Forensic Engineering Evaluation of Premises Maintenance

Forensic Engineering Evaluation of Premises Maintenance

Abstract

A premises (building and its site) consists of components to form a safe, usable facility. The components must be maintained in order to keep them functioning. Forensic engineers are often asked to render their opinions concerning a component’s performance and the maintenance it has received. Because the results are to be used in a forensic forum, the engineer must have a well-documented methodology and a firm basis for his or her opinions. One method of making such an evaluation is to employ a systems approach.

When a component and its maintenance are treated as a system, the engineer considers its various aspects and the interaction between those aspects. Furthermore, the examiner can test “what if” hypotheses using the same method. This article discusses a method to achieve that end while giving the forensic engineer a strong foundation for his or her opinion.

THE FORENSIC EXAMINER Fall 2007

Fall 2007 THE FORENSIC EXAMINER

This article is approved by the following for continuing education credit:

(ACFEI) The American College of Forensic Examiners International provides this continuing education credit for Diplomates.

By John A. D’Onofrio, MS, CE, PE, DABFE, DABFET, DNAFE

Key Words: buildings, premises, maintenance, systems evaluation

Introduction

A premises (buildings and its site) consists of a group of systems working together to form a facility. The components of these systems must be maintained in order to keep them functioning. Following an accident or system failure, a forensic engineer is often asked to make an examination and render an opinion concerning a component’s performance and the maintenance it received. Such requests are most common in civil litigation, but may be required in a criminal case as well. Because of the complexity of a premises (both the building and its site), such services may be requested from engineers in many disciplines and some examinations may require an interdisciplinary team. Because the result is to be used in a forensic forum, the engineer must have a well-documented methodology and a firm basis for his or her opinions.

One method to make such an evaluation is to employ a systems approach. System analysis, as defined in this article, is the critical examination of the technical and managerial skills used to maintain the premises. This approach recognizes that continued, acceptable operation of a component is dependent upon a system consisting of the component itself and the maintenance it receives. Systems, whether including human activity or not, are subject to limitations whose effects can best be understood through system analysis. Furthermore, the examiner can test “what if” hypotheses by assuming changes in the system and analyzing the results. The result of an analysis is a simple statement of opinion; however, time, work, and data are needed to posit an opinion with a strong foundation.

The remainder of this article discusses a method to achieve that end. Many of the principles discussed have their origin in health and safety engineering. Often, premises maintenance evaluations are required when an accident or injury has occurred. Therefore, the method described here is closely related to safety engineering practice.

The Flow Chart (Figure 1)

By applying the evaulation flow chart, the examiner covers a wide range of pertinent topics. Not only does this provide a guideline to the examination, but it also provides an excellent foundation for the engineer’s opinions. The flow chart has two flow paths, Component and Maintenance. Each path consists of decision points where the engineer finds the aspect under consideration either acceptable (yes) or unacceptable (no). A “no” evaluation leads to an Inadequate System rating. A series of “yes” evaluations leads to the And gate toward the bottom of the flow chart. Both paths of the flowchart must be evaluated and lead to the And gate in order for the system to receive a Good rating. If the first path leads to the And gate, then the second path must be evaluated to complete the process.

Once an Inadequate System rating is reached, theoretically, there is no need for further evaluation. However, an Inadequate System rating is often the beginning of the next phase of the investigation, an explanation of cause. Because a system may be inadequate for numerous causes, the engineer alone must decide whether he or she should continue the evaluation further.

An Example

The following example follows Figure 1 and includes a discussion of the evaluation process. The example is a request to evaluate the floor of a small mercantile establishment where a patron slipped and fell on a rainy day. There is an allegation that water was present on the floor at the time of this fall. The component to be evaluated is the flooring. The maintenance program is that which the proprietor uses for safety during inclement weather.

Operating Conditions

The first step in the evaluation process is to determine the operating conditions. These are the conditions under which the system is expected to operate and give the engineer insight to the system when working the evaluation paths.

The operating conditions are best determined by site inspection, document review, and testimony of various parties. A document review may include but is not limited to:

• Plans and specifications prepared by the building architect or design engineer
• Lease documents that may specify permitted activities within the building
• Building and maintenance codes
• Zoning ordinances and other regulatory documents
• Indoor environmental standards common to the industry

In this example, the site inspection revealed that the space was being used as a haberdashery. Flooring was a commercial grade vinyl tile. The slip location was approximately 7 feet from the entry. The document review has determined that, at the time of the fall, the building was approximately 25 years old. The architect’s plans indicate the space to be used for retail use. The use of the space for mercantile purposes is consistent with the permitted uses in the zoning ordinance. The lease between the owner and tenant indicates that the space is to be used for the legal, retail sale of goods, not to include food or personal services. Based on the site inspection and document review the engineer can reasonably conclude that the use of the space is “anticipated.”

Note from Figure 1 that the evaluation process does not depend upon the operating conditions; however, if unanticipated conditions are involved, the examiner must decide and note if the evaluation is made for the actual conditions encountered, the anticipated conditions, or both. The examiner must also recognize that a component may be exposed to an unanticipated condition and continue to function well.

Component

Component evaluation follows the right side of Figure 1. Here, the specific component under examination is scrutinized under the chosen operating conditions.

Component Specifications. The next step in component evaluation is to determine if it meets specification. This step implies that the engineer has determined the component’s specification and an appropriate test for compliance. The component specification may be either specific (specified by size, make, and model) or performance (i.e. 100 cfm fan, 230VA) oriented. Oftentimes, component specifications are not specific and must be derived from document review. These include, but are not limited to:

• Plans and specifications prepared by the building architect or design engineer
• Manufacturer’s specifications
• Building codes
• Typical architectural and engineering details (graphic standards)
• Engineering organization standards
• Authoritative consensus standards

In the example, the architectural plans were silent on the flooring material. According to testimony, the vinyl tile was selected by the owner and was in place when the tenant moved in. The manufacturer is unknown at this time. The tenant space was inspected by the construction official before opening to the public and received a certificate of occupancy. The local building code requires that all walking surfaces be slip-resistant.

A literature search revealed an ASTM standard that relates slip resistance to the floor’s static coefficient of friction with a shoe-leather test surface and a threshold level. On-site testing of the floor material was conducted and determined it to be slip-resistant.

Based on the site inspection, document review, and testing, the engineer can reasonably conclude that the material used to construct the floor surface meets specification.

Component Installation. The next step in Figure 1 is to examine the component installation. Poor workmanship should be noted and described. The manufacturer’s installation guide for the component should be consulted, if possible, whenever installation is drawn into question. In the example, the vinyl tile was examined and found to be tight, stable, and planar. Based on the site inspection, the engineer was able to reasonably conclude that the installation was not an issue and probably followed the manufacturer’s specification.

