Nearly four years ago, “Sam’s” paranoia had grown so intense that he believed spies followed him in the shadows everywhere he went. His house, car, motorcycle, workplace, were all bugged, he believed. “I was in a very bad place, psychologically,” said Sam, who asked that his name not be used for this story, by phone from the Kerrville State Hospital last month. “I thought everyone was after me.”
After a number of increasingly intense psychotic episodes, those delusions reached a breaking point. In 2008, he set fire to his motorcycle in the driveway of his parents’ small San Antonio cleaning business. The fire quickly spread, destroying his parents’ shop. It took over a year and a half inside the Bexar County jail, much of it in solitary confinement, and a suicide attempt before Sam was transferred to one of Texas’ 10 mental hospitals for intensive treatment for what he later learned was a schizoaffective disorder. “I really thought I would die in that jail cell,” he said last month.
Mental health advocates say Texas’ mental health care system is failing those like Sam, and that stories like his are far too routine. Defendants with severe mental illness land in the criminal justice system where they’re forced to languish for months behind bars while an overburdened state hospital system struggles to find room. The state’s mental hospitals have long hovered at or near full capacity, with roughly 2,400 patients at any given time pushing the system to its limit, according to numbers from the Department of State Health Services. And while the state hospital system avoided the budget axe this past legislative session — state hospitals even saw a slight bump, from $778 million to $783 million — according to the University of Texas Hogg Foundation for Mental Health, the 82nd legislative session was anything but a win for mental health care in the state. In its wrap-up report on the session, members note that the state’s Health and Human Services deliberately shortchanged itself $4 billion needed for services in the new biennium. And while mental health services faced much smaller cuts than other state services (say, education), the report states: “Long-term community supports and services designed to prevent institutionalization received significant reductions.”
Wait times for civil commitments to state hospitals remained relatively low in December, ranging from 24 hours to five days on the outside. However, so-called “forensic commitments,” those hundreds of incarcerated criminal defendants who were declared incompetent and unable to participate in their own defense, languish on a growing waiting list that can take months to clear.
“We’ve got such a long wait list because we just don’t have the services in this state for people with severe mental illness. We never have,” said Beth Mitchell, an attorney with the advocacy group Disability Rights Texas. “The Legislature has never ponied up enough money to make sure that we can appropriately take care of people needing mental health services. … They end up in jail, and many wait there for months and months.” Those suffering inside that institutional limbo, mental health advocates fear, continue to deteriorate behind bars while their conditions make them potentially more vulnerable, victims to the larger jail population. Some attempt to hurt themselves inside city and county lockups ill-equipped to handle severe and complex mental illnesses.
Jeremy Weaver’s adopted parents didn’t know the severity of his condition when they took him in at just four weeks old. His biological mother drank while she was pregnant, leaving Weaver suffering from brain damage caused by prenatal alcohol exposure along with a host of other behavioral and psychiatric issues. Though he turns 19 years old in February, “He’s basically functioning on a 9 and a half year old level,” said his mother, Tabitha Weaver. “We’ve always had extreme behavioral problems with him.”
With an IQ of 55, putting him in the range of mild mental retardation, Jeremy Weaver also has a history of psychosis, his mother says. He spent years at the Mission Road Developmental Center in San Antonio until he aged out at 18 and was no longer eligible for care. After trying and failing to get Weaver into a group home in New Braunfels, where he was turned away due to a long waiting list, he wound up back near Victoria with his parents. His mother says she struggled to find adequate, specialized care. “There was just nothing here. We looked everywhere but there were no options.” A court granted Weaver’s parents full guardianship when he turned 18.
Police arrested Weaver in May when two boys in his neighborhood claimed he touched them inappropriately, charges his mother vehemently disputes. Facing multiple counts of indecency with a child by contact, a judge declared Weaver incompetent to stand trial in July, ordering him into state hospital treatment. In a competency evaluation filed with the court, Dr. Joel Kutnick described Weaver as having problems performing simple math. In addition he noted: “He doesn’t know exactly why he is in jail and he doesn’t remember how long he has been in jail. … The defendant does not have the cognitive ability to be competent to stand trial. There is a good possibility he will never be competent.”
