| Abstract|| |
The tragedy of maternal filicide and extended suicides has occurred throughout history. Maternal filicide-suicide perpetrators most often suffer from depression, suicidality, or psychosis. Interventions in such cases are not commonly reported in the psychiatric settings, and the components of psychotherapeutic approach and its efficacy are also not known. Here we present a long-term therapy carried out with a 36-year-old married lady, with the complaints of low mood, suicidal ideation, severe guilt feelings, and depressive cognitions. There was positive family history of depression, past history of dysthymia, suicidal attempt, and severe marital discord. Therapy was carried out for a period of 9 months with follow-up for 4 years and addressed existential issues and grief with the components of existential therapy, grief therapy, narratives, religious beliefs, and interpersonal acceptance. The case highlights the need for blending of multiple approaches to meet the challenges such cases can pose.
Keywords: Existential therapy, maternal filicide, spouse revenge
|How to cite this article:|
Manjula M, Chandrashekar C R. Filicide as a part of extended suicide: An experience of psychotherapy with the survivor. Indian J Psychiatry 2014;56:194-6
| Introduction|| |
Maternal filicide is defined as child murder by the mother. Reasons for maternal filicide may be altruistic motives, acute psychosis in mother, birth of an unwanted child, fatal maltreatment of the child or spouse revenge.  The mothers often face multiple psychosocial stressors such as financial problems/unemployment, social isolation, full time care giver status, being victims of domestic violence, or have other relationship problems like conflict with family members, ongoing abusive adult relationships, and lack of social support. , A significant proportion (16-29%) of filicides end in completed suicide by the mother. 
Bourget and Bradford (1990)  noted that 31% of parents who committed filicide had a diagnosis of major depression, compared with none of the perpetrators of nonparental homicide. A recent review of 85 filicide cases in Turkey  showed that nearly half of the perpetrators had been diagnosed of psychiatric disturbances, including schizophrenia (61%) and major depression (22%). Most frequently, these mothers had altruistic motives. Spouse revenge filicide is difficult to prevent because there is usually little warning. This behavior most often occurs after learning of spousal infidelity or in the course of child custody disputes. 
The intervention with the survivors often includes addressing bereavement, trauma, guilt, and existential issues. The interventions with survivors indicate that participants experienced high levels of psychological distress, including elevated symptoms of depression, guilt, anxiety, and trauma. They experienced substantial difficulties in the social arena (e.g., talking with others about the suicide). Majority of them viewed professional help as beneficial, although many informal sources of support were also valued (e.g., one-to-one contact with other survivors). Depression and lack of information about where to find help served as barriers to help-seeking behaviors. Higher levels of functional impairments were associated with higher levels of psychological distress, social isolation, and barriers for seeking help.  However, there is very little research on intervention with the survivors of filicide and there is a need for evidence-based interventions.
The case is presented in the background of lack of literature on intervention with such cases, and also to highlight the need for integration of various techniques in therapy, and therapist's unique therapeutic experience.
| Case Report|| |
Mrs. N., a 36-year-old married lady working as a nurse, was brought from central prison with the complaints of low mood, severe guilt feelings, depressive cognitions, suicidal ideas, and crying spells. She had charges of attempted suicide and homicide of her two children.
The patient was unconscious for 2 days after the attempt and was referred to NIMHANS for high suicidal risk. The history is as follows: About 1½ years before the incident, she came to know about the extramarital affair of the husband. After that, quarrels became more frequent between the couple; her husband promised fidelity, but did not keep his word and continued the relationship. The problems aggravated and she became more and more detached in the relationship and determined to commit suicide. She constantly planned for a month without giving a hint to anybody and with no changes in her routine work.
The night before the incident, she collected the required injections and sleeping pills; next morning, she brought her son from boarding school and daughter from school saying that there was an emergency. She told them that there is some vaccination that everybody has to take and she is going to take it after injecting them. She injected the daughter first, though nervous but with determination, she next injected the son and herself and lied down next to the son whom she loved much. She had to inject him again to silence his screams and she took some more tablets to ensure death. The reasons explained by her and written in the death note were that she did not want her children to suffer because of the bad and irresponsible nature of the husband, and also that he would remarry and not care them. She wanted to punish and teach him a lesson through this.
There was family history of depression and absconding from home in her mother and brother. She contemplated on committing suicide several times and had attempted once. Personal history revealed that she was from a semi-urban background, with good academic history, and could not do medicine because of financial difficulties. After her nursing course, she started working in a city where her husband met and proposed her. He is primary school educated and into real estate business, politics, and producing movies. They got married after much persuasion from his side. After marriage, she found him to be irresponsible, spending most of his time and money for friends. She had to manage both home and children. In addition, he was abusing alcohol, used to quarrel using abusive words when intoxicated, and suspected her fidelity.
The patient always contemplated separation, but it was not possible because of his possessiveness and antisocial nature. She felt trapped; she never shared any of these either with friends or family members.