Maintenance

The maintenance flow path follows the left side of Figure 1. Here, the maintenance program under examination is scrutinized under the chosen operating conditions. This flow path incorporates work on safety done in the United States and the United Kingdom. The U.S. recommendations were developed and promulgated for workplace safety. The U.S. Department of Labor, through the Occupational Safety and Health Administration (OSHA), publishes a document entitled Keeping Your Workplace Safe (1999). This document describes four elements that every effective program should have:

• Management, leadership, and employee involvement
• Workplace analysis
• Hazard prevention and control
• Training and education

Similarly, the Health and Safety Executive of the United Kingdom publishes a document entitled Managing Health and Safety – Five Steps to Success (1998). The document states: “This leaflet contains notes on good practice which are not compulsory, but which you may find helpful in considering what you need to do.” The five steps are

• set up your policy;
• organize your staff;
• plan and set standards;
• measure your performance;
• learn from experience.

Figure 1 incorporates these into the four aspects of the maintenance procedure flow path.

Maintenance Procedure

Maintenance procedures may be written and formalized. This is commonly found at locations that have a maintenance department or are part of a nationally operated or franchised establishment. Managers responsible for large buildings or multiple premises may have routine and preventative maintenance scheduled and noted by computer. On the other side of the spectrum, other business or industrial locations may not have a written plan, and the examiner must determine the maintenance procedure through investigation, interview, or testimony.

The second aspect of the maintenance procedure is to determine if it conforms to or follows a standard. The examiner must keep an open mind and not judge the book by its cover. Policies and procedures that are extensive, written, and neatly bound are not necessarily more compliant with standards than those that are less organized. A lack of organization and record-keeping may be a regulatory violation, but is insufficient by itself to consider the system inadequate. However, policies and procedures that are unclear may be considered outside the standards because of ambiguity. Further, loosely stated maintenance procedures can have an effect on other aspects of the maintenance program.

The engineer must determine the appropriate standard by which to measure the subject procedure. The manufacturer’s specification on how to maintain the component should be investigated and may specify a performance standard for maintenance. For example, certain filters may need to be checked at a maximum time interval and cleaned following a specified process. Property maintenance regulation may specify the maximum time that snow or ice may be allowed to remain untreated or the length of time that rainwater may accumulate before it is considered stagnant.

In cases where the standard is not straightforward, the engineer must be prepared to ascertain industry standards for maintenance based on authoritative and circulated industry publications. Standards organizations such as the American Society of Testing and Materials (ASTM) and the American National Standards Institute (ANSI) publish a wealth of information. The insurance industry has a long history of underwriting standards for buildings and sites. They pioneered sprinkler system standards for fire control, and many insurance companies sponsor safety research to this day. Over time, these findings become industry standards and find their way into loss-control and underwriting literature. The National Safety Council (NSC) and the American Society of Safety Engineers (ASEE) are another source of information. The U.S. Army Corps of Engineers and the Air Force have extensive procedures for maintaining buildings and sites with a wealth of information available on their websites (Secretary, 2004; U.S. Army, 2003).

When deciding on an appropriate standard, the examiner must be sure that the standard is widely circulated and does not conflict with jurisdictional building codes, maintenance regulations, or site improvement standards. The challenge is to determine reasonable industry standards for a given situation, especially in view of critics that are always present around any issue. Cutting-edge academic and scientific papers should be used with caution. They may be useful to explain or substantiate a principle, but most are not widely circulated amongst maintenance practitioners, and the author’s view may not be widely accepted or adopted as a standard.

When researching standards, remember that a maintenance procedure in practice must include a method of discovering conditions that need to be maintained. Discovery of a condition that has developed relative to a component is an essential part of maintenance. The time required to correct such conditions (correction time) includes both the amount of time the condition exists before it is discovered (discovery time) and the amount of time required to do the work using reasonable dispatch (work time). Hence, there will always be a time interval between the instant a component develops a condition requiring work and when the work is completed. Often a condition that develops will not be obvious and the maintenance procedure must be proactive to minimize the discovery time. For example, mechanical equipment should be checked on a periodic basis to assure it is either functioning properly or exhibiting telltale signs of impending failure.

Published standards must also be read with this principle in mind. They will often indicate that certain actions must be taken “immediately.” This should be interpreted as acting “without delay upon discovery” because instantaneous discovery (zero discovery time) and correction (zero work time) is, in most cases, impossible.

The procedure and standard examination may require some iteration. The examiner should have the standard in mind when examining the procedure and the procedure in mind when examining the standard. After interviewing the various parties or reviewing their deposition testimony, review both the procedure and the standard for modifications afterward. This will help assure that nothing out of the ordinary is missed.

In the example, the engineer researched Best’s Loss Control Manual (2000), a loss-control engineering guide and authoritative publication for insurance underwriting. After selecting the appropriate use, he reviewed the various items of concern and selected those that were appropriate to floor maintenance and the conditions at hand. This subset of conditions became the performance standard for the evaluation. Also, it was determined that local building and maintenance codes provided no performance standard for floor maintenance. Further review of a NSC publication concerning falls on floors revealed similar recommendations therein. The engineer felt confident that the items selected represented good practice and industry standard.

The maintenance procedures for floor maintenance were written and posted on the bulletin board in the employee area of the store along with emergency phone numbers. While not detailed, they covered the items in the standard and were straightforward and easy to understand. They included employee assignments and response measures to inclement weather conditions. The engineer determined that the maintenance procedure did follow standard.

Education

Education refers to the training that maintenance personnel receive. Depending upon the maintenance tasks, the education may require specialized training or schooling. Most commonly, however, maintenance personnel receive on-the-job training, especially if the maintenance tasks are more janitorial than repair in nature. Management must be involved to assure that education is not a one-time experience. New equipment or changes in business operations may require re-training of maintenance personnel. Further, it must also be determined that the specific personnel responsible for the maintenance had received the training and understood their duty. Maintenance personnel must be taught and encouraged to trust their judgment and report their opinions concerning the component or the maintenance procedure to management without fear of reprisal.

In the example, it was determined that all employees are instructed as to the safety procedures for inclement weather. The maintenance was basically a janitorial function. Safety posters were on the employee bulletin board, and the owner discussed safety at all employee meetings, instructing them to place mats on the floors and warning cones at the entrance when it starts to rain. Employees were instructed how to properly clean water and spills from the floor and to watch for such conditions as they move about the store. The specific employee at the store when the incident occurred had 3 years of experience with the company and was thoroughly familiar with the procedures. The engineer concluded that the personnel were sufficiently trained to properly maintain the floor.

Management

Management works hand-in-hand with education and is a critical component in resources. Management must consider maintenance a priority aspect of their business and be committed to keeping the system working. The attitude of management influences the personnel; if the boss does not care, neither will the staff. Management should

• have a system of reporting and tracking maintenance functions. This data can point to problems and the need for improvement in the system;
• check to assure that adequate resources in the form of manpower and equipment are available to keep the system running;
• reinforce education amongst the workers;
• create a climate where maintenance is a priority.

