Minding Houston Episode V – Criminal Justice & Mental Health: Connected Because of Failure

We’ve talked about funding and workforce needs for mental health services. So why is it so important that Texas lawmakers prioritize mental health services in view of all the other needs in the state? Well, my argument would be we are already paying for these mental health services, in a much more costly and difficult way: the criminal justice system.

This is Minding Houston, I’m Bill Kelly.

Before we start this, I have a caveat I’d like to place on the connection between mental health and criminal justice. Way too often, we closely associate the two and it sometimes seems that having a mental health condition makes you a criminal or a risk to society.

Hogg Foundation for Mental Health

The Hogg Foundation for Mental Health recently hosted a forum about violence prevention and mental health at the State Capitol. Some interesting stats that Dr. Joel Dvoskin the University of Arizona brought up included:

  • People suffering from a Severe and Persistent Mental Illness are 11 to 12 times more likely to be victims of a violent crime
  • If all violence related to mental illness were to go away, the overall reduction in violent crime would be only 4%
  • The odds of someone with schizophrenia killing someone is approximately 1 in 140,000

Let me be very clear: the only thing criminal about mental illness is the way we have failed to invest in access for treatment.

With that, let’s get back to how mental health and criminal justice are connected. Far too often, this failure to invest in access has lead to individuals entering the criminal justice system, instead of the public health programs. This leaves jails and prisons becoming the safety net for Texans suffering from a mental illness. The statistics clearly bear this out.

The Meadows Mental Health Public Policy Institute list “Smart Justice” as a priority for their work. The statistics they offer show exactly why:

  • Individuals with untreated mental health and substance use disorders at 8 times more likely to be incarcerated, often due to the lack of access to appropriate crisis services and ongoing care.
  • 34% of Texas inmates have a mental health need and most have substance use disorders
  • 17% of adults entering jails and state prisons have a serious mental health illness (SMHI)

Hogg Institute - Smart Justice

What does that mean for us here in Greater Houston? Well, just listen to Sheriff Garcia talk about how much of his work is consumed caring for inmates who are mentally ill:

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Houston Matters – June 9, 2014

Sheriff: I completely agree and look, I take pride in a lot of things being Sheriff of Harris County, but the one I don’t take pride in is the fact that the Harris County jail system is often referred to as the largest psychiatric facility in the state of Texas. And look, we don’t want people in the county jail for being sick. We want them there for having committed some terrible crime, but we don’t want them there because they are sick and that it is there illness that principally drives them to come to the attention of local law enforcement. And so we need the state to be responsible about this issue, responsible about the care that these individuals need and provide the citizens of Texas a better way to respond to those challenges that some families inadvertently are confronting.

Craig Cohen: Roughly speaking, what percentage of the jail population falls under the category of ‘these are people who are mentally ill and need in patient care and by default you have to provide it?’

Sheriff: Approximately 30%. I mean, just as Bill mentioned that number is very accurate. It’s about 30% of my population at any given time and you have to recognize the significance of the fact that it’s been 30% regardless of when I was overcrowded and at 12,000 – nearly 12,000 capacity or right now when I’m not overcrowded it’s still 30%. And again, they’re there principally because they are sick, not because they are bad people.

Now, Sheriff Garcia sees the consequences of a lack of access. Another elected leader who has dealt with the state’s criminal justice system is long time Texas Senate Criminal Justice Chair Senator John Whitmire. He clearly draws the line between the lack of access for the population to mental health care and prison.

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Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

According to the Department of Criminal Justice, roughly one third of the people in the Texas prison system have some form of mental illness.

Houston state Sen. John Whitmire chairs the Senate Criminal Justice Committee. He says those inmates end up in jail because they fell through the cracks and were not being treated for their illness.

Harris County Crisis intervention Response Team

“Thirty-two-thousand have been identified, that were in a mental health program before they ever committed a crime. But because of the lack of community mental health services in this state, because of budget cuts at 2003, they do not get assistance when they’re having an episode or crying out for help,” said Whitmire.

The re-entry program for these people doesn’t exist anywhere in the state, and Whitmire says that probably means a return to prison.

“They don’t get their counseling. They don’t get their medication. They’re bipolar; they’re schizophrenic. They have an altercation with their family or a neighbor. Law enforcement is called, then they have an altercation with law enforcement. Welcome to the criminal justice system,” said Whitmire.

With these statistics and testimonials, I think we can all agree about the problem facing those with mental illness and the unfortunate burden on the criminal justice system in providing care.

So how do we make treatment more available and accessible so jails aren’t the largest providers of mental health services?

Harris County has an idea: let’s keep patients out of jail.

Last Session, Senate Bill 1185 created the Harris County Mental Health Jail Diversion program. With bipartisan support from Senators John Whitmire and Joan Huffman, County Judge Ed Emmett pushed the Legislature to match Harris County’s investment to establish a system to address individuals suffering from a mental illness that cycled in and out of the Harris County Jail. SB 1185 looks to concentrate resources and coordinate social services so that patients get the care they need outside of jail cell.