Despite the order, Weaver waited in jail for over five months after being declared incompetent. He lost more than 30 pounds in jail and his behavior grew increasingly erratic, his mother says. “Mentally and physically, we were losing him,” she said. “He had no business being in jail for that long. … He was just deteriorating.”
Weaver was finally transferred to the Vernon State Hospital in late December, and his mother hopes to eventually have him placed in the Mexia State Supported Living Center for the developmentally disabled for long-term care.
In 2011, lawmakers saw a concerted pushback from both county jail officials and mental health advocates as the Lege considered severe cuts to state mental health care services. The tumult was loud and persistent enough to keep lawmakers from dolling out across-the-board reductions as deep as 20 percent, as had been proposed by a chorus of tax-averse conservative lawmakers at the start of the session. Advocates warned that defendants with serious mental illness already pack the jails, and that further cuts would only exacerbate the growing crisis.
Of course, the crisis shouldn’t have been news to state lawmakers. In 2005, the Texas Commission on Jail Standards and the Texas Correctional Office on Offenders with Medical or Mental Illness (TCOOMMI) reported to the Lege that at least 17 percent of adult offenders inside the state’s county jails had previous contact with state’s mental health care system, though anecdotal evidence suggested the number of mentally ill inmates could actually be much higher. Mental illness floods the criminal justice system largely because communities lack comprehensive treatment options, the report found. Many in the jails, the report speculates, could be unidentified, undiagnosed, and without the legal assistance to even push for needed competency hearings. And while there has been change since those findings were published, it’s been small and inadequate, according to advocates. In 2009, legislators allocated some $10 million for 20 additional state hospital beds in Harris County. They shuffled $30 million toward an extra 100 beds in Montgomery County, all the while drafting five new pilot programs for outpatient mental health treatment — including one in Bexar County.
The National Alliance for Mental Illness’ national report gauging mental health services in all 50 states released in late 2011 shows how far Texas has yet to go, ranking the state dead last when it comes to funding mental health care services. That is: Even though the state kept program funding relatively flat over the past three years, it still spends less per-capita on mental health care than any other state, according to NAMI — $38.38 compared to a national average of $122.90. And NAMI worries mental health treatment centers across the state were forced to tighten after June when federal stimulus cash that boosted the federal match for Medicaid expired. Texas, the group says, could see its share of the costs rise to the tune of $851 million due to the reduced federal match. “We have a rationed system here,” said Robin Peyson, executive director of NAMI Texas. “We’re at the lowest, we’re at the very bottom. … And I can’t think of a single other illness that we are so inured to, so callous to.”
Family members of those with so-called forensic commitments say getting placement is a battle. State hospital beds in Texas have declined gradually since the mid ’90s after a push to de-institutionalize those battling mental illness. Back then, the state had some 400 more beds available than it does today. “They started shutting down beds with the promise that the money would follow people into the community for treatment,” said Leon Evans, CEO of Center for Health Care Services, Bexar County’s main channel for mental health care for low-income and indigent patients. “Of course, that money never came.”
Now the number of beds can’t keep up with the number of patients needing, or ordered into, state hospital treatment. As community mental health care providers juggle the high demand — one 2011 report out of Bexar County warns that demand for local mental health care already far outweighs available services – Evans says he and others on the community-treatment side fear the Texas system bounces individuals with mental illness in and out of jails and hospitals. “Over half of all our state hospital resources here (in Bexar County) are taken up with the people that come through the criminal justice system,” Evans said. “We don’t have money on either side of the ledger, so the only door that’s open to a lot of these folks is jail. … With our funding system, that’s the road, the fate they’re left with.”