Sometimes an evaluation of management can be simple and straightforward. In other situations, it can be complex and difficult. A proprietor of a space that ships and receives merchandise from one or two loading docks may have no problem both scheduling and managing his truck traffic. The traffic manager for an industrial or warehouse operation may have traffic engineering and safety problems to be solved while, at the same time, keeping the system running. It is important that the examiner keep his own house in order and recognize when a consultant or team approach is required.

The proprietor of the establishment in the example had two locations to manage. He visited both of them more than five times a week and had constant cell-phone contact whenever the stores were open for business. He met with employees and conversed with each one every 2 weeks. Premises maintenance was always discussed. Furthermore, he rotated and replaced the signs, posters, and instructions posted in the employee areas. Based on this testimony, the engineer concluded that the management of the system is adequate.

Resources

Resources are the manpower, equipment, and material required to keep the maintenance program working. It is tied to management because management allocates the funds, hires the people, and sets the work schedules. Management also determines how and when the resources are allocated. Personnel view resources as a management statement, equating adequate allocation of resources to a top management priority. Conversely, management that is perceived as “doing-it-on-the-cheap” is considered to have maintenance as a low priority.

Although budgets are an important factor in any business, resources are best measured by what takes place at the premises. It is one thing to budget for an adequate number of filters and another thing to have them in the supply room when they are needed. It is one thing to budget for a snow removal contractor and another thing to have sufficient manpower to do the job properly. Therefore, resources are a topic of investigation with both management and the personnel at the site.

At many small premises, maintenance responsibilities are shared amongst the general staff. Workers in a machine shop may also do regular maintenance on the machines and pitch in for janitorial work. At large premises, there will be a maintenance department. Each can be satisfactory, and each presents challenges to the examiner. Staffing levels will vary from place to place, and the examiner will often rely on management testimony concerning overall staffing levels. However, the examiner needs to assure him or herself that there is adequate manpower to maintain the component under consideration. In any examination, testimony from the personnel specifically assigned to the component’s maintenance will be valuable. This is another area where the examiner may need input from a consultant.

Communication is another resource. At small premises, a few employees can respond quickly when a condition arises based on verbal communications. Larger premises may require radio or telephone communication systems to report a condition when it is discovered and to dispatch personnel to do the work.

The engineer must keep in mind that a maintenance evaluation of a particular building component is not an examination of the entire building. If the examiner fails to properly limit his investigation, he runs the risk of following many irrelevant paths at a cost of much time and effort. He also exposes himself to irrelevant information that clouds his judgment. This leaves the engineer open to charges of bias or “witch-hunting.”

In the example, the proprietor scheduled a minimum of two employees on each shift, one for general operations and one at the cash register. The retail space is not large and the operations employee were easily able to make half-hour inspection rounds. Furthermore, he observed the store while moving about and assisting customers and responded to instructions from the cash register station by a hand-held radio. Floor mats, warning signs, mops, and buckets were kept in the maintenance closet. Floor mats were serviced by an outside contractor every 2 months. Three mops and buckets were available—one for each employee and a spare.

Based on the site inspection and testimony from the various parties, the engineer concluded that the system was supported by sufficient resources to properly maintain the floor during wet weather. This results in a “yes” for resources.

However, during his examination the engineer discovered that one employee was sick the day of the incident, leaving only one person to man both the cash register station and cover general operations. There was no one else available to cover the shift. When the rain started he placed the mats and warning signs at the entrance. However, he was unable to make regular rounds of the store looking for water and spills on the floor. The water on the floor was brought to his attention when the patron fell.

Opinions and Conclusions

According to the flow chart, when there are two “yes” results at the And gate, the engineer can feel confident that the component is adequate and the maintenance system can keep it functioning properly under the expected operating conditions. Therefore, a Good System rating is in order.

The fact that a component has failed does not affect this rating; it is the system being evaluated and not a single event. Components and maintenance can fail, even in a good system, because all systems have limitations; they are subject to randomly occurring and unpredictable events.

In the floor accident example, the system recieved a Good rating. However, insight into the event under consideration was gained by analyzing the conditions at the time of the failure. A re-analysis using the staffing conditions on the day of the component failure resulted in a “no” (not adequate) classification for resources because staffing fell below management’s recommended levels, and proper inspections were not taking place because of the short-staffing condition. Under these conditions, the flow chart leads to an Inadequate System rating for that particular circumstance. The forensic engineer must clearly make the distinction between the system’s rating overall and its rating as operating at a particular time. This distinction can be important in a forensic forum.

The use of systems analysis, as presented here, offers the forensic engineer a methodology of evaluation that is both comprehensive and flexible. The example presented shows that the method has application to simple as well as complex systems. The engineer must remember that the analysis is only as good as the input data, the end result is the opinion of an engineer who may have to defend it, and this analysis and opinion are seldom the end of the questions to be answered.

References

A. M. Best Company, Inc. (2000). Best’s loss control manual (version 2006). Oldwick, NJ: Author.

Brauer, R. L. (1990). Safety and health for engineers. New York: VanNostrand Reinhold.

Health and Safety Executive Books. (1998). Managing health and safety—Five steps to success. United Kingdom: Author.

Secretary of the Air Force. (2004). Safety and health standards. Washington DC: U.S. Government Printing Office.

U.S. Army Corps of Engineers. (2003). Safety and health requirements manual. Washington DC: U.S. Government Printing Office.

U.S. Department of Labor. (1999). Keeping your workplace safe. Washington, DC: U.S. Government Printing Office.

Wausau Insurance Company. (1990). Hazard survey guide. Wausea, MN: Author.

About the Author

John A. D’Onofrio, MS, CE, PE, is a professional engineer in private practice with more than 30 years experience in the engineering design and forensic evaluation of buildings and premises. He holds a bachelor’s degree and a master’s degree in civil engineering from the New Jersey Institute of Technology. D’Onofrio is a licensed professional engineer in New York, New Jersey, and the Commonwealth of Pennsylvania and has been recognized as an expert in federal court and in the courts of all three states. He has taught at Rutgers University in New Brunswick, New Jersey, and at the Community College of Morris in Randolph, New Jersey. He has been a guest lecturer before the New Jersey Municipal Engineer’s Foundation and the New Jersey Society of Professional Land Surveyors.

This article published by Dr. O’Block

Strategies for Understanding and Assessing Suicide Risk in Psychotherapy

This 1-credit continuing education opportunity is co-sponsored by the American College of Forensic Examiners International (ACFEI) and the American Psychotherapy Association. ACFEI maintains responsibility for all continuing education accreditations. This article is approved by the following for 1 continuing education credit:

APA provides this continuing education credit for Diplomates.

The American College of Forensic Examiners International is an NBCC Approved Continuing Education Provider (ACEP) and may offer NBCC approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. Provider #5812.

