Correctional officers and medical staff of the Montgomery County Correctional Facility in Boyds explain treatment for the mentally ill in the Crisis Intervention Unit. (Astrid Riecken/For The Washington Post)

Just before 6 p.m., a prison transport van pulled up to a state mental hospital in central Maryland. Inside were two deputies and James Geeter, a 77-year-old man arrested for trespassing at a library in Prince George’s County — and so mentally incompetent that a judge ordered treatment before he could face the charges.

Four hospital staffers, including the clinical director, met the deputies at the door that night last month and turned them away.

The psychiatric facility was full.

The deputies and their prisoner returned to the county’s jail, where Geeter took a spot on a list of 84 inmates throughout Maryland waiting to get into one of the state’s five forensic hospitals — including some inmates charged with violent felonies.

The crisis at Maryland’s mental hospitals is playing out nationwide, putting pressure on jails and testing the patience of judges.

In 25 states surveyed this year by the nonprofit Treatment Advocacy Center based in Arlington, Va., 1,956 inmates were in local jails waiting for psychiatric hospital slots, leaving them in facilities that were not designed to meet their needs at what can be triple the cost of tending to other inmates.

“If you could design a system to treat these people as ineffectively and as expensively as possible, you’d use jails the way we do,” says the Treatment Advocacy Center’s executive director, John Snook.

At least six states have longer wait lists than Maryland, but the state’s numbers have risen quickly — from 49 in early March to 84 in early May, according to numbers tracked by the Maryland Department of Health and Mental Hygiene (DHMH).

One reason for the long waits, say corrections officials and the Treatment Advocacy Center, is that more people with profound mental illness are being arrested and booked into jails, while the number of beds at state hospitals is not growing. The patients in the hospitals, meanwhile, are more acutely sick and more dangerous than in years past, which extends their stays.

When inmates are successfully treated, it can be hard to find a program outside the hospital where they can move for after-care.

“We have a humongous ­patient-flow problem,” said Paula Langmead, the head of Springfield Hospital Center in Sykesville, Md., at a court hearing in Geeter’s case last month. The hospital had turned him away. “There is an inability to find providers willing to take some of these people back into their communities.”

Finding spots for an increased number of undocumented immigrants suffering from schizophrenia can be particularly difficult, she said.

In Maryland, the waiting lists persist as health department officials ask for leeway even as they openly defy judges’ orders to treat defendants deemed mentally incompetent.

“We value our collaboration with the judiciary and make every effort to comply with court orders,” DHMH Secretary Van Mitchell, who started his job last year, wrote in a letter sent this spring to Maryland judges. “We are requesting your support and assistance to ameliorate the potential negative impacts related to the crisis we are currently facing.”

‘Nothing gets done’

Under Maryland law, mental illness and criminal justice intersect in two major areas.

A person who is too mentally ill to understand his surroundings in court cannot be tried. Also, at the time of the alleged crime, if mental illness kept the accused person from understanding he was breaking the law, he can be found not criminally responsible — commonly known as the insanity defense.

In both circumstances, judges issue court orders to send defendants to state psychiatric hospitals for evaluation and treatment.

Given those requirements, some judges are asking state health officials to come to court to explain why inmates who are a risk to themselves or others cannot get a psychiatric hospital bed.

At a May 18 hearing devoted to Geeter’s case and the inability to secure him a hospital bed, Prince George’s District Court Judge Robert Heffron told Mitchell that he appreciated the department’s challenges — to a point.

“You seem like a wonderful person,” Heffron told him. “But I don’t understand how this can be so evident to everyone — and nothing gets done.”

Judges who make direct appeals to the state often get inmates into treatment, which helps a specific patient but ignores the larger problem.

After the May hearing, Geeter got a bed at Springfield hospital.

But others still are on hold.

The state’s most recent waiting list includes 30 people court-ordered to Clifton T. Perkins, the state’s maximum-security forensic psychiatric hospital in Jessup, where those charged with violent felonies are sent.

At Talbot County Detention Center on Maryland’s Eastern Shore, jail director Doug Devenyns sees the effects of decades-old policies intended to move mentally ill patients from massive hospitals to community-based care.

