A Crisis in Care

Susan Garnett remembers what it was like in 2003, when the legislature created DSHS by merging the Texas Department of Health, Texas Department of Mental Health and Mental Retardation, Texas Health Care Information Council, and Texas Commission on Alcohol and Drug Abuse.

“Texas was broke then,” recalled Garnett, the CEO of MHMR of Tarrant County. “So 2003 became a tremendous cost-saving session. There was fervor over Health and Human Services and concerns about its growth. It was really about streamlining, and the intention was for efficiency. But while these pieces were being put together, there wasn’t any legislative direction about integrating services.”

Garnett’s organization contracts with DSHS and other government and private groups to provide services in Tarrant County.

With the sunset report and other major attention being paid to mental health delivery, Texas appears to finally be addressing the problems that arose from that merger, she said.

Since then, DSHS has been mired in lawsuits and criticism from health groups. During that time, the state’s per capita spending on mental health services, always low compared to other states, has dropped even further, from 46th in 2001 to dead last in 2010. A study by the Kaiser Family Foundation that year found that Texas spent an average of $38.38 per person on mental healthcare compared to a national average of $122.90.

The chronic lack of community resources that resulted has led to a system where jails now provide far more mental health treatment in Texas than the agency tasked with the job. In 2007 the advocacy group Disability Rights sued DSHS because mental patients were languishing for years in jail without either being tried or getting treatment, charged with crimes that were often related to their psychiatric and drug-abuse problems.

Disability Rights won the lawsuit, but Texas jails are still serving as the default treatment centers for the vast majority of Texans with mental illness. According to a recent article in The Texas Observer, Harris County Jail alone treats “more psychiatric patients than all 10 of Texas’ state-run public mental hospitals combined.”

Beth Mitchell, lawyer and director of Disability Rights, said many of those inmates could have avoided jail if adequate treatment had been available in their communities and if more courts participated in jail-diversion programs. Such programs single out “at-risk” people with mental illness for specialized job-placement and treatment programs.

Dire statistics and ruined lives didn’t drive the legislature to take action; it took a national tragedy to bring that about. In December 2012, Adam Lanza killed his mother in Newtown, Conn., then drove to Sandy Hook Elementary School and killed 26 children and staffers before turning his gun on himself. That and several other mass shootings that year spurred a broad re-examination of mental health treatment in this country. Many Texas legislators, including Nelson, cited that tragedy as providing the impetus for a re-examination of Texas’ mental health code, its mental health services system, and its historically inadequate funding.

Mental health groups in Texas worked with legislators to increase the annual budget of State Health Services by 15 percent in 2013. The move drew wide bipartisan support, Nelson said.

The unprecedented increase added $260 million to DSHS’ annual budget. The largest chunk, $48.2 million, went to community clinics to address a backlog of requests for help that had patients waiting up to eight months for treatment. Another $43 million went to expand badly needed beds and resources at community clinics. The remaining funds were used to create jail-diversion pilot programs and new programs for the homeless mentally ill.

At about the same time, the Hogg Foundation for Mental Health, along with other groups, began a campaign to convince the state to overhaul its mental health code, which governs policy in handling and treating patients. The effort was led by Dr. Susan Stone, a lawyer and psychiatrist working for Texas Appleseed through a grant from the Hogg Foundation.

Stone died unexpectedly in 2013, but her recommendations, some of which were enacted into law last session, stand as the model for future attempts to revamp the mental health code. Two of nine bills based on her findings passed; those measures require the standardization of medical forms, which had varied from county to county, and allow minors 16 and older to receive outpatient mental health treatment without parental permission.

Other measures proved too controversial at the time, including a bill that would have allowed hospital staff to forcibly detain patients for up to four hours in certain circumstances, allowing time for a psychological evaluation. Another bill that failed would have eliminated mental health warrants, which some groups said were being unevenly used across the state and unnecessary in many circumstances.

Jacques Ntonme, director at Texas Appleseed, worked alongside Stone during her research into the state mental code. He said his group is getting ready to take up the battle for reform again when the legislature convenes in January.

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