The American College of Forensic Examiners International is approved by the American Psychological Association to sponsor continuing education for psychologists. ACFEI maintains responsibility for this program and its content.

The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualifications for 1 hour of continuing education credit for MFTs and/or LCSWs as required by the California Board of Behavioral Sciences.

This organization, American College of Forensic Examiners International Approval Number 1052, is approved as a provider for continuing education by the Association of Social Work Boards 400 South Ridge Parkway, Suite B, Culpeper, VA 22701. www.aswb.org. ASWB Approval Period: 9/13/2004 to 9/13/2007. Social workers should contact their regulatory board to determine course approval. Social workers will receive 1 continuing education clock hours in participating in this course.

Suicide is one of the few topics that almost uniformly triggers anxiety and apprehension in clinicians, both novice students and seasoned practitioners (Rudd, 2006). Moreover, the actual assessment and subsequent treatment plans for suicidal clients are perhaps the most challenging clinical endeavors mental health practitioners may face during their careers. Literature shows that this is often the case because one concrete outcome of negligence in this area is a client fatality and resultant liability for the clinician (Jobes, 2006; Jobes & Drozd, 2004; Packman, Marlitt, Bongar, & O’Connor-Pennuto, 2004; Peruzzi & Bongar, 1994). Perhaps this explains one reason why psychotherapists seem to focus on collecting data surrounding lethality and risk factors instead of exploring the narrative story of the suicidal client (Rogers & Soyka, 2004). As Schwartz and Rogers (2004) explain, psychotherapists should realize that although they will be unable to successfully prevent all instances of suicide due to the unpredictability of human nature, clinicians can lessen the number of completed suicides by being able to better identify at-risk populations and common themes of suicidality. However, clinicians should also remember not to omit a thorough exploration of the individual meanings of suicidality for a particular client.

Approximately 71% of psychotherapists report managing at least one client who has attempted suicide, with 28% reporting having had at least one client die by suicide (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001). For psychotherapists, the psychological impact of losing a client by suicide is similar to the stress and trauma that would be experienced in the death of a loved one (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988). Therefore, updated information surrounding suicide risk factors, myths, assessment strategies, treatment options, and additional resources are crucial when working with this particularly challenging population.

Information on Suicide Risk Factors

Suicide takes the lives of over 30,000 Americans every year according to the Centers for Disease Control and Prevention’s (CDC) Fatal Injury Report, making it the eighth leading cause of death for males and the 19th leading cause of death for females (Centers for Disease Control [CDC], 2006). Overall, in the United States, suicides outnumber homicides 3:2 and take the lives of twice as many persons as HIV/AIDS (CDC, 2006). Over the last century, researchers have tried to produce a set of “risk factors,” which, when identified, would label a client as someone who might take his or her own life (Maris, Berman, & Silverman, 2000). The underlying premise is that if there were a way to predict suicidal behavior, lives would be saved (Maris et al., 2000). Unfortunately, research has not yielded a specific flow chart that all clinicians can follow when working with a suicidal individual. In fact, according to research by Plutchik (1995), 41 factors correlate with the risk of completed suicide. Although no one person could either remember or assess all potential risk factors, below are some of the most common ones discussed in the literature.

First, suicide among young people between the ages of 15 and 24 ranks as the third leading cause of death (National Center for Health Statistics, 2002). This represents 7.9 deaths per 100,000 persons, with a male-to-female ratio of 3:1. Between the ages of 20–24, suicide claims the lives of 12 persons per 100,000, with a male-to-female ratio of 7:1 (National Institute of Mental Health, 2001). Within the last few decades, teen suicides have steadily been on the rise. In fact, in a study conducted of high school age students, as many as 15% have made at least one suicide attempt (King, 1997), with teen girls being particularly vulnerable (Lewinsohn, Rohde, Seeley, & Baldwin, 2001). Teens who suffer from depression and substance abuse are at a higher risk, and both of these factors are on the rise (Gould & Kramer, 2001). Perhaps teens are more at risk due to their lack of financial and social resources, lack of emotional self-control, poorer problem-solving capacity, and lack of mobility (Reynolds & Mazza, 1994).

Currently, the age group considered most at risk contains white males who are over the age of 65 (CDC, 2006). Suicide among the elderly represents 14.6 deaths per 100,000 persons, a highly at-risk age group that is often under-assessed by mental health professionals. Particularly distressing is that 75% of the elderly use a gun of some sort, leaving a significantly reduced margin for failed attempts (Frierson & Melikian, 2002). It has been speculated that at this age, the elderly are struggling with physical and mental depreciation, as well as with the loss of friends and family members, leading to a mild or moderate depression that they may never have experienced before. Therefore, their coping strategies may be inadequate (CDC, 2006; Maris et al., 2000).

Although age is considered one important risk factor to evaluate, gender also provides information regarding the plausibility of a client attempting and/or completing suicide. As stated above, suicide is the eighth leading cause of death for males and the 19th leading cause of death for females (CDC, 2006). Subsequently, there are four male-completed suicides for every one female-completed suicide, but there are three female-attempted suicides for every one male attempt (CDC, 2006). Simply stated, more men complete suicide, while more women attempt it.

In addition to age and gender, people suffering from a mental illness (e.g., DSM diagnosis) are another at-risk group, accounting for an estimated 95% of all completed suicides (Shea, 2002). One of the most reliable predictors of suicidality is current, severe, depressive symptoms. In fact, the risk of suicide in clients with Major Depressive Disorder is approximately 20 times that of the general population (American Association of Suicidality [AAS], 2005). Research shows that seven out of every 100 men and one out of every 100 women who have had clinical depression at some point in their lifetime will go on to complete suicide (AAS, 2005). Although depression is a primary risk factor, a diagnosis of schizophrenia, bipolar disorder, and severe borderline personality disorder are also considered to put an individual at risk for completing suicide (Maris et al., 2000; Schwartz & Rogers, 2004; Shea, 2002).

It is important to monitor clients with mental illness under a psychiatrist’s care, as well as those currently in psychotherapy. Between 50% to 67% of individuals completing suicide had seen a doctor less than one month prior, between 10%–40% saw a doctor in the week preceding death, and in over half of suicides via overdose, the prescription had been either written, or refilled a week prior to the overdose (U.S. Preventive Services Task Force, 1996). Therefore, clients taking psychotropic medications should be monitored closely. Also, clients who are actively engaging in substance use and abuse are more likely to complete suicide due to the exacerbation of other environmental problems, as well as lowered inhibition when making a suicide attempt (Maris et al., 2000; Westefeld et al., 2000). Moreover, clients who are dependent on substances often have a number of supplementary risk factors for suicide (i.e., depression, engagement in high risk/self-injurious behaviors, or financial problems), which should be assessed by psychotherapists (Jobes, 2006; Shea, 2002).