Last week , 20 of his 74 inmates had serious mental illnesses. None of the inmates, he said, were scheduled for transfer.

“They closed the hospitals, the mentally ill came back,” Devenyns said, “but guess what did not? The resources.”

By 2012, there were fewer than 1,000 beds at state psychiatric hospitals in Maryland. And the vast majority were filled by those transferred from jails.

About that time, the state commissioned a consultant, Cannon Design, to project how much bed space would be needed in state psychiatric hospitals over the next decade.

A medical examination room at the Montgomery County Correctional Facility in Boyds. (Astrid Riecken/For The Washington Post)

Correctional officer David Olthof shows how he keeps watch inside a cell at the Montgomery County Correctional Facility. (Astrid Riecken/For The Washington Post)

Cannon concluded that even if the system grew more efficient, an extra 216 beds would be needed. The health department’s secretary at the time, Joshua Sharfstein, rejected the consultant’s conclusion, saying that the state could relieve the pressure on beds through better management and expanded community-based treatment.

Reached last week, Sharfstein declined to comment about his decision and any effect on waiting lists.

But Larry Fitch, who served under Sharfstein as director of forensic services for the state’s mental-health system, said part of the problem stems from judges who send inmates to state hospitals and will not allow their release until a complete after-care plan is set up for housing, counseling and monitoring.

“I understand what they’re doing: Somebody has to step in for these people,” says Fitch, an instructor at the University of Maryland School of Law.

But in many cases, Fitch says, the judges are using their power to order the state to treat and hold inmates in hospitals as a way to set up community services for low-level offenders who don’t have to be confined.

“A judge can sort of hold the system hostage,” he adds.

To the judges, though, their orders are meant to keep the community safe while addressing an inmate’s mental illness. And they’re increasingly frustrated with the wait times to get into state facilities.

In 2014, Baltimore County judges reported an average wait of 27 days for inmates to be moved to one of the state sites. Their worries about the risks that delays pose to inmates and staff were heightened last month after a 46-year-old homeless man, Clabon McCullers, died in the county jail while awaiting a hospital bed. The cause of McCullers’s death is not known, because an autopsy has not been finished. But in a sharply worded letter to health agency officials May 25, Baltimore County Judge Alexandra Williams demanded an explanation for the delay that left McCullers in Baltimore County.

“Court orders cannot be ignored,” Williams wrote. “These sensitive cases must be dealt with properly, promptly and in accordance with statute.”

A more restrained approach

Judges and jails are not attempting to transfer every inmate with a mental illness.

Devenyns, the Talbot jail warden, said that in years past, he would seek civil hospital commitments for his sickest inmates — a process that requires the signature of two clinical professionals. But he found that the commitment orders almost always expired before a spot opened, and he would have to bring the clinicians into his jail to restart the process.

Now, Devenyns said, he takes a more restrained approach: identify the mentally ill, have them see a doctor who comes to the jail, and give them medication if the proper type and dosage can be determined. Devenyns stays away from talk therapy. “To engage in treatment,” he said, “can be like opening Pandora’s Box.”

In extreme cases, Devenyns said, he will force the hand of administrators at the Eastern Shore Hospital Center 30 minutes away, even when they say they’re full. Twice in the past two years, he said, he has called the hospital with a brief, direct message: “We’re on our way.”

Both times, Devenyns said, the inmates were taken in.

Larger jails have set up entire housing units for mentally ill inmates.

“I never felt what I’ve been doing would become the long-term solution. But it has become the long-term solution,” said Robert Green, a corrections official for three decades who ran Montgomery County’s main jail for 15 years and who has been running the department in that county for a year.

Robert Green, director of the Department of Correction and Rehabilitation at the Montgomery County Correctional Facility, has worked in corrections for 30 years. (Astrid Riecken/For The Washington Post)

From 2011 to 2015, the number of inmates arriving at his jail in need of mental-health services climbed from 1,011 to 2,137. Many ended up at his Crisis Intervention Unit, with a capacity for 39 inmates. A staff psychiatrist treats them, as does a rotating team of four therapists who cover about 12 to 16 hours of the day.

