Mentally Retarded But Comptetent To Stand Trial

The intersection of law and medicine can be a real sticky wicket.

Most people have heard of someone being “not guilty by reason of insanity” and most people know that some defendants might be found incompetent to stand trial.

But the processes are sometimes vague and often confusing – especially to the lay audience.

In a recent case a woman was previously found guilty of starving someone to death.  Now they are going to try her for imprisoning some folks in her basement and stealing their government checks.

She is not a nice lady, but she has done some things that take at least a little organization and planning.

Finding people competent or incompetent is one of the few “powers” psychiatrists still have.  It is not as simple as most folks think it will be.

There is no such thing as “globally incompetent,” except in bad jokes.  Every single task a human can do they can be either competent or incompetent for.

Most people would agree I am a globally incompetent auto mechanic.  If I were crazy enough to let someone pay me money to fix their car, I would be surely found incompetent to do so by any court of law, and guilty of fraud.

The duty of the psychiatrist who would determine competency would be to see that somebody administered to me some kind of a test customarily given to auto mechanics, and to calculate my score, which would doubtless be in the “clueless” range.

The kind of competency I have been most often asked to determine in my professional life is competency to handle money.  I developed my own mental “test” for that several years ago — a little math with two figures to the right of the decimal point, a little discussion of what information usually goes on a check, and the ability t0 produce that information on a piece of paper.  I go even a little deeper, delving into real world budgeting; queries about what things cost, how large a check one receives from (usually) some government agency, how much food and utilities cost.  Usually it is possible to specify that someone be monitored for a certain period of time before that someone is left to their own devices. Mild mental retardation is generally regarded as the condition of someone with an IQ of 50 to 69.  It is possible to meet them and not notice that a condition of retardation could exist.

I have helped lots of people with this designation, in other incarnations, get jobs as greeters at WalMart, so chances are most folks have met at least one. (This also explains why greeters from people at Wal-Mart may not be giving very helpful directions regarding the store.)

The criteria for competency to stand trial have been pretty well determined by usage and precedent, so the job of the forensic psychiatrist who specializes in this sort of thing is pretty well cut out.  The judge or attorney does have to specify to the psychiatrist what he or she has to make sure that the client can understand.

“Competency to proceed generally means an ability to understand the charges and ability to participate in one’s own defense; there are a lot of structured scales – standardized tests accepted in most jurisdictions — but the judge usually has the right to make determinations without them, and it seems to me every defendant has the right to be evaluated on a case by case basis.

Although I am obviously in no way directly involved with the case described, I do wonder what it is that makes her get involved with this sort of activity. Certainly, having a low IQ does not make someone do horrible things to other people.

With the previous conviction this defendant has, I wonder if there is not something in her character that makes her tend to want to subjugate others for her own advancement.

Character orders (now formally known as personality disorders) are one of the things we psychiatrists note in an evaluation.  We have five different categories (which are called axes) –with Axis I being a major mental illness (such as schizophrenia or bipolar disorder) and Axis II looking for a personality disorder.

The Axis II diagnosis usually results from some type of mistreatment, deprivation or other unfortunate circumstances during formative years.

The very idea of personality disorders is not universally accepted, and the diagnosis is admittedly subjective.

The “tough-on-crime” advocates don’t think you should excuse somebody for a major crime just because his daddy spanked him or his momma didn’t hug him enough.

Of course, that’s a gross over-simplification, but typical of the hot-button-pushing that goes on when we get into these types of complicated situations.

Some Axis II diagnoses are relatively benign – such as dependent or avoidant personalities.  But some are potentially dangerous – such as antisocial behavior.

The “bible” of psychiatric diagnosis, Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR (fourth edition, text revision) published by the American Psychiatric Association, agrees on the criteria for diagnosing each mental illness on each Axis.  There are some variations over time as clinicians have more experience with the behaviors described.  For example, DSM-III listed “Sadistic personality disorder” as a proposed diagnostic category needing further study, but is not listed in DSM-IV-TR.

The lady held in the so-called “basement captivity” case was determined to be mildly mentally retarded.  So far, I haven’t seen any official word of her personality disorders, but given the charges as well as her previous experience – conviction for starving her sister’s boyfriend to death about 20 years ago and serving a sentence – it would come as no surprise.

It’s now up to the legal system – not the medical establishment – to make sure she does not harm anyone again.