Clients who are coping with chronic illness or chronic pain may be unable to imagine the possibility of change or progress in their struggle and may look to suicide as a way of absolving themselves of being “stuck” (Reeves, Bowl, Wheeler, & Guthrie, 2004). Moreover, these clients may be psychologically overwhelmed to the point that they can no longer cope with their current suffering, nor find a means of relief from it (Jobes, 2006; Shneidman, 1993; Schwartz & Rogers, 2004). Finally, the three most critical at-risk factors for suicide assessment are the number and severity of previous attempts, a family history of suicide, and current suicidal ideation (Jobes, 2006; Maris et al., 2000; Peruzzi & Bongar, 1994; Rogers & Soyka, 2004). Consequently, research by Packman, Marlitt, Bongar, and O’Connor-Pennuto (2004) found that multiple attempters possessed a greater overall baseline risk, indicating that suicide attempts increase the overall vulnerability for future suicide completion. Moreover, a familial pattern of suicidal behavior is considered an amplifier of risk through genetic and temperament influences and possible behavioral modeling (Packman et al., 2004).

Myths About Suicide and the Psychotherapy Relationship

There are several myths surrounding suicide that may inadvertently influence a clinician’s ability to accurately assess a client’s lethality. Most importantly, individuals in general (and some clinicians, as well) often believe that discussing suicide may directly lead to increased suicide risk. As Schwartz and Singer (2005) point out, clients kill themselves because they decide to, not because it was discussed in a psychotherapy session. In fact, there are data suggesting that psychotherapists rarely explore with their clients past experiences with suicidal thoughts or attempts (Rogers & Soyka, 2004). This clinical pattern may serve the purpose of helping clinicians to “feel better” while unwittingly contaminating the suicide assessment process (Schwartz & Singer, 2005).

Other common misperceptions about suicide are that suicide is an “irrational” act, or that suicidal behaviors are always “impulsive” acts, that children and elderly may be at risk but do not actually complete suicide, and that people who commit suicide usually do not actively seek help beforehand (Peruzzi & Bongar, 1994; Schwartz & Rogers, 2004; Schwartz & Singer, 2005; Wingate, Joiner, Walker, Rudd, & Jobes, 2004). However, a review of 71 completed suicides showed that more than half of the victims communicated their suicidal ideation within 3 months before the fatal attempt (Isometas et al., 1994). A final myth that should be noted is that people whose suicide attempts have failed really were not seriously contemplating suicide. That is, these clients were only looking for sympathy or attention (Segal, 2000). Unfortunately, research has shown that 40% of all suicide victims (i.e., those who completed suicide) made previous attempts or threats, and as the number of attempts increases, so does the likelihood that a future attempt will be fatal (Goldstein, Black, Nasrallah, & Winokur, 1991). In fact, all of the myths described above have been disputed both by clinical reports, as well as empirical research findings. Even though these suicide-related myths abound in American popular culture, it is crucial that clinicians do not succumb to their damaging influence. For various reasons—discomfort with the suicide assessment process, fears of client vulnerability and suicidality, clinician countertransference (perhaps one’s friend or relative attempted or completed suicide)—psychotherapists are at risk of not hearing clients’ calls for help. Clinicians should be aware of the myths outlined above because by increasing their understanding of what is, and is not, linked to suicidality, psychotherapists can remain open and objective during the assessment process (Schwartz & Rogers, 2004).

It is vital that psychotherapists listen intently to what clients mean behind what they say, objectively and empathically, in order to fully engage clients in a thorough suicide assessment (Schwartz & Singer, 2005). Jobes (2006, p. 7) observes that given what we currently know about people who commit suicide, there are “three essential truisms” for clinicians to note:

1) Most suicidal people do not want to end to their biological existence; rather, they want an end to their psychological pain and suffering.

2) Most suicidal people tell others (including mental health professionals) that they are thinking about suicide as a compelling option for coping with their pain.

3) Most suicidal people have psychological problems, social problems, and poor methods for coping with pain—all things that mental health professionals are usually well trained to tackle.

Strategies for Suicide Assessment

Despite the fact that several useful surveys and questionnaires are available to help clinicians evaluate suicide risk, a face-to-face clinician/client interview is thought to be both preferential and necessary to the assessment process (Reeves, Bowl, Wheeler, & Guthrie, 2004). Whether this interview is done from a crisis intervention framework, a cognitive framework, an existential-constructionist framework, or a collaborative framework, a face-to-face thorough assessment remains the only valid method for determining risk (O’Connor, Warby, Raphael, and Vassallo, 2004). The psychotherapy relationship therefore becomes the pivotal pathway for clinicians to access clients’ lethality. In order to accomplish this task, it is the responsibility of the psychotherapist to maintain an awareness of current information on suicide risk assessment practices (Westfeld et al., 2000). In this regard, the crisis interview method utilizing Shea’s validity techniques (2002), the Collaborative Assessment and Management of Suicidality (CAMS) model (Jobes, 2006), and the Aeschi Group’s Guidelines for Clinicians will be examined below.

One of the first things a clinician must be willing to participate in is a self-inventory for the identification of biases regarding suicide as an act. This self-reflection can determine whether an intervention will be a success or a failure (Shea, 2002). Self-exploration is not a static awareness, but on ongoing process (Shea, 2002). Attitudes can range vastly from “suicide is wrong” to “suicide has intrinsic positive worth” (Shea, 2002). Suicide is a difficult topic for discussion, even for the experienced therapist. It is for this reason that the therapist should be aware and keep track of his or her values and ongoing emotional experiences. Counter-transference is one phenomenon the psychotherapist should be continually checking in with, as this can create a power struggle between client and therapist. For example, Maris, Berman, and Silverman posit that suicidal clients can actually be “help-rejecting” as well as engaging in a wide variety of “interpersonally alienating behaviors” (p. 513), which may create negative counter-transference.

There are many schools of thought on how to assess a suicidal individual. One such assessment is the crisis interview wherein the psychotherapist directly asks questions regarding suicidality (e.g., ideation, intent, plan, means of completion). During this process, a helpful hint is to use very specific and concrete wording such as “kill yourself” or “commit suicide” versus general “softer” words such as “stop the pain” (Shea, 2002). The client needs to know that the psychotherapist can handle their thoughts surrounding taking their own life, as many clients do not have anyone else with whom to discuss these confusing thoughts.

Shea (2002) offers several other points to keep in mind when assessing a client’s lethality. First, the slightest hesitancy in a client’s response may suggest that he or she has thought about suicidal ideation (even if they deny it). Next, answers such as “no, not really” when clients are questioned about suicidal ideation usually means there have been at least some suicidal thinking. Clinicians should also try to be as present with the client as possible to pick up on any non-verbal cues he or she may be sending. For this reason, it may be beneficial for clinicians not to take notes (or to do so sparingly) during the suicide assessment, so they may be 100% available to the client during the process. Clinicians should routinely check themselves during the interview, asking “What am I feeling right now?” and “Is there any part of me that doesn’t want to hear the truth right now?” These simple preparations can help guide the techniques the clinician will use when eliciting suicidal intent.