Therapy with the patient
Therapy started from the 3 rd day of hospitalization, continued for 9 months on inpatient basis, and there were regular follow-up sessions up to 2 years.
Ventilation and grief therapy:
- Reliving of the incident: The initial 10-15 sessions focused on ventilation, she experienced severe distress and guilt feelings recalling the incident, repeatedly requested for help to commit suicide. The sessions were longer than 2 hours at this stage.
- Exploring the relationship: The patient was allowed to talk about her children - happy moments, current feelings, death, and burial. In the process, she experienced difficulty to think that their bodies were decomposing, dreamt about them, and felt their presence around. She held her husband responsible for the incident, and felt that curse of those suffered from his hands has taken her children. But questioned why in her hands? Why her good deeds, honesty, dedication, and commitment for work, did not help?
- Existential and narrative therapy: The why questions were discussed in terms of givens of life like death, sorrow, suffering, pain, uncertainty (existential and religious explanations), and absence of correct answers for past? present? fate?, etc., The need to take what comes in life as given by the God was reiterated.
- Narratives: In the discussion of existential issues, narratives of hardships, loss and illness, trauma, fate, destiny, harassment, and finding purpose of life were taken up. The hospital staff, police, and friends contributed by giving narratives from their life experiences. The meaninglessness of life without children and feeling of responsibility for their death was dealt by using religious stories and sayings which explained the futility of such thinking; temporary nature of life, and doing one's duty in what is given. Books were given for reading to strengthen these ideas.
- Relationship issues: Feedback about their relationship in terms of ambivalent feelings toward husband and the fact that both wanted to be together was discussed (based on her dependency needs and affection toward him). She was told to think about the choice that she would like to make and take responsibility for the same. After a few weeks time, she came out with a decision that even if there is a chance for her to separate, she would like to choose to live with him. The work focused on forgiving, reducing the expectations, understanding his personality, and open communication.
The grief process was a gradual one and had to go through ceremonies, birthdays of children, festivals, TV programs, school day, etc., "Anniversary phenomenon" was seen during these incidents. The joint sessions addressed issues like respecting each other, alcohol abuse, use of the abusive words, blaming, and suspiciousness.
6. Facing the world: Fears about reactions of people, stigma, the court, and prison were discussed in the light of temporariness, inevitability, and acceptance. Some of these fears were disproved by the concern shown by relatives, friends, doctors, and other staff.
At the end of 2 years, she joined back work and was acquitted of the case. She was not thinking of suicide and wanted to live for the husband accepting all his drawbacks, because of the struggle he had to go through during this period and to serve people. At 4 years, the fights for small reasons still went on and she had learnt to put up with them. Sometimes she felt guilty for living at the cost of her children.
| Discussion|| |
In this case, the reasons for attempted suicide and extended filicide seem to be two: (1) altruistic in the light of concern about the welfare of the children and (2) spouse revenge in the background of marital problems and infidelity, and intent to induce pain, sorrow, and guilt in the husband by taking away children. The demographic characteristics and the background history are similar to common features reported in the literature such as lack of social support, primary care giver status, and relationship problems between the couple. The reasons for not giving any hint may be spousal infidelity, wanting to take revenge, depression, and lack of knowledge about availability of help. ,,
It is important to understand the integration of different components like existential, grief, narratives, and religious beliefs. The common theme across these therapies seems to be searching for meaning/purpose; accepting the life/anxieties: awareness of self, death, and goals; and taking responsibility in addition to reconstruction of life. Moreover, the approach seems to fit in the kind of the problems, the socio-cultural background, and the kind of questions the patient had. Thus, the stories from religion (karma theory) answering the questions about events of life, for example, time and nature of death as decided by God/one's destiny; person as an instrument in the hands of God to cause death; death as the beginning of life and dead child going to God's abode, and the real life narratives helped her to gain flexibility in understanding the suffering of life and to accept the lack of control over these. This also helped to work on the anger, guilt, and sense of responsibility associated with filicide and in contextualizing the existential questions and choosing the life goals. With respect to the relationship, when she was given an option of choosing what she wants in life, she was able to take up responsibility for choosing to live with the husband and not to repent for the same.
The long-term therapy was possible because of the following reasons: inpatient setup in the beginning, strong therapeutic bond, severity of distress; psychological mindedness, religious background, and abstraction ability of the patient.
With respect to experience of the therapist, it was extremely difficult to contain the emotions in the beginning sessions because of the content, life stage, and the painful process involved. It evoked emotions of insecurity and fear of loss in the therapist which took time to lose its intensity. Finding convincing options for creating the purpose in patient's life was a challenge because therapist also sometimes would get convinced of the fact that nothing can bring happiness to patient's life. However therapy in this case was a journey of learning to the therapist. The case illustrates the need for longer duration of therapy to deal with the guilt and grief and also the need for integration of various approaches and sources for facilitation of therapy process.
| Acknowledgment|| |
We acknowledge the cooperation of the patient and the treating team.
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Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka