The charge was stealing a tow truck. The defendant was a baby-faced 27-year-old in shorts and a Chicago Bulls jersey. His hair was slightly matted, wrists cuffed in front, hands clutching a brown paper bag, demeanor slackened by anti-psychotic medications.

“Why don’t we take testimony?” began Judge Patrice Lewis, inviting a psychologist to the witness chair.

The man was still hearing voices, but they were not telling him what to do, she testified. He denied having delusional thoughts. He knew what day it was and that he was standing in a courtroom.

Now Lewis had a decision to make, the kind that made her pray she was right and worry she was wrong and which she made a dozen times each day: not whether the man was guilty or innocent, but whether he was stable enough to be released from the psychiatric hospital in suburban Maryland where he had been confined since his arrest.

With the support of medication, counselors, a case worker and a judge’s monitoring, could he be trusted to deal with his own mental health? And at a moment of public concern about the link between mental illness and violence, there was another consideration: Was he dangerous?

It was a Tuesday in mental health court in Upper Marlboro, Maryland, one of a growing number of such courts being established across the nation to address the fact of a criminal justice system swollen with the mentally ill. More than half of all inmates in U.S. jails and prisons — more than 1.2 million people — reported symptoms of mental illness, according to a 2006 federal study, the most recent national data available. That number had quadrupled since a similar federal study in 1998, and some state and local studies suggest that the number has continued to rise in more recent years.

State and local court systems are adjusting to this reality, with about 300 jurisdictions setting up specialized dockets for judges who use the power of the legal system to impose mental health treatment on some of society’s most troubled citizens. They are people charged with assault, theft, arson, trespassing, harassment, stalking and other crimes short of homicide. They are also people whose mental illness is often part of a tapestry of problems that might include drug addiction or other complications that increase their risk of violence.

The courts operate in different ways from state to state. The one in Upper Marlboro — the seat of Prince George’s County, Maryland, just outside Washington, D.C. — handles only misdemeanor cases. Defendants must agree to participate, and after that, the judge can make mental health treatment a condition of their pretrial release or probation. The goal is to restore healthier, more stable people back to a community that is ultimately safer for the time, tax dollars and energy spent.

The reality, however, is that challenges are inherent in trying to impose the order of the judicial system on the most disordered of minds — in asking someone with a serious mental illness to deal with court dates, therapy appointments, medication and other logistics of a decentralized and often inadequate mental health care system.

As Lewis said one day in her chambers after a particularly difficult session: “Sometimes I don’t know who can solve all of these problems. Maybe no one can.”

Unusual case load

On any given day, the cases might be as benign as that of a 57-year-old woman who shoplifted or as alarming as that of a 28-year-old man who had an arsenal of semiautomatic rifles, allegedly called himself “the Joker” and threatened to “blow everybody up” at his workplace.

Most days, whatever they might bring, begin the same. The judge puts on her freshly creased robe, walks to the courtroom entrance, and, as she did one recent morning, presses her fingertips together in a meditative pose.

“I’m getting centered,” she said, looking through an open door as defendants began filling in the wooden benches of the courtroom: a woman with fading pink hair; an older man quietly talking to himself; a younger man who had been told to dress up and now wore a black bow tie and tuxedo vest.

Others would arrive in handcuffs from jail or from the psychiatric hospital through a fortified door: a woman with imaginary bruises, a man who sometimes gave as his address the woods behind Tick Tock Liquors.

“All rise!” said a guard, and Lewis called the first case, a man charged with trespassing who had been diagnosed with a mood disorder.

“I’m right here, Judge Lewis!” he yelled from the back, bounding toward the front.

“And how are you?” Lewis said in the tone of a patient parent.

“I’m blessed, Judge Lewis. I am blessed,” he said, almost breathless.

“You’re taking your meds?” she asked, referring to his mood-leveling prescriptions.

“I sure am, Judge Lewis. I can’t complain. I came by earlier but there was no access to the court yet, so I walked around and I was looking for you and —”

“Madam State?” Lewis said to the prosecutor, cutting off what she recognized as the start of a rambling speech.

This was how Lewis spent most of her time: checking up on defendants and deciding whether they would be all right until the next court date. If a defendant was uncooperative or deteriorating, Lewis could send him to jail or possibly order a psychiatric commitment.

This first case, though, was an example of how well things could work.

The man had been attending therapy regularly. He had been calling his case worker and taking his medication. Now the prosecutor offered to essentially drop the charges.