In The Practical Art of Suicide Assessment, Shea (2002) discusses six validity techniques that clinicians can utilize to explore sensitive material with a client. These can be used with a variety of sensitive topics, such as domestic violence, substance abuse, antisocial behavior, sexual abuse, and suicide. The first validity technique, the behavioral incident, is when the clinician asks about concrete behavioral facts. Questions like, “Exactly how many pills did you take?” provide the facts of the incident. The next technique is shame attenuation, which relates to the therapists’ ability to inquire about information without making the client feel shame or guilt. Instead of asking the client, “Do you have a bad temper and tend to pick fights?” the clinician could ask, “Do you find people tend to pick fights with you when you are out trying to have a good time?” Or, “Some people have told me that when they get angry they tend to pick fights, has that happened with you?”

The next technique is designed to help increase the chances the client will be open with sensitive information. Gentle assumption is a technique that proposes that the behavior is already happening. Instead of asking, “Do you drink?” The therapist can ask, “How much do you drink?” In the case of potential suicidality, if the client is severely depressed the clinician may ask, “During the past two weeks how difficult has it been to not think about taking your own life?” This technique helps clients bypass the psychological hurdle of admitting to problem behaviors in the first place.

The technique symptom amplification uses the client’s natural tendency to minimize or downplay quantitative information about problem behaviors. By setting the upper limits of the quantity higher than average during questioning, the client has “room to move” while being more truthful about the actual number. For example, rather than asking, “Have you had thoughts of suicide during the past week?” the therapist could ask, “How many times has the thought of suicide entered your mind during the past week, fifteen or twenty?” This allows the client to ease his or her natural defense mechanisms and avoid confrontation. The question may be particularly effective after a gentle assumption (see above) has already exposed suicidality.

The technique denial of the specific involves asking the client specific questions versus generic or global questions. The rationale is that it is easier to deny a generic question than a specific one. If trying to assess the use of drugs a clinician might ask, “Have you ever tried cocaine?” or, “Have you ever smoked crack?” or, “Have you ever used crystal meth?” or, “Have you ever dropped acid?” rather than, “Do you use illegal drugs?” Regarding suicidality, when assessing a plan after suicidal ideation and/or intent has been revealed, the clinician may ask, “Have you thought about overdosing on your medication?” and, “Have you thought about taking your life by hanging?” and, “Have you considered using a gun to take your life?”

The last validity technique Shea (2002) offers is normalization. By normalizing their problem behavior, the client may not feel as embarrassed or anxious when discussing it. For example, regarding depressive symptoms, the therapist may ask, “Sometimes when people are depressed they will have a decrease in their sex drive . . . has this happened to you?” When assessing suicidality, a therapist might ask, “Many times when people are sad and ‘in the dumps’ as you have described yourself, they say the thought of wanting to die comes into their minds . . . has this thought surfaced for you?” Letting people know they aren’t the only ones to experience the behavior allows them to feel less anxious about it and free to share it with the interviewer.

When completing an assessment of a potentially suicidal client, the clinician must be aware of the most important information needed from the client: mainly, the client’s current level of suicidal ideation, suicidal intentions, whether a plan for action has been considered, and what access the client has for the means of completion (O’Connor et al., 2004; Packman et al., 2004; Schwartz & Rogers, 2004; Shea, 2002; Wingate et al., 2004). As the amount of information from these four areas increases, so does the probability that the client may be truly at risk. For example, if suicidal ideation is present, the clinician should evaluate how often these thoughts are occurring, how long the thoughts have been present, whether or not the thoughts have become more intense over time, and how difficult is it for the client to keep from acting upon these thoughts (Schwartz & Rogers, 2004). Another clinically important area would be to determine whether or not the client has a specific plan to harm him or herself. If a plan exists, the clinician would need to determine how well developed the plan is and whether the client has the means accessible to complete the plan. Not only will this exploration of ideation help to determine the lethality of the client, but it will also provide direct suggestions for setting up a safety plan.

Lethality is a function not only of risk factors, but also of whether or not protective factors are present (Maris et al., 2000). Below are some general guidelines provided by Schwartz and Rogers (2004) that may be helpful in determining the lethality of a client who acknowledges suicidal ideation:

* Low lethality—suicidal ideation is present but intent is denied, client does not have a concrete plan, and has never attempted suicide in the past.
* Moderate lethality—more than one general risk factor for suicide is present, suicidal ideation and intent are present but a clear plan is denied, and the client is motivated to improve his/her psychological state if possible.
* High lethality—several general risk factors for suicide are present, client has verbalized suicidal ideation and intent, has a coherent plan to harm him or herself, and reports access to resources needed to complete the plan.
* Very high lethality—client verbalizes suicidal ideation and intent, he or she has communicated a well thought out plan with immediate access to resources needed to complete the plan, demonstrates cognitive rigidity and hopelessness for the future, denies any available social support, and has made previous suicide attempts in the past.

Although suicide involves a complex range of behaviors, thoughts, and affective states, the evaluation of concrete suicide markers (i.e., ideation, intent, planning, and means) may increase a clinician’s success in predicting a client’s overall lethality (Schwartz & Rogers, 2004; Shea, 2002). However, as O’Connor et al. (2004) state, it is important to realize that “every clinician lives with the knowledge that even with our best efforts and exemplary care, there will still be some suicide deaths” (p. 359).

Another assessment approach that has been gaining popularity is an inclusive or “team-building” approach called the Collaborative Assessment and Management of Suicidality (CAMS), created from the research of David Jobes and associates. The main focus and uniqueness of this assessment model is that it targets the client’s subjective suicidality as the central clinical problem, independent of objective diagnosis (Jobes, 2006). In addition, by utilizing the Suicide Status Form (SSF), both the clinician and client develop a shared understanding of the client’s suicidality by rating the client’s current psychological pain, press (stress), perturbation (agitation), hopelessness, and poor self-regard (self-hate) (Jobes, 2006; Jobes & Drozd, 2004). With the CAMS model, even the traditional face-to-face seating is changed once suicide is mentioned. The clinician asks for permission to sit side-by-side the client while filling out the SSF in order to facilitate a more collaborative feeling (Jobes, 2006; Jobes & Drozd, 2004).

In addition to ranking risk-related characteristics, the CAMS model also helps the client to identify reasons for living as well as reasons for dying. In doing this, the clinician receives a glimpse at some of the protective factors that have kept the client from taking his or her life up to this point. As Jobes & Drozd (2004) profess, it is our job as clinicians to help suicidal individuals find alternative ways of coping with the unbearable pain and stress in their lives in order to alleviate suicide as a viable option. Finding a common ground and being able to agree on mutual goals increases collaboration immensely (Ellis, 2004).

The CAMS model incorporates its own documentation throughout each of the stages. In this model, the SSF has 4 sections:

Section A: This initial section is completed collaboratively in order to extract a true understanding of the meaning the world has for the client currently.

