• deaf
• hearing-impaired
• incompetent to stand trial

Editor:

I appreciated the recent article by Kuntz et al.¹ For more than a decade, I worked at Springfield Hospital Center, a state hospital in Maryland, which, pursuant to a consent decree in the 1980s, operated an inpatient unit for patients, both civil and forensic, who are deaf and hard-of-hearing. I was involved in the forensic evaluation and management of at least a dozen patients on this unit. I concur with Dr. Kuntz and her colleagues regarding the complexities of working with such patients, but I wanted to emphasize the following two points.

First, people born deaf or who become deaf during the preverbal stages of life and who are not exposed to sign and to other forms of communication before age three never develop fully realized language skills. Because of this lack, these people do not have the ability to think symbolically or abstractly, rendering many of them permanently unable to engage meaningfully with the legal system. Thus, when working with such people, it is important to gather a complete developmental history, with special focus on how they became deaf and what exposure they had to sign language during the first three years of life.

Second, I saw several criminal defendants who were, indeed, incompetent but who had no mental illness. Our systems are not generally equipped to manage such people. The criminal codes assume that incompetence to stand trial can only be caused by mental disorders or by intellectual or cognitive disorders, but these defendants had none of these. Rather, they had never developed the comprehensive language skills that they needed to understand the legal system and to manage their defense.

Here are two illustrative examples.

A young woman was arrested for solicitation of prostitution. She was unresponsive in her bail review and her subsequent competency evaluation. She was then committed to our hospital, where we discovered that she was deaf. Eventually, we learned that she was from another country, that she had family in the community where she had been arrested, and that she was profoundly hearing impaired from a very young age. Her family had no idea where she had gone and were very concerned about her disappearance. During her months-long hospitalization, she did not demonstrate any evidence of any mental disorder. Her family reported that she was walking from one family member’s home to another at the time of her arrest. Her charges were dropped.

A middle-aged man whose deafness was caused by congenital rubella was arrested for cocaine possession. He lived with his mother in an impoverished, socioeconomically deprived community and had never gone to school. He was limited to a few very simple signs, as well as “home sign” (idiosyncratic sign language created by a deaf person who is not exposed to language early in life). He was committed as incompetent to stand trial and remained hospitalized for many months, despite having no mental illness.

These and other cases indicate the complexity that deafness interposes in forensic mental health and spotlight some of the blind spots in our forensic and general mental health systems.

• © 2023 American Academy of Psychiatry and the Law