“Congratulations,” Lewis said to him. “. . . If this court had a graduation, this would be it. . . . OK, who do we have next?”

The woman with the fading pink hair stepped forward.

“Now, you’re working with People Encouraging People?” Lewis asked her, referring to one of the many mental health programs to which defendants are sent.

“Yes, your honor, I’ve been following the program and I am looking for a job and I —”

“Well, why don’t we not look for a job? Why don’t we focus on the things we have to do right now?” Lewis said slowly, noting that the woman, who had been charged with assault, had not been calling her case worker, which was often a first sign of things spiraling out of control.

“There were so many people in my house, Judge Lewis, and they moved things around. They moved my phone around, and I couldn’t find it, and then . . .”

“OK,” the judge said after a while, reminding the woman to return to court in two weeks. “Who else is here?”

The older man who had been talking to himself stepped forward.

He had a decent report from his case worker, though the prosecutor noted that he had been making false police reports.

“Now,” Lewis said gently. “I need for you not to report things that are, well, not happening. So, you’re going to behave yourself, right?”

“I promise,” the man said.

Growth of mental health courts

The idea of mental health courts grew out of the “problem solving” court movement of the late 1980s, which aimed to address the underlying causes of criminal behavior. Courts dealing with drug addiction were the first example, and over time the approach extended to the realm of mental health.

The first widely recognized mental health court was started in Broward County, Florida, in 1997, prompted in part by a series of suicides in local jails, and now most states have at least one such court. Lewis saw the need while working as a criminal court judge, with many defendants cycling in and out of her courtroom appearing to be mentally ill. She volunteered to start the mental health court in Upper Marlboro in 2008.

Studies on the effectiveness of mental health courts are still emerging, but Lewis said that former defendants often show up in court just to tell her how well they’re doing. She told the story of a man who barricaded himself alone in his house, prompting a neighbor to call the police, who surrounded the house with guns drawn until the man managed to tell them that he was “one of Judge Lewis’ people,” the meaning of which police have come to understand. Almost every court session, a defendant shows some small sign of improvement, such as wearing a tie.

But most people show how difficult solving serious mental health problems can be, along with all the absurd, sad and complicated situations that can arise.

There was the case of the elderly man who sometimes lived behind the Tick Tock liquor store in Langley Park, Maryland, who had come through Lewis’ courtroom so many times that she wondered whether he might be trying to come back deliberately.

“What is going on?” she said to the man after he had been charged with shoplifting a utility knife, a screwdriver, a Snicker’s bar and two pairs of reading glasses from Target.

“Maybe I like court too much,” he said.

“Maybe,” Lewis said.

There was the case of the 24-year-old who shuffled into the courtroom, his shackles clanking in the quiet. He had been charged with assaulting his parents, who sat on a bench just behind their son.

“How are you doing?” Lewis asked in a calm, deliberate tone.

“Um, I’m doing OK — um, um, um, I don’t see my parents?” the man said, looking around frantically until he saw them, and they nodded.

“Your honor,” said his attorney, “the last time he was able to go home with his parents. This time that is not an option.”

Lewis decided she could not release the man until he had secured a bed in a residential rehabilitation program, which was for the most serious cases short of psychiatric commitment. But it was a solution that raised two more problems: The man was refusing to fill out the housing application, and, even if he did, the waiting lists stretched for months.

“Um, I would like to live with my family?” the man said when Lewis asked him to complete the application. His mother turned away.

“That’s not an option,” Lewis said. “It’s not an option.”

There was the 33-year-old man who had accumulated more than 100 charges in 45 cases stretching back to his 18th birthday, the most recent including theft, assault and resisting arrest. Lewis had seen him on days when he seemed bright and capable, but on this day he arrived in an orange prison uniform, his manner lethargic. He groaned.

“Dr. Katz, you’ve opined that he’s not competent?” Lewis asked the psychiatrist who had evaluated him.

“Yes,” the psychiatrist said. “I’ve opined he’s dangerous, too.”

So Lewis recommitted him to the psychiatric hospital, hoping that he could be restored to competency so that he might be released into another mental health program that might work this time.

“I know you are doing your best,” Lewis said as he was led out.

“I don’t know what I’m going to do with him,” she said in her chambers later.

“Good afternoon,” she said to another man in another orange uniform, this one making his first appearance in court. His hair was messy. He stood quietly, his chin up.

“How old are you?” Lewis asked.