Evans insists mental health care providers in Texas are essentially “forced to ration care” — something Bexar County got a glimpse of this summer. Medicaid rate cuts and inadequate state funding forced the Center in June to start accepting only those with full Medicaid coverage, bumping those on Medicare or some other combination insurance plan to a growing wait list. Funded by DSHS, the Center gets about $6.8 million each year to enroll nearly 4,000 adult clients into outpatient services such as medication, counseling, or some combination of the two moderated by case managers to help keep patients stable and out of psychiatric crisis. Evans says the Center regularly treats 1,000 to 2,000 patients beyond their funding level, and patients discharged from hospitals that can’t find community treatment are bound for repeat stints in emergency rooms or jail, he warns.
Evans says the Center and other providers never really recovered from cuts the state delivered in 2003, when the Legislature slashed community mental health services in the name of reform and efficiency — the Center itself took a $6 million hit and was forced to cut nearly 150 positions. The impact was stark and immediate around the state, says Maurice Dutton, a Waco-based advocate with NAMI Texas who’s worked closely with the Texas Correctional Office on Offenders with Medical or Mental Illness for years. “The indications are that after that, like six or so years ago, we reached parity in the worst possible sense. … It looked like we had as many seriously mentally ill people in the criminal justice system as we had recorded in the mental health care system.”
Dutton routinely testifies before criminal justice sub-committees in the state House and Senate, insisting the current funding of mental health services in Texas is not only inhumane but financially irresponsible. “It’s financially inconceivable to refuse to adequately fund the mental health system, and then you turn around and pay two to three to four times as much to incarcerate somebody instead. … Because that’s the other option you’re left with.”
A ramp-up in jail diversion programming in Bexar County, for instance, saved over $15 million over a two-year period, officials say, keeping some 4,000 people with mental illness in treatment and out of jail. “We still have far too many mentally ill people spending far too much time in county jails across Texas,” Dutton said.
By mid-December 2011, just over 250 defendants declared incompetent by judges sat in jails across Texas waiting for beds to open up in the state hospital system, according to numbers from DSHS. For the 200 ordered into treatment at the Vernon State Hospital, the state’s only maximum-security treatment center, DSHS officials say they could endure waits of up to 9 months.
At the Dallas County jail, officials last month said 67 inmates were waiting for treatment. The Harris County jail, the state’s largest lockup, had 31 inmates ordered into state hospital treatment, the longest having already waited 200 days. The Bexar County jail last month had 32 inmates waiting for placement a state hospital, the longest being on the DSHS wait list for 265 days and counting, said Martha Rodriguez, the jail’s medical director. “Our physicians here have even called [the jail] like a little mini state hospital,” Rodriguez said. The lockup’s 281 mental health beds are always full, she added. “You have mentally ill individuals in here that need additional programs, but we just don’t have anywhere to send them. In terms of providing mental health care, in Texas we’re pretty much at the bottom. … We don’t have enough re-entry programs, diversion programs, not enough to meet the needs of the mentally ill in our communities, so they wind up coming to jail on charges that really should have been avoided. This just shouldn’t be happening.”
By phone from the Kerrville State Hospital, where he’s been ordered into treatment until at least August, 34-year-old Sam recalled his mental breakdown. “I started thinking that everyone around me was working with the FBI, that people were after me for some reason.” By 2008, he had landed in the Bexar County jail after torching his car, motorcycle, and his parents’ San Antonio business. In jail, he was afraid to eat or take the medication doctors prescribed, he says. He rapidly lost weight once in lockup. Months into his incarceration, Sam started hoarding his medication. One day he swallowed 30 pills inside his cell in a suicide attempt. “I lost hope, I thought I’d never never leave that cell. … I was suffering, I was humiliated, I decided to end things.” Sam claims he was routinely humiliated, harassed, and threatened by a guard at the jail because of his appearance, his accent, and his religion. Soon after his suicide attempt, a judge declared Sam incompetent to stand trial on multiple arson charges. Still, he was forced to wait in jail for nearly five months before being transferred to the Vernon State Hospital. He says he was increasingly delusional by the time he made it into treatment. “I had no idea where they were taking me. I thought, I don’t know, that maybe they were going to kill me,” he said.
