AUSTIN (KXAN) – For years, Texas’ state hospital system has operated at capacity, causing hundreds of mentally ill county jail inmates to wait months for a bed and treatment. The state’s $1 billion revamp of the system will add space in the coming years, but some state and county officials and local mental health providers are focusing on alternatives that circumvent the state hospitals altogether.

In Texas, if a person is found incompetent to stand trial, the state is most often required to send them to a state hospital for treatment, called competency restoration. A person cannot proceed through the criminal justice system without being able to understand and aid in their own defense, and the state’s ballooning waitlist has sparked a federal class action lawsuit alleging it is a violation of people’s constitutional rights to be forced to sit in jail if they cannot be tried or transferred quickly for treatment.

At the start of 2020, state hospitals had a total of 970 individuals on a wait list for one of the state’s 2,269 funded beds. The $1 billion state hospital construction plan will add just 350 total beds to the state’s stock available for inmates. Given current demand, that would still fall 555 beds short, according to a KXAN analysis of state data.

The situation has forced mental health experts and county and state officials to explore alternatives, such as outpatient competency restoration, jail-based competency restoration, tele-psychiatry and specialized county mental health courts that can divert individuals from jail.

Recently retired State Sen. Kirk Watson, D-Austin, said the state is working on a variety of ways to cut back on the waitlist. Watson has pushed legislative funding to rebuild the state hospital system, including Austin State Hospital in his district.

“Particularly in the area of competency restoration, there’s been a recognition that you may not need to be in a state hospital in order to have your competency restored, thus adding to the wait times and problems,” Watson said.

Rebuilding state hospitals, including Austin State Hospital at a cost of $305 million, will provide more efficient services and a “continuum of care,” he said.

One problem, Watson said, has been a misunderstanding by people conflating competency restoration with clinical care. It could be possible to restore competency more quickly, and release a person from a state hospital, before completing all clinical care. That would move individuals through the system faster and mental health care could continue for the individual after they leave the state hospital, he said.

“Someone’s competency to stand trial can be restored in many instances before their clinical treatment is over. So, can you restore that competency in a setting other than the state hospital?” he said.

Watson said the state hospital plan has recommendations for using services like tele-psychiatry and tele-pharmacy that allow people to be treated outside a hospital setting.

‘Tele-psychiatry model’

While Texas redesigns state hospitals, some counties focus on mental health inside jails to reduce wait times, but critics question the effectiveness of such stressful environments.

In Lubbock County, 375 miles northwest of Austin, officials are using tele-psychiatry.

“The tele-psychiatry model, I’m told, is working really well where there is actually an intake session with a psychiatrist,” said State Sen. Charles Perry, R-Lubbock.

Perry, who has authored legislation to address mental health issues in the criminal justice system, acknowledged Texas is a vast state. The approach to mental health innovation should consider discrepancies in access to services between urban counties, like Harris or Travis, and more sparsely populated outer counties in his West Texas district, he said.

For example, rural counties face a lack of psychiatrists and professionals who can quickly assess people charged with crimes to determine their competency. Perry supported a measure to introduce tele-psychiatry, which allows psychiatrists to provide remote assessments, psychiatric services and expand their reach.

Lubbock is the only mental health authority in Texas using telemedicine inside jails to help restore competency, according to the Texas Health and Human Services Commission. The program began in late fall of 2018. As of March, 53 inmates have gone through the virtual treatment, in half the cases competency was restored. HHSC provided the following breakdown of the 53 cases in March:

  • 25 individuals were restored to competency
  • 15 individuals were still awaiting determination
  • 7 individuals were found not restored to competency
  • 4 individuals had their cases dismissed without a final determination of competency
  • 1 individual died
  • 1 individual became medically incapacitated

But jail-based competency restoration programs have been slow to take off. HHSC attempted to award a contract in fiscal year 2016 for a pilot program but couldn’t because of a “lack of a strong competitive pool,” according to a 2017 report. The pilot program is still in the procurement phase, an HHSC spokesperson said.

Mental health authorities in Lubbock, Dallas, Tarrant and Midland counties have used legislative grants to launch jail-based restoration programs. Those don’t involve telemedicine, and it’s too soon to tell whether they’ve been effective, according to HHSC.

Jail-based competency restoration

But mental health experts, like Greg Hansch with the Texas branch of the National Alliance on Mental Illness, say jail is not the right place to restore competency for people with serious and persistent mental illness.

			Greg Hansch’s organization NAMI Texas works to improve the lives of mentally ill Texas, according to the nonprofit’s mission statement. (KXAN photo)
Greg Hansch’s organization NAMI Texas works to improve the lives of mentally ill Texas, according to the nonprofit’s mission statement. (KXAN photo)

“If you’re exposed to the conditions that are seen in county jails around our state, it’s going to make your symptoms worse, not better. It’s not therapeutic. It’s un-therapeutic,” Hansch said. “They’re going to suffer as a result of that. And it’s going to be harder to restore their competency.”

Danny Smith, director of inmate health with the Travis County Sheriff’s Office, echoed Hansch’s concerns about jail-based programs.

Smith said housing mentally ill inmates waiting for a state hospital bed has strained his jail’s resources. If individuals were taken within three weeks to a competency restoration program, rather than spending months waiting in the county jail, the jail could close “an entire unit, if not more,” he said. One unit houses 48 inmates and requires at least six officers over a 24-hour period.

			Danny Smith oversees treatment and care of mentally ill inmates in Travis County’s jails. (KXAN Photo)
Danny Smith oversees treatment and care of mentally ill inmates in Travis County’s jails. (KXAN Photo)

Smith said community competency restoration programs allow mentally ill that can bond out an opportunity to get care outside the jail. Integral Care, the local mental health authority in Travis County, operates a community-based program where individuals receive outpatient competency restoration, he said.

Getting inmates out to therapeutic environments in the community or at a state hospital is key, Smith said, because jail is not conducive to restoring competency.

One way individuals can get out of jail and treated in the community is through the Travis County mental health diversion docket, which is part of one of the state’s two dozen mental health courts.

‘A reason to be dedicated’

There are 24 mental health courts registered with the state, providing services in fewer than 7% of Texas’ 254 counties, according to the Texas Judicial Commission on Mental Health. Travis County Court Judge Nancy Hohengarten oversees one mental health diversion docket.

Some Texas courts and counties work together to divert arrestees to services outside of jail in the community, but there are often challenges with decisions and resources.

“Travis County like other communities acknowledged that there were too many people in custody that had severe mental health disorders that were related to their offense, meaning that if their mental health was being managed and treated the offense may have never occurred,” Hohengarten said. “It’s part of a movement across the country to recognize that we have a special population that merits a different type of adjudication, perhaps.”

Hohengarten said she had about 340 cases in March on one of three mental health dockets. Individuals found incompetent are moved to a separate docket and the progress of their case is monitored while they are incompetent. A person could also be offered a pre-trial diversion program where the individual would agree take care of their mental health outside of jail in exchange for their case being dismissed usually within nine months to a year, she said.

Travis County also has residential treatment facilities that provide outpatient competency restoration programs. These facilities differ from locked-down state hospitals, but not all counties have that service, Hohengarten said.

“We created this [mental health] docket without any additional funding. The only funding that we have gotten for this docket has been for a judicial aid and some assistance in court administration,” she said. “It’s a very compelling need. It can be heart-wrenching. It’s difficult to see families with members that are mentally ill. It’s hard to see people suffer from mental illness, but at the same time it gives you a reason to be dedicated to your job.”