After a federal judge ruled that Jared Loughner is mentally incompetent to stand trial for January's shootings in Tucson, questions abound about what that means for Loughner and the victims of the shootings.
Loughner, who allegedly opened fire at a Jan. 8 political meet-and-greet, faces 49 charges stemming from the attack. Six people died and 13 were injured -- including, most seriously, Arizona Rep. Gabrielle Giffords. But an evaluation by two court-appointed mental health experts -- to say nothing of Loughner's behavior in court -- suggests he does not understand the gravity of the case against him.
"A person has to be able to understand what's happening and be able to participate with his lawyer in his own defense," said Dr. Anthony Lehman, chair of psychiatry at University of Maryland School of Medicine.
The court-ordered psychiatric evaluation concluded that Loughner suffers from delusions and hallucinations -- symptoms of paranoid schizophrenia, an illness that can distort a person's perception of reality.
"In people judged to have this type of psychotic illness, it's really that they have an inability to recognize a shared human reality," said Dr. Charles Raison, associate professor in the department of psychiatry and behavioral sciences at Emory University School of Medicine in Atlanta. "They can't realize that they don't think about things in a way the rest of us would think is normal."
Loughner will undergo four months of treatment at a government mental facility in Springfield, Mo. Prosecutors say they hope he will become mentally fit enough to stand trial.
"People that have severe psychotic disorder almost always need medication," Raison said, adding that current drug treatments are "far from perfect" and have side effects. "When you give people medication, most of the time you see an effect within the first month. And people who have the types of symptoms he has tend to be the ones that respond to medication."
If Loughner is still considered mentally incompetent after four months, he will likely be confined to a mental institution indefinitely, Lehman said. But he stressed that "mentally incompetent to stand trial" and "not guilty by reason of insanity" are two very different things.
"You can have a person who was essentially insane at the time they committed crime, didn't understand what they were doing then and now does, and is able to participate in his own defense," he said.
Lehman said it would be very hard for someone to fake mental incompetency, and even harder for someone to be ruled not guilty by reason of insanity.
"I think there's a public concern that this is a sort of gaming of the system," Lehman said, adding that Loughner's lawyers would have to prove he was mentally competent during the trial but not at the time of the crime. "It's often not a very successful route to go."
Loughner reportedly rocked back and forth in his chair during the proceedings Tuesday before blurting out, "Thank you for the freak show!" and "She died in front of me." U.S. marshals escorted him from the stunned courtroom.
If the treatment is successful and Loughner becomes mentally competent to stand trial, the realization of what he's charged with could be horrifying, Raison said.
"It's such a tragedy because, in many cases, when people are made less psychotic they're horrified at what they've done," Raison said. "I've known people that have killed themselves because of that."
But for the victims of the Tucson shooting and their families, sympathy for Jared Loughner may not come easily.
"The problem here is it's hard to apply justice to an insane act," Raison said. "You want somebody to blame."
Raison used the analogy of one rowboat slamming into another, knocking its passengers into the water.
"Does it make a difference that the rowboat had no driver?" he said. "That's what's going on here. There's no one driving the boat."