Whitlock, of Tennessee’s mental-health department, says that there are N.G.R.I. patients whom her state’s hospitals are trying to discharge but for whom they “just can’t find a provider.” Under her lead, Tennessee, more than any other state, has been trying not to commit forensic patients to begin with. Since 1974, it has done its pretrial competency evaluations on an outpatient basis, no insignificant matter given that elsewhere these can take six months or longer. In 2009, the state also started doing post-N.G.R.I. evaluations to see if N.G.R.I.s even needed hospitalization, also on an outpatient basis. “We did not think there was a need to spend 60 or 90 days in the hospital to determine if N.G.R.I.s fit the involuntary-commitment standard,” Whitlock says. “Once you get someone into the hospital, it’s hard to get the court to take them back out. We could probably determine it in a day.” Now only 55 percent of Tennessee’s N.G.R.I.s are committed. Their typical length of stay ranges between seven months and 4.5 years, and they get out, on average, in about two. The state’s new initiative adds to the body of evidence that less hospitalization doesn’t lead to higher crime rates. Since Tennessee stopped automatically committing N.G.R.I.s, says Jeff Feix, the state’s director of forensic services, “the recidivism rate we have is no different than it was before.”

Despite the clinical benefits and cost savings — in 2015, according to a Samhsa report, the average annual cost of one forensic patient, nationwide, was $341,614 — Tennessee’s model is still unusual. There is no outcry, from the public or politicians, for alternatives to indefinitely institutionalizing N.G.R.I.s. After 45 years of studying the issue and filing lawsuits on behalf of patients, Michael Perlin, an emeritus professor at New York Law School and an expert on mental-disability law, thinks he knows why: “Everybody except for people who take the Constitution seriously and people who are in the hospital are happy the patients are there. Prosecutors, police, they’re glad they’re not going anywhere. I believe that the disability rights community has never gotten substantially involved in the issue because some of the people have been charged with very horrific crimes.”

As he put it: “This is an area that everybody kind of wishes would go away.”

Nearly two decades into James’s confinement, it remains unclear if he will ever be considered fit for release. He says that currently his entire medication regimen consists of “fish oil twice a day, calcium, vitamin D and two Kool-Aids and prune juice and Metamucil.” In the 2004 appellate court overturning of his transfer, the hospital doctor testifying in favor of his continued retention pointed out that there was no medication for his diagnosis of antisocial personality disorder — just therapy, to which he was resistant. The hospital forensic committee said that they believed James was insufficiently willing to take responsibility for his actions. One of his doctors called him “sexually preoccupied”; the appellate court concluded that “the disorder will continue to cause him to be dangerous at least until such time as he decides he wants to change and begins working seriously with his treatment providers.”

The court-appointed psychiatrist at the hearing two years earlier, when James was ordered for transfer, said quite the opposite. In his opinion, James “acknowledged the wrongfulness of his actions, and although he does not show much remorse or regret for his actions as a result of limited insight, he certainly realizes that what he did was wrong and against the law.” He said that James “has benefited from [the state psychiatric facility] as much as he will benefit, and at this point he could be transferred to a civil hospital, where he will continue to benefit from the structured environment and continue to receive individual treatment, hoping that he will eventually gain further insight.” But in its appeal at that time, as in every review since, the hospital successfully petitioned to retain him.

How much James’s perceived dangerousness is due to his illness and how much to his extended hospitalization can be difficult to untangle. During a phone call last year, he confessed that lately he’d been “going through a lot of crap.” He was referring to recent fights on the ward. The 2004 appeal notes that he was assaulted twice in 2002 and “got into an altercation with another patient” that year; all of the incidents read as demerits against him. Such disputes are not uncommon for patients with personality disorders, says Norko, the Yale professor and clinician. A hospital is generally “not a good place for them,” he says. “Clinically you try very hard not to hospitalize people who have personality disorders. They can’t quite seem to ever get it right. To them it looks like: ‘The staff want me to do this, they want me to do that, they keep changing the rules,’ and they don’t understand the rules, and they get into arguments, they get into fights. It’s all part of their personality disorder, which in itself isn’t necessarily all that dangerous, but it’s kind of hard to move somebody along when their record is dotted with all of these altercations.”

Perhaps the most cleareyed view of the compromises inherent in N.G.R.I. commitments comes from Paul Appelbaum, professor and director of the division of law, ethics and psychiatry at Columbia University. Appelbaum acknowledges that some N.G.R.I.s are “unnecessarily detained for a longer period than what seems to be warranted by their mental disorder and its impact on their likelihood of being violent in the future.” But, he says, such exaggerated concerns about public safety may be necessary to the survival of the insanity defense. “There are injustices that are imposed on individuals,” Appelbaum says. “But I also see at a 30,000-foot level why the system works that way, and recognize perhaps the paradox that if it didn’t work that way, we might lose the insanity defense altogether, or at the very least have an even more restrictive system that we have to deal with.”

For many, Appelbaum says, an N.G.R.I. verdict is still superior to a conviction. “It exempts them from a formal finding of guilt, which can be important later in their lives. It enables them to serve their time of confinement in what is generally a much better and safer environment than an overcrowded state prison.” While one way to look at indefinite confinement is as an unbearable uncertainty, another is that it offers hope: “Compared to a life without the possibility of parole, you know, maybe that’s better.”