of family committed suicide in July 2018, According to police, the family was reeling under financial hardships. In March, 2013 the same thing happened in Gangapur District of Rajasthan where eight members of a family consumed poison to committed suicide together. The family was highly religious. They also made a video before suicide.
Recently in July, 2019 three members of a family ended up their life by consuming some toxins in Punjab. According to police records, some sort of family tension within the household led to this extreme step. Again after few days three of family members were found hanging on IIT campus.
Farmer Suicide: Two thirds of India's population are dependent on agriculture for their livelihood. The earth is most generous employer in this country of a billion [14] 'It is the agricultural sector that the battle for long term economic development will be won or lost. For over a decade, famer suicides have been a serious public policy concern. More recently, this has also led to shrill outcry from the media and much politicking. The government response to the crisis of farmer suicide has mostly been simplistic and in some cases perhaps aggravating [1]. This is a particular concern for country. It is observed that huge debts, inadequate income from agriculture to repay the borrowed money, the absence of any help from outer sources, are the main cause of farmer's suicide, making them choose to end their lives. Factors contributing to the high rate of suicide in this vulnerable population include economic adversity, exclusive dependence on rainfall for agriculture, and possibly monetary compensation to the family following suicide.

Contagion of suicidal behavior
Contagion has been defined as an underlying assumption that "suicidal behavior may facilitate the occurrence of subsequent suicidal behavior, either directly (via contact or friendship with the index suicide) or indirectly (via the media) [9].

Imitation
It is necessary to distinguish various types of individual suicide that might be imitated. One type of suicide relates to some symbolic or group activity which creates group pressure(s) that cause an individual to kill oneself (a form of altruistic suicide. A second type that might trigger imitative suicide involves individual's prominence in specialized occupations, e.g., a well-known artist or businessperson. It is possible that such suicides might cause suicide among individuals with similar occupational backgrounds who have experienced crisis or failure. However, this imitation is only likely to occur among a small subgroup of the population. A third category that might trigger imitative suicide is the suicide of national celebrities, i.e., individuals who are well known and recognized by name and pictorial image by the larger American public. These individuals have usually achieved prominence in an occupation subject to significant public exposure, but some social actors may become celebrities through their social connections with other prominent celebrities [15].

Suggestibility
Philips [16] examined U.S. and U.K. suicide rates from 1947 to 1968 and reported that suicides increased after highly publicized deaths by suicide. He proposed that news reports of suicides influenced suicide risk by means of "suggestion". He dubbed this the "Werther effect." Projective identification has been regarded as a psychoanalytical concept, which refers to feelings of empathy towards suicide. There is a blurring of self and suicide followed by a re-internalization of projection, leading to suicidal behavior.
In Priming [17], activation of one thought may trigger related pre-programmed thoughts. Media images stimulate related thoughts in the minds of audience members.
Social Integration and regulation: Where there is a lack of social ties in the community, social integration is low, leading to individualism and egoistic suicide and where interests of groups dominate those of individuals, altruistic suicides result [18].
Homophily or assortative relating [10]: The tendency of people to preferentially associate with one another and associative susceptibility, [19] where a stressful event occurring in a local community will affect several vulnerable individuals independently of each other.
Certain religious beliefs may leave people feeling guilty for things they have done and may lead them to think that they cannot be forgiven. Some believe that sacrificing themselves will earn them a reward (like going to heaven) or in countries like Japan, shame or dishonor may be a reason, like hara-kiri or seppuku.