Section B: This section is completed by the clinician who asks specific questions regarding plan, preparation, rehearsal, history of suicidality, and so on.

Section C: This section is completed collaboratively and explicitly states what the outpatient treatment plan will be.

Section D: This section is completed by the clinician post-session and includes a mental status exam, preliminary diagnosis, and the client’s overall suicide risk level. Also, this section provides a place for the clinicians to jot down any additional information not otherwise covered in sections A-D.

There is a place at the bottom of each section for the client and clinician’s signature and date. This aspect of the model also reinforces collaboration during the assessment process, because the information collected is reviewed and agreed to by both clinician and client. This same process would be completed each session until there were three consecutive sessions without suicidal ideations (Jobes, 2006). As Jobes (2006) states, “I truly believe that through collaboration all things are possible, not the least of which is coaxing a life to be meaningfully lived back from the jaws of suicidal death” (p. 137)

By Michelle E. Toth, MA; Robert C. Schwartz, PhD; and Sandy T. Kurka, MA

When Women Kill Together

When Women Kill Together

By Katherine Ramsland, PhD, CMI-V

Traditional ideas about female serial killers hold that such offenders are motivated primarily by gain, are less violent than males, are largely reactive rather than initiating, and are not sexually compulsive in their bid to kill. But there are exceptions to every rule, particularly when it comes to stereotypes about serial killers. Some women who repeatedly kill have certainly been predatory and brutal. A few have even been sexually compulsive. There’s no reason to believe that females are immune to an erotic rush from the act of murder, and we’ll examine several cases to illustrate this. Not surprisingly, many turn up in the healthcare industry.

Jane Toppan, a nurse at the end of the nineteenth century, experimented on patients with a mixture of drugs that killed slowly. As they gradually lost consciousness, she would climb into bed to cradle them while they slipped into oblivion. (Schechter 2003). After she went to work for a family, its members began to die, one by one, with gentle Jane by their side. Finally, someone grew suspicious and examined these deaths more closely, leading to Toppan’s arrest. During her examination and trial, Toppan admitted to being aroused by death, which places her squarely in the category of a lust killer. In fact, she said that her sole regret was that she had been stopped so soon, and had she married and had a family, she was certain she would have killed them all as well.

There has been little to no research on female lust killers, in part because it’s an unexpected phenomenon and in part because the cases are rare. However, similar to male lust murder, the female counterpart is often driven by a paraphilia, such as arousal upon viewing a corpse or when rubbing inappropriately against someone. Often, there’s something deviant in their sexual development that consistently triggers arousal and thus feeds a compulsion.

Erotic motivation is even more prevalent among women who kill in partnerships with other women (although this behavior does not show up in all cases). There aren’t many documented examples, but those we have identified involved at least one person with a scheming mind, a degree of psychopathy, and the capacity for getting a thrill from deciding that others should die. In our first case involving two women, it’s not altogether clear who was actually the dominant partner, but violence apparently gave them both a sexual rush.

Catherine May Wood was described by her former husband, Ken Wood, as flighty, overly sensitive, moody, and unpredictable (Cauffiel 1992). She would start something and even pursue it for months, but would then drop it to do something else. He said that he could never count on her to commit and believed that she had never known unconditional love. As a result, he thought, she was both needy and insecure. She surprised him once by admitting that she wondered what it would be like to stab someone. She also felt no maternal affection for their daughter. Bothered by her excessive weight, she nevertheless continued to eat junk food.

The Woods separated in 1986, but not before Ken caught a glimpse of the kinds of friends Cathy was keeping at the nursing home where she worked as a supervisor —the Alpine Manor in Walker, Michigan. Apparently, a clique of lesbians employed there had become party friends, Cathy among them. Her sense of morality, already tenuous, seemed to Ken to have taken a back seat completely.

Cathy told Ken that she was in love with an aide, Gwendolyn Gail Graham, but that some of the things they did together frightened her. Graham had arrived from Texas, and this 22-year-old motorcycle rider had a tough side. Cauffiel (1992) states that people viewed her as masculine. She had been seriously injured several times and she often displayed the scars on her arms, sometimes lying about how she got them. She apparently had severe reactions to what she perceived as abandonment, which included the type of self-mutilation common to people with borderline personality disorder. Several of Graham’s coworkers liked her, but she took up with Cathy and they became lovers. Then they became killing partners.

Alpine Manor, with more than 200 beds, averaged about 40 deaths a year, and thus, six unnatural deaths, especially of “total care” patients who required the most attention, did not stand out. One victim had gangrene, another had Alzheimer’s, and all of them had been expected to die there at some point. It was an easy situation to exploit, especially with 70 staff members covering all the shifts.

According to Wood, whose tale became the primary legal record, it was Graham who first broached the subject of murder. At first Wood claimed she was just a witness, but later admitted to participating. Under interrogation and later at trial, Wood described how they had practiced sexual asphyxia to achieve greater orgasms, so she thought Graham was kidding when she suggested killing a patient. Yet the linked pain and pleasure of their sexual games had become threaded with images of cruelty against others. Just talking about murder, she said, got them both sexually excited. Finally, they decided to do it.

They started killing patients in January 1987 and continued for three months, initially attempting to select victims whose names would be part of a spelling game. The idea occurred while working on a crossword puzzle. They knew that the Alpine Manor recorded the names of patients who had died or were discharged in a book. Just for fun, they wanted to make the first initial of six names in a row, when read down, spell MURDER.

However, it proved too complicated to select the right patients in a way that minimized risk and also spelled the word, so they just selected patients that seemed easy to kill without discovery. Their new motive, said Wood, was to share this secret so they would be bonded “forever.” With each killing, they added one more day to that time period, so that after the third murder they might sign a love letter, “forever and three days.” Wood said she agreed to be an accomplice because she feared losing Graham, who apparently killed to relieve personal tension.

Acting as sentry, Wood watched as Graham attempted to smother elderly women, but some struggled so hard she had to back off. Oddly enough, none registered a complaint, and in fact most of the patients liked these two women. In many respects, they appeared to be good at this job, patient and compassionate.

The first victim to actually die was a woman suffering from Alzheimer’s disease whom both knew would be unable to fight. Her last name began with an “M.” Placing a washcloth over the woman’s nose and mouth, Graham smothered her to death. In the weeks that followed, Graham moved on to another, and then another, leaving a washcloth in the room as her “calling card.” After she failed at killing one of the male patients, they stuck to females, especially those who proved difficult to care for. In one version of the story, they had targeted at least 20 different people, including other aides.

To relive the crimes, Graham took items off the victims, such as jewelry, personal keepsakes, and socks. She and Wood placed these souvenirs at home on a special shelf. In a morbid postscript, they sometimes washed down the bodies as part of the postmortem routine, and handling their deceased victims further excited them.