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Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

The Harris County Mental Health Jail Diversion program is the product of legislation passed by Texas lawmakers last year, that provided $5-million dollars for the launch.

Director Reginia Hicks says some goals of the program include the reduction of the frequency of arrests, incarcerations and the number of days spent in jail, to increase access to housing, health and social services, and to improve the quality of life.

“We have a special mental health program within our jails. We have specialty courts with judges that are focusing on behavioral health issues,” said Hicks. “We have providers with many years of experience.

We have the opportunity of making some earlier interventions.”

After the official launch, Harris County Judge Ed Emmett said he felt confident the Mental Health Jail Diversion program will serve as the model for other cities to emulate.

“The Legislature wants us to do it for four years, and then we will present to the Legislature what works,” said Emmett. “Because if it applies in Harris County, it clearly applies in the rest of the state, and then perhaps even the nation. So, I hope that what we develop here is the model program for the whole nation.”

Emmett and other officials often describe the county lockup as the “largest mental health facility in the state of Texas.”

It seems an obvious notion that people suffering from mental illness would be better served in clinical, rather than criminal settings. It is also much less expensive to provide acute inpatient or outpatient mental health care than the constant cycling of through county jails, prisons, and courts. The Houston Chronicle lauds the local programs that try and address this problem with this from their Editorial Board:

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Harris County has adopted some strong programs. Teams of police officers and mental health professionals partner on targeted calls to help ensure that people with mental illness are not arrested unnecessarily. Through its pilot jail-diversion program, judges work with these professionals to keep those with mental illness from cycling through the criminal justice system.

However when Texas fails to invest in the needed clinical capacity for providing mental healthcare, we pay for it in terms of tax dollars and suffering. In a separate Editorial focusing on this need, the Chronicle states, “Our current system is pennywise and pound foolish,” and concludes with the following:

Harris County is the most populous region in the state. One in 5 people, or 350,000 adults residing in Harris County, will suffer from mental illness during their lifetime, according to Harris County Psychiatric Center. The Legislature should act next session to expand the capacity of the mental health system and give us more beds for patients in Harris County, preferably in a modern facility closer to home.

Given the strong support from our local elected leaders about the need for resources to expand capacity, who are our state leaders making these decisions? As of last week, both the Texas House and Senate have named committee chairs. What do those positions mean for mental health policy in Texas? More on that, next time.

This is Minding Houston, a presentation of Mental Health America of Greater Houston. I’m Bill Kelly.


Music from this episode: “Please Listen Carefully” by Jahzzar, “The War of the Sun Fist” by Gasc@t, “Impact Prelude” by Kevin MacLeod, “Manhattan Skyline” by DeeTunez , and “I’m Fine, Dear” by Dexter Britain. To listen to the full interviews and news sampled in this program visit Houston Matters, Houston Public Media and the Houston Chronicle. And a very special thank you to Cody McGaughey for lending your voice to this episode. 

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Minding Houston Episode IV: The Mental Health Workforce

With the 1115 Waiver making investments in behavioral health services throughout the state, and especially here in Greater Houston, it’s natural to ask the question about the professionals needed to staff these new programs. And we don’t just mean psychiatrists, but the full spectrum of mental healthcare positions, just like those masters degree clinicians from MHMRA riding along with police officers for our CIRT units. In this episode, we’ll look at the best data to describe the mental health workforce shortage that should catch everyone’s attention, especially our lawmakers.

This is Minding Houston, I’m Bill Kelly.

Before jumping into legislative solutions about how to attract more mental health professionals, it makes sense to ask the question, “do we really need them?” Or, to say it another way, what are the consequences of not having an adequate mental health workforce? A 2011 report by the Hogg Foundation for Mental Health entitled “Crisis Point: Mental Health Workforce Shortages in Texas” gives a clear answer on what we face:

The cost of mental illness does not simply disappear when service providers are not available. Instead, these costs transfer to other less effective, more expensive and unprepared environments, such as prisons and hospitals. Research and experience clearly show that the lack of sufficient mental health services often results in hospitalization, incarceration or homelessness, creating far greater economic and human costs.

Supporting a strong system of mental health services isn’t just for the benefit of people with mental illness. Mental health and wellness are important to all Texans. Without a strong mental health system, communities suffer through lost productivity, unemployment, job absenteeism, increased involvement with law enforcement, and increased local hospital costs.

Now, for anyone who cares about the bottom line in budgets, the quality of life for patients, and need for a healthy Texas, these consequences are simply unacceptable. Alright, so we know there is a problem, but how bad is it?

Hogg 11

The report sites the following:

  • Compared to California, New York, Illinois and Florida – the other four most populous states – Texas has the most severe short¬age of psychiatrists, social workers and psychologists
  • The pool of mental health professionals is aging. In the coming decade, many psychiatrists, social workers and other providers will leave the workforce for retirement.
  • These shortages are felt most acutely in rural and under served areas of Texas, such as the border region.

Code Red LogoUnfortunately, things haven’t