Multidimensional nature of suicide
The multidimensional nature of suicides is reflected in the array of motives and risk factors associated with it. It has been referred to as "multidimensional, DOI: http://dx.doi.org /10.5772/intechopen.89439 multifactorial malaise" [20]. Previous researches have mostly studied the psychosocial risk factors associated with suicides. It appears that both individual factors as well as situational factors intermingle in a complex manner to determine suicidal behavior. The demographics of suicide in India [21] reveals factors such as Age, Gender, Marital status, Education, Family structure, Urban vs. rural residence, Occupation and Precipitating event, play a role determining suicidal behavior. As per the National Crime Records Bureau 2009 data [22], the top 10 causes or correlates of suicide in 2009 were identified as family problems (23.7%), illness (21%) [including insanity/mental illness (6.7%)], unemployment (1.9%), love affairs (2.9%), drug abuse/addiction (2.3%), failure in examination (1.6%), bankruptcy or sudden change in economic status (2.5%), poverty (2.3%), and dowry dispute (2.3%). In addition, the high rates of suicide among persons with mental illness and drug abuse/addiction are of much concern. Substance abuse, problems with parents-in-law and spouses and mental illness are the risk factors that are increasingly gaining momentum in the Indian society [23].
There are vulnerable individuals with negative self-esteem, socially isolated, who tend to internalize feelings and conflicts and are over-dependent on their families. Drug and alcohol abuse, employment problems, a history of self-harm have been quoted as possible causes [24].
Mass suicides are seen as suicide pacts in couples or families rather than as part of religious cults as in western societies. Suicide pacts almost always involve people well known to each other, mostly spouses, most of them childless. However, there is an emerging trend for cyber-based internet-facilitated suicide pacts which increasingly involve two or more strangers who meet on the internet and share similar world views. Such cases have been reported in the press, but have not been studied in a scientific manner [20].

Role of mental illness in suicides
Those who are especially susceptible to suicide contagion are adolescents with suicidal thoughts and people with depression, bipolar disorder, anxiety, schizophrenia and PTSD.
Exposure to previous trauma makes a person susceptible to develop PTSD, especially in cases of physical and emotional proximity to the event and victim. Rumination followed by intrusive thinking are additional causes. In such instances long term emotional support is needed, which if found missing, has its adverse consequences. The mass trauma caused by mass suicide is likely to affect the mental health of individuals. Depression has been regarded as a key risk factor for suicide. Substance abuse, chronic pain, a family history of suicide, a prior suicide attempt and impulsiveness plays a major role in adolescent suicides.

The dual role of media
The media sometimes gives intense publicity to "suicide clusters" -a series of suicides that occur mainly among young people in a small area within a short period of time. These have a contagious effect especially when they have been glamorized, provoking imitation or "copycat suicides". This phenomenon has been observed in India on many occasions, especially after the death of a celebrity, most often a movie star or a politician. The wide exposure given to these suicides by the media has led to suicides in a similar manner. Copying methods shown in movies are also not uncommon. This is a serious problem especially in India where film stars enjoy an iconic status and wield enormous influence especially over the young who often look up to them as role models.

Methods of suicide study
Two prominent methods are psychological and psychosocial autopsy. In depth study of the history of suicide prior to the suicidal act is known as psychological autopsy [25]. Psychological autopsy is a method created by Shneidman [26]. It has become widespread in the last 2-3 decades.
Psychological autopsy is a depth study of a person's mental state by analyzing medical records, interviewing friends and family and conducting research into their state of mind prior to death.
The psychological autopsy report provides detailed information about the death using various sources including the autopsy report, medical records, relevant documents and information gathered from interviews with key informants.
It was conceived as a means to help forensic pathologists clarify the nature of deaths regarded as unresolved and that could be associated with natural or accidental causes, suicide or homicide. The method was also used to investigate the reasons behind self-inflicted deaths and to provide comfort to family members of individuals who have died this way.

Psychosocial autopsy
Psychosocial autopsy is understanding of emotional, social, economic and cultural reasons and circumstances associated with suicide among individuals. The aim is to investigate and analyze the relevance of interacting variables.
Some of the key goals of the Psychological Autopsy: Obtaining an in-depth understanding of the decedent's personality, behavior patterns, and possible motives for suicide; identify behavior patterns-reactions to stress, adaptability, changes in habits or routine Establish presence or absence of mental illness.

Methodological issues in studying clusters
The demographic and clinical features of suicide cluster victims have been described by researchers. Only some studies [19,27] adopt a more methodologically robust design, such as case-control study. Only a small number of possible risk factors for suicide were examined, like gender, age-group, marital status, area of residence, method of suicide. Studies using multi-level methodology are needed to determine which individual or contextual factors contribute to clustering of suicidal behavior. Longitudinal studies on suicide clusters combined with environmental factors are needed. It is not always possible to determine retrospectively whether or not a person in a suicide cluster knew about the suicide of another cluster member [28].