Then they grew bolder. They told colleagues what they were doing, because the confessions added to their heightened sexual drive, but their accounts were dismissed as sick jokes. No one could believe that a person who entered healthcare would actively kill a patient, let alone become an outright predator. Wood, in particular, was known to lie and play mind games, so few associates took her seriously. Even her shelf of souvenirs impressed no one.

Graham then pressured Wood to take a more active role: she would have to kill one of the patients herself. Wood wasn’t ready for this, or so she later claimed. This angered Graham, who took up with another woman and returned to Texas. From there, she wrote disturbing letters about wanting to smash the faces of babies in her care at another facility. Wood swore her ex-husband to secrecy and confessed everything, admitting they had killed patients because it was fun. Despite his promise to her, Ken felt endangered just by knowing about their activities, so he notified a therapist, and a year later, the police. Wood attempted to deflect their investigation but quickly caved and blamed Graham. (There is some speculation that she set Graham up with this confession to punish her for leaving.)

After an investigation that involved two exhumations (which offered no physical evidence), both women were arrested. Wood turned state’s witness against her former lover for a sentence of 20 to 40 years, with the possibility of parole. Graham, too, testified, but the most telling witness was Graham’s current lover, who admitted that Graham had confessed six murders to her. Others testified in a similar vein.

On September 20, 1989, the jury deliberated for only 6 hours before they rendered a verdict: Graham was convicted of five counts of first-degree murder and one count of conspiracy to commit murder. She drew six life sentences, with no possibility of parole. In media accounts, Wood’s role was downplayed to “occasional lookout,” and the case remains controversial today over whether there were more murders, as well as whether there were any murders at all. There is some speculation, especially after a psychological evaluation of Graham, that even if Graham did the killing, Wood had been the mastermind.

In studies of team killers, researchers have found that many couples, no matter what gender, follow a common pattern: Two people meet, feel a strong attraction, and establish an intimate familiarity that allows them to share fantasies—even violent ones. When eroticized, this approval encourages acting out, and if the partners succeed in committing a violent crime without getting caught, they grow bolder. The dominant person is generally charismatic and maintains psychological control—his or her erotic preferences set the tone.

In the case of Graham and Wood, regardless of who actually performed the murders, their fantasies and activities enhanced their sadomasochistic sex. Thus, until they broke up, the “game” became an essential aspect of their pleasure and a way for each to manipulate the other. They egged each other on, but they also exploited the fear of discovery to threaten each other. The fact that killing elderly women also gave them an outlet for issues they both had with their mothers added yet another level of motivation. All in all, murder was both fun and satisfying.

When lust is not the propellant, but females nevertheless kill for camaraderie, there still appears to be an element of thrill with erotic manifestations. They don’t kill specifically for a sexual thrill, but their pact and the actions that sustain it provide the stimulation. We see this phenomenon in a series of murders in Vienna, Austria.

It was again a nurse’s aide who initiated the 6-year spree at Lainz General Hospital. Most of the victims were elderly, many terminally ill. The killing began in 1983, and by the time officials began to investigate, the death toll stood at 49 (Protzman 1989). Reports of the trial turned up in the New York Times.

Waltraud Wagner, 23, had a 77-year-old patient who one day asked for help to end her suffering. Many nurses in elder care units or facilities face such requests. Wagner hesitatingly obliged, overdosing the ailing woman with morphine. Once she accomplished this without being caught, she apparently felt a surge of energy. She soon recruited accomplices from the night shift to engage in this “mercy-killing.” Maria Gruber, 19, and a nursing school dropout, was happy to join. So was Ilene Leidolf, 21. The third recruit was a grandmother, 43-year-old Stephanija Mayer. While the initial idea was to do something beneficial, they soon found pleasure in killing patients who got on their nerves. Many were not even deathly ill; they were just annoying.

Wagner showed the others how to give lethal injections with insulin and tranquilizers, and added a mechanism of her own creation: the “water cure.” This brutal method involved holding a patient’s nose while forcing him or her to drink water, which then filled the lungs and caused an agonizing death. Yet it was virtually undiscoverable as murder, because many elderly patients already had a certain amount of fluid in their lungs.

At first, the nurses killed sporadically, but by 1987 they had escalated and rumors spread that there was a killer on Pavilion 5. Allegedly, Wagner may have killed as many as 75—her own estimate before she withdrew parts of her confession. She then said she had only killed nine, although one of her accomplices placed her victim toll closer to 200.

As they grew bold, the nurses also grew careless. Over drinks one day, they relived one of their latest cases. A doctor overheard them, and he went to the police, who launched an investigation. It took 6 weeks, but all four women were arrested on April 7, 1989. The doctor in charge of their ward, who had been alerted to the killings a year earlier, was suspended.

While Wagner and the others insisted on selfless motives, the jury did not agree. Ultimately, Wagner was convicted of 15 murders, 17 attempted murders, and two counts of assault. She received life in prison. Leidolf, too, got life for five murders, while the other two drew 15 years for manslaughter and several attempted murder charges. This set of relatively light sentences may indicate how difficult it is for society to accept the idea of a predatory female killer—let alone four working together.

Researcher Carol Anne Davis (2001), who wrote about Graham and Wood, states that many female killers do plan their crimes, feeling empowered when they get away with them. Alone, they might be “bad news” in other ways, but engaging a partner willing to go the distance can provide a catalyst for repeat murder. Dominant women intent on violence, she says, tend to be sexually-driven, narcissistic, secretive, and manipulative. Often victimized in some manner during their lives, they turn this around by victimizing others. Having an approving or submissive partner energizes them, perhaps even making them feel invincible. Once caught, they attempt to manipulate the system, still believing in their own power. Sometimes they even succeed, thanks in part to the misperception of violent females fostered by erroneous stereotypes. As more cases emerge, we’ll learn more about this type of crime, and formal studies of female killing teams is clearly in order.

References

Associated Press. (1989, November 3). Ex-nursing home aide gets life term in five patient killings [Electronic Version]. The New York Times.

Cauffiel, L. (1992). Forever and five days. New York: Zebra Books.

Davis, C. (2001) Women who kill. London: Allison & Busby.

Yeomen, B. (1999). Bad girls. Psychology Today, 32(6).

Protzman, F. (1989, April 18). Killing of 49 patients by 4 nurse’s aids stuns the Austrians [Electronic version]. The New York Times.

Schechter, H. (2003). Fatal: The poisonous life of a female serial killer. New York: Pocket Books.

Women killed to assure love, one testifies,” (1989, September 14). Detroit Free Press.

About the Author

Katherine Ramsland, PhD, CMI-V, has published 25 books including The Human Predator: A historical Chronicle of Serial Murder and Forensic Investigation. Dr. Ramsland is an assistant professor of forensic psychology at DeSales University in Pennsylvania. She is a Certified Medical Investigator (CMI-V) and has been a member of the American College of Forensic Examiners since 1999.