Disability Rights Texas is now embarking on year six of its court battle over funding to house mentally ill defendants waiting for treatment in jails across the state. Beth Mitchell, an attorney with Disability Rights, said the organization sued state health officials in 2006 hoping to force their hand and make them cut the time mentally ill defendants are allowed to wait in jail for treatment. The suit demands waiting periods be cut to three days at most — something that, if enforced, would surely force the state to create more bed space, likely at the expense of emergency bed space or other crucial programming if no more money flows into the system. “I think we’d be happy even they agreed to make the wait time seven or 10 days at this point,” Mitchell said. She expects a ruling from a state court of appeals in the coming months.
In the meantime, Adan Castaneda, 25, a Marine Corps veteran from San Antonio who bounced from one psychiatric crisis to the next upon his return from the Iraq War (see “Walking Wounded,” November 30, 2011), landed in the Comal County jail last May when, during a psychotic episode, he fired over 20 bullets into his mother’s house. In November, he was deemed incompetent to stand trial for two counts of attempted murder and two counts of aggravated assault with a deadly weapon, among other charges. By that time he had already spent months in jail, most of it in solitary. His mother insists he wasted away without the necessary treatment. “He’s lost 60 pounds in six months. … He’s so fragile every time I see him,” mother Maria Anna Esparza said last month. “To spend Christmas in jail when you’ve already been there for over seven months, it’s just incredibly sad for someone who gave up his mind, his life for his country.”
Esparza spent months tracking down organizations and advocates hoping to find help for her son, finding instead only dead ends. However, late last month she found Austin-based defense attorney Keith Hampton, who helped her file legal paperwork with Castaneda’s Comal County judge days before Christmas, pushing to force DSHS to make room for her son.
To hear Hampton explain it, he’s itching for a confrontation with state health officials.
The attorney started working with Travis County Court-at-Law Judge Nancy Hohengarten, the judge overseeing that county’s mental health docket, this past summer. Frustrated that defendants ordered into state hospital treatment faced wait times of months, and worried that the system was denying mentally ill defendants their constitutional rights to due process and fair treatment, Hampton began filing legal action asking for immediate commitments to the local state hospital. The reaction was swift. Roughly 15 mentally ill defendants under Hampton were placed within days or even hours.
If DSHS ever refuses to place a client within a “reasonable amount of time” — Hampton considers that to be five days, max — then he’s ready to push for a contempt hearing, something he insists could force state officials to explain why they haven’t complied with a judicial order. And really, Hampton already knows the answer: the Legislature simply hasn’t appropriated enough funds. “DSHS is not enforcing judicial orders. They’re not funded to. They can’t, and that’s where the problem lies,” he said.
Hampton’s taking his fight statewide, petitioning judges to put time limits in their orders for state hospital treatment and making his legal briefs available to anyone who wants them. Since the summer, he’s given his briefs out to roughly 50 judges and defense attorneys across the state. He squarely blames state lawmakers for skimping on mental health care, and takes a deliberately provocative tone. “I want the state to know there’s this asshole lawyer out there and he’s after us,” he said. “I want to shake them up and let them know this is not just a flash in the pan.” And he doesn’t expect his game of chicken with DSHS to last indefinitely. “At some point, somebody’s going to have to be refused placement (at a state hospital), and that’s when you’re going to see the contempt hearing and the final endgame to this,” he said. “Essentially, we’ve been accommodating this crisis with the use of our local jails, which are not built to warehouse people who need treatment for long periods of time.”
Days before Texas rang in the New Year, Hampton and Esparza got word from jail and state health officials that Castaneda, after 8 months in incarceration, had been transferred to a North Texas state hospital for treatment. As Hampton sees it, that’s one down, another 250 to go.