Prevention strategies
Suicide is often related to depression, social isolation and loss of meaning in life. Some strategies at the individual level are: 1. Talk to those intimately connected first prior to media coverage, possibly one who is trained in crisis care therapy.
2. Identify vulnerable persons for mass/cluster suicides, e.g. people who had a negative interaction with the person before suicide and feel that they were DOI: http://dx.doi.org/10.5772/intechopen.89439 responsible for suicide, people who were in suicide pact, people who were previously suicidal.
3. Screen those at high risk, screening by trained counselors, screening for emotional and mental health problems, symptoms of depression and suicide risk.
4. Provide post-care after suicide counseling by crisis counselors available in schools and make sure students know these resources are readily available.
5. Offer case-management services at schools and universities.
6. Provide mental health screening for depression and suicide.
7. Share information about mental health with parents.

Community level
Mass suicides can be prevented at community level by designing of strategies by community leaders. All sectors of the community need to be included: public health, mental health, Education, Local government, parent groups, media, as no single agency has the requisite expertise to deal with the suicide cluster. The plans need to be adapted to the particular needs, resources and cultural characteristics of the community. Suicide prevention training needs to be provided in schools. Peer-helping needs to be encouraged. It is based on the premise that an informal helping network exists. This group teaches how to reach out adults for help. Tele-health services need to be in places which are manned by counselors, mental health clinicians, social workers and clinical psychologists. Having counselors on the sites of memorials, suicide anniversaries and other events related to suicides can also be of great help.
Addressing the environment, e.g. the internet environment and how students interact with each other on the net is also needed. Mass suicides can impact those living in the community deeply. Hence strategies at the community level have a great role to play.

Role of culture
The cultural/social resources include guidance from elders for addressing grief, informal community gatherings, where community members share stories and draw on a shared sense of spirituality and cultural history to overcome crises and impact of suicides and suicide clusters. The elders can pass on the wisdom and traditions on how to thrive through harsh conditions. The mutual care and concern for others, shared purpose. Spirituality helps to a great extent in dealing with traumas of life. Traditional culture helps to ground individuals and provide a framework to view their place in the world. Communities need to connect youth to their culture. Elders can share stories of how they used to deal with crisis situations in the past before our generation. School-based programs need to be organized on suicide signs and risk factors. Developing and promoting prosocial adult and peer mentors and role models are likely to help in a great way. Culture camps can be organized where youth (at community and school level) are exposed to their traditional life ways.

Role of media
Psychological autopsy studies have found that media can be of great help by not publishing/telecasting the method used to kill oneself, not suggesting that the death was due to a similar reason or achieved a goal such as fame or revenge and listing resources to those who are struggling.

Addressing the symptoms of mental illness
Treatment of mental illness can reduce the risk for suicide and increase the quality of life. One needs to be beware of warning signs like increased use of drugs/ alcohol, statements threatening to hurt self, looking for access to fire arms, pills etc. statements of hopelessness, helplessness etc., increased anger and rage, highly reckless behavior, paired with recent losses, including deaths, break-ups, job or financial losses.

Conclusions
Mass suicide in across the globe is an age-old act which was carried out by individuals and was neither condemned nor glorified nor seen as a crime. The intent of the act determined its approval or disapproval. With the change in scenario, more number of cluster suicides has been reported in the present Indian society which can be categorized into family, farmers and students. Psychosocial autopsy has revealed imitation, suggestibility, contagion, lack of social integration, priming, associative susceptibility, guilt, mental illness and a host of other causes behind this act. Preventive strategies need to be addressed at individual, community and cultural level. In future, more methodologically sound and preferably longitudinal studies are needed to gain better insight into this suicide type so that preventive strategies can be targeted appropriately.

Author details
Nishi Misra*, Harshita Jha and Komal Tiwari Defence Institute of Psychological Research (DIPR), Delhi, India *Address all correspondence to: nishi.nishi067@gmail.com © 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.