But there is only so much that even a unit such as Montgomery’s can do given the realities in a jail setting with inmates alone in cells and hours passing without access to mental-health professionals — and an extremely limited ability to force anyone to take medication.

Earlier this year, 22 of the mentally ill Montgomery inmates were awaiting space in a state hospital.

Their behavior can be frightening: screaming, tossing food, throwing bodily fluids. And witnessing it can be so draining and sorrowful that correctional officers who work in the unit often tell their supervisors they need a day off — to work where the general population is housed. “They’ll say: ‘Boss, I just can’t do it another day. I need a break,’ ” Green said.

To manage the most extreme cases on the unit, jail officials make sure that at least one, sometimes two, corrections officers are within four to six feet of an inmate — with an open cell door — around the clock. Last year, Green said, he needed 4,070 hours of officers’ time — the equivalent of 508 shifts — for that kind of monitoring.

The constant monitoring has kept inmates from committing suicide. But it is impossible to predict which inmates will need such care. Late last year, an inmate in the Crisis Intervention Unit rammed his head, hands and dinner tray into the security window of his cell door, breaking it. Later, after a spot opened for the inmate at the state hospital, the inmate was transferred and his condition quickly improved.

And that reinforces a point Green makes repeatedly when talking to county and state officials about the state facilities.

The security window of a cell door was broken by a mentally ill inmate in crisis at the Montgomery County Correctional Facility. (Astrid Riecken/For The Washington Post)

“They do great work; they just need more beds to do it,” Green said. “When we have a person who is physically ill, we send them to the hospital. Because it’s mental illness, we leave them sitting in a jail.”

Problem bigger than funding

James Geeter’s problems at the Hillcrest Heights library began last year when he was accused of sexually assaulting a deaf woman in a bathroom, according to Prince George’s County court records. He was sentenced to 234 days in jail and banned from the library. Geeter went back after his release and ignored warnings from library staffers, who called police.

On April 25, officers charged Geeter with trespassing and with failing to register as a sex offender.

At Geeter’s first court appearance, Heffron ordered him to undergo a mental-health exam at the jail. A week later, Heffron concluded that Geeter was mentally incompetent to stand trial and ordered him sent to Springfield state hospital for treatment.

When Geeter was turned away, the judge issued a swift and strong response.

Heffron ordered three top officials of the Department of Health and Mental Hygiene to appear in his courtroom to explain why they should not be held in contempt for not finding Geeter a bed as his order required.

“I’ve got a live human being who is illegally detained,” Heffron told Mitchell in court May 18.

He permitted Mitchell to answer at length, turning the hearing into a wide-ranging discussion of how treatment of mentally ill arrestees got so off track.

All five of his psychiatric hospitals were beyond their patient limit, Mitchell testified.

Money is part of the reason, Mitchell said, according to the audio recording of the hearing. He said he spent an extra $8.2 million on staffing and overtime over a recent six-month period to care for and treat a growing number of patients with increasingly complicated needs.

Heffron pressed Mitchell about why he had let the most recent legislative session pass without asking for more funds — noting that there are provisions in the law to free money for agencies that aren’t following court orders.

But Mitchell and two of his top administrators said the problems that created waiting lists extend beyond funding, such as the challenges of hiring hospital personnel and placing patients in after-care programs.

“You can pour all that money in, but right now nobody’s grabbing at state-of-Maryland wages, because it’s state-of-Maryland wages and it’s coming in with a group that you know might assault you any day,” said Langmead, director of the Springfield hospital.

Next year, Mitchell said, he wants to move forward with a request to build a state-of-the-art facility, which he said would be the first new state-run hospital in more than 40 years. For now, in the short term, he is exploring placing some of his patients in private hospitals.

And on Friday, his office mailed invitations to 23 people throughout the state — including health department officials, judges, jailers, those involved in community treatment — inviting them to join a work group to address the problems. The group will meet four times over the next two months.

“I felt it was time to own it, bring everybody together, and try to find some solutions,” Mitchell said.