Agencies Struggle to Provide Mental Health Services in Central Texas

In "Mentally Ill Don't Belong in Jailhouse" (July 27, 2008), the Temple Daily Telegram presents a compelling and comprehensive picture of the issues facing people with severe mental illness in Central Texas. It also explores the limitations imposed on government agencies, given funding cuts, a decrease in facilities, and other constraints.

The following article is a lengthy but worthwhile read.

"Before Carolyn Law was sent to prison in March 2006 for killing her mother, she was a college educated woman who had worked in real estate and tried to control her schizophrenia through medication.

At one point, she was so successful at controlling her illness, the state used her in a video that promoted the services that helped her cope.

'She was a poster child for services offered through the (Central Counties Center for Mental Health Mental Retardation),' said Eldon Tietje, executive director for MHMR.

Tietje said Ms. Law could still be considered a symbol for the mentally ill, only now she would be a symbol for what is wrong with the state’s treatment of the issue.

'She is someone who did pretty good for a long time,' Tietje said. 'She could and did take advantage of services when they were available, but she deteriorated over time and didn’t comply with treatment.'

Much like Ms. Law’s condition, the state’s funding for mental health programs has eroded over time, Tietje said.

And Tietje is not the only local official voicing concern over the treatment options for mentally ill in the state.

Judge Martha Trudo, 264th State District Court, sentenced Ms. Law to 45 years in prison for murder. Judge Trudo thinks it’s time for the state to do a better job addressing mental health issues.

'It isn’t a problem to be hidden,' she said. 'We really need to be doing something about (the mentally ill). They end up being warehoused in the pen.

'We do not do a good job of taking care of the mentally ill in Texas. There are tremendous waiting lists, doctors won’t see them unless they get picked up and put in jail. Then we are obligated to do it.

'A lot of people can function and work if they have support.'

In March 2006, Ms. Law addressed the court before her sentencing and said that mentally ill people such as her are misunderstood. She also said she hoped to see advancement in the treatment of mental patients.

'You have heard from many people here who have been hurt. I’ve been hurt for the last 20 years,' she said. 'I’m the biggest victim of all, as I see it.'

The local mental health picture

In his 16 years at the top post at Central Counties MHMR, Tietje said referrals have doubled as the population in the area has increased.

'The prevalence of mental illness may not be greater but we have more people and the resources are less, also during that time most of the private hospitals have closed, so there are fewer in-patient services,' he said.

A 2003 state budget crunch took more than $100 million out of the community MHMR system. But rather than this being an anomaly, it looks more like a pattern. In 1994, Tietje said his budget was $16.5 million. It was slashed to $12 million in 1995, a 25-percent cut.

'A result of that budget cut, we lost a Fort Hood work program that served 200 people,' Tietje said.
Closely supervised program participants cleaned buildings and restocked the commissary on base.
Budget constraints have also contributed to the closing of a three-quarter-way house in Gatesville that helped get people back on their feet. It had 30 beds and was a place where people could stay and look for work while they stabilized on their medications.

'It was a structured environment that made sure they got meds and food,' Tietje said.

And the Gatesville center has not been the only facility that has been shuttered.

Clinics in Bell, Coryell, Hamilton, Lampasas, and Milam counties have all been closed.

Patricia Roy-Jolly, MHMR supervisor who works with community support services, said she has witnessed a general pattern with many of the mentally ill she attempts to help.

She said mentally ill people often commit a crime and are incarcerated in Bell County Jail, which, in turn, ships them to Austin State Hospital. In Austin, the person gets stabilized on medication and usually within about a month is sent back to the area with three weeks of medication and the charge to regularly visit a doctor.

Ms. Roy-Jolly said usually the patient makes one or two appointments before he or she stops taking their medication and disappears for a while until he or she is rearrested and the process starts all over again.

'We’re just in a terrible predicament. A lot of these people do not have family members or they have family members who can’t help them anymore,' Judge Trudo said.

'It’s probably time for Texas to look at having group homes or do something.'

One funding cut came at the hands of the Texas Commission on Alcohol and Drug Abuse when the agency overextended funds by not regulating properly.

'Our funding from substance abuse services went from $80,000 to $15,000. We gave up our patient substance abuse services,' Tietje said. 'We got rid of it because we couldn’t afford it.'

Right now the best option for temporary inpatient care for mentally ill patients is the Austin State Hospital, but up until about eight years ago Temple was able to provide inpatient crisis stabilization.
'We had to give it up because it became too expensive for us to run,' Tietje said.