“Twenty,” he said.

“And do you have family?” she asked.

“Lan Ham,” he said.

Lewis figured he was mispronouncing Lanham, a community in Prince George’s County.

“I didn’t ask where,” she said slowly. “I was asking who.”

“Basically, uh, basically, uh, um, what do you mean?” the man said, starting to mumble unintelligibly and falling apart from there.

“OK,” Lewis said. “We’re going to order a competency evaluation.”

“Thank you, lovely ladies!” the man yelled as a guard led him out.

Falling through the cracks

Once a month, Lewis convenes sprawling meetings with mental health agencies, social workers, program managers, psychiatric hospital officials, attorneys — anyone who has a hand in dealing with the mentally ill. She worries about troubled people falling through holes in a decentralized system.

She thinks about Seung Hui Cho, who had a mental illness and killed 32 people at Virginia Tech University in 2007, after family, friends, counselors and others — including a judge — failed to help him. After certifying that Cho was dangerous, a Virginia judge released him from a psychiatric facility to be treated as an outpatient.

In Lewis’ chambers one day, the judge said that she fundamentally believes that such tragedies are not inevitable. She also believes that even in their most chaotic states, the people in her court want to be well. Still, she recognizes that her power as a judge is limited.

“People want me to do so many things, but we are not a service provider,” she said. “We do our best, but I have no ability to control the quality or quantity of services out there that are clearly not enough.”

Or, as she said more simply from the bench one day, faced with another decision: “It’s hard.”

Perhaps no case illustrated this more clearly than the man in the Chicago Bulls jersey, who had arrived from the psychiatric facility for a competency hearing.

Strictly speaking, Lewis had to decide whether the man understood the court proceedings and could assist in his own defense. As a practical matter, her decision would have an array of implications.

If she found him competent, he could be released back into the community on the condition that he participated in a mental health program — except that he was homeless. She could send him to jail — except that he could not bring the psychiatric medications in the brown paper bag he was tightly clutching. If she found him incompetent, he would go back to the psychiatric hospital — only it was not clear the expert testimony would allow for such a ruling.

Lewis listened as the psychologist testified.

The man’s hallucinations were becoming “less intrusive,” she said. He seemed less agitated than he had been in an earlier evaluation. He had a history of drug use, she noted, and of not taking his medications. He understood the role of the judge and the court, and he had a “rational narrative” to explain what happened the night he was arrested, the alleged facts of which Lewis reviewed:

For reasons that are unclear, the man had been bleeding from the neck. He had staggered onto a road in Maryland. He had approached a tow-truck driver assisting a motorist and asked the startled driver to take him to a hospital in Virginia. When the driver declined, he took the tow truck and drove off.

“He said he wanted to get to a hospital in Virginia,” the psychologist said, explaining that she found this rational. ” . . . He did not think he was on a ‘special mission.’ “

Lewis was skeptical that the man had stabilized, but she had a decision to make.

Was the testimony sufficient to involuntarily commit the man to the psychiatric hospital again? Probably not. If the man was not dangerous today, would he be dangerous tomorrow? Impossible to know. If she sent him to jail, would he deteriorate? Perhaps. If he were released, where would he go? Unclear.

Could a defendant with a serious mental illness be trusted to manage his own mental illness?

The man stared blankly at the judge, who had no solutions.

“All right,” Lewis finally said, addressing the man. “I’m going to find you competent. I’m concerned about the decisions you will have to make, but they are your decisions. OK?”

“OK,” the man said quietly.

“Your doctor is saying, ‘He’s here right now.’ Now, I need to keep you there. I need you to stay there, day after day after day.”

“OK,” the man said.

Legally, it was the correct ruling, Lewis would say later. But she was troubled nonetheless.

“I’m underwhelmed by the discharge plan,” she said as she began signing documents that would allow the man’s release back into the general public.

Except that now the man was whispering something to his attorney, who was nodding and standing up to address the judge. The man had made his own decision.

He wanted to stay at the psychiatric hospital voluntarily. He did not want to be released.

“Oh,” said Lewis, suddenly relieved.

She sighed. She rubbed her forehead. She told the guard he could remove the man’s handcuffs and told the man he could sit on the wooden benches until someone arrived to take him back to the hospital.

Then she called the next case: a man charged with theft who knew what day it was but not that it was July or 2013, and who believed that all meat was poisoned.

“Good afternoon,” she said to him. “Can you tell me your name?”

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