And the Austin State Hospital is often near capacity. For at least two weeks this month the hospital was so full it was on diversion and recommending people go to San Antonio for services. The other option for jails was to warehouse the prisoners until a slot opened at the hospital.

Other programs or services impacted by budget constraints include: two-day treatment services in Temple and Killeen that served 30 to 40 people, access to counseling services, transportation and noon meals.

'There’s a whole lot less mental health services in these five counties than there was 13 years ago,' Tietje said. 'When there are no support services, people are less likely to seek or stay up on treatment.'

This year’s budget for Central Counties MHMR is $14.5 million.

'We have fewer resources today and inflation has eroded our spending ability. We have had no inflationary increases from any funding groups, county or state,' Tietje said. 'As a result, our services have eroded and more and more people with mental illness show up in jails or emergency rooms.'

The impact on the community

The struggles of the state in answering the question on how to deal with people who struggle with mental illness is often shared by the families and church communities of these individuals.

In Ms. Law’s case her former minister Joe Baisden, Belton Church of Christ, said he spent a tremendous amount of time ministering to her in the years preceding the killing of her mother.

'Carolyn used to be a member of my Bible class. I was called in many times when her mother and her had problems,' he said. 'She freely talked about mental illness and gave us a great deal of insight. When she was on her meds she came to support group and was smooth as silk - other times she was erratic.'

Baisden said he will never forget when his church community was having a fellowship day in Yettie Polk Park in Belton and he was called to help Law’s family.

She had dropped her boys off at a mall in the Austin area and was later arrested at the State Capitol building when she pulled a fire extinguisher off a wall and sprayed paintings on display in the building.

'It grieved me that she had this kind of destiny in this life,' Baisden said about Ms. Law. 'It’s sad.'"

Stop Criminalizing the Mentally Ill

That's the title of this week's column by Dr. María Félix-Ortiz ("Society, and judges, should stop criminalizing the mentally ill," San Antonio Express-News, February 26, 2008). Dr. Félix-Ortiz reinforces the fact that people with mental illness are not inherently prone to violence; in reality, they are more likely to be the victims of crime. She also provides suggestions for outpatient treatment and other preventative programs.

"Recent comments made by Judge Tom Rickhoff of Probate Court 2 to KSAT evening news (Feb. 15), suggest a need for educating our criminal justice community about severe mental illness. I was not surprised by his recognition of a problem, but quite disappointed by his proposed solutions.

The judge's comments reminded me of what might happen if you ask a carpenter to fix your sink: He's likely to address the problem with the tool he uses most, his hammer. But that hammer is likely to cause bigger problems for those rusty pipes.

Bipolar disorder is not a crime; it is a disorder of the brain. Few people who are mentally ill ever commit a violent crime; the rate is similar to that found in the general population. If we did an analysis of the number of people who have diabetes who committed violent crimes, we might want to fingerprint every one of these people as soon as they're diagnosed (and close all the ice cream parlors across town).

However, people with mental illness are two and a half times more likely to be victimized (raped, mugged, etc.) than are any of us in the general population. Dr. Virginia Hiday at North Carolina State University-Raleigh also found that court-ordered involuntary outpatient treatment (OPC) for at least six months was associated with dramatically lower incidents of violence among those who were mentally ill and had a history of violence.

Other studies have found intensive case management another effective way of reducing violence and increasing adherence to the treatment plan. Case management involves old-fashioned social work where the mental health professional visits the individual at home to monitor his or her adherence to the treatment plan, help him or her make connections with other services and offer the support that can really keep people healthy.

While somewhat costly, intensive case management and OPC can reduce the more costly expenses of law enforcement, criminal justice and hospitalizations.

If Judge Rickhoff wants some real solutions, why not consult with mental health professionals and advocates, people who have the right tools in their toolbox for the job? We don't need to further criminalize mental illness; we do need more, and more diverse, mental health services and an approach that balances civil/human rights with the community's need for safety.

Contrary to popular opinion, the best mental health professionals can't reliably predict violent behavior; we can identify risk factors, but there is no test, no equation that accounts for all the variables involved in such a prediction. Lo siento, we can't read minds either.

Substance abuse is more strongly associated with violent behavior. We're in sore need of a variety of empirically validated public drug rehab programs, and I'd like to emphasize 'variety.' The programs shouldn't all be 'hammers.' Different people have different needs. Needs vary across age, gender (pregnant women need treatment, too) and sometimes culture.

If we need to find a scapegoat, let's not blame the ill for their illness. Rather, we might ask our legislators why Texas spends only $38 per person on mental health when most states spend about $80 per person, and Washington, D.C., spends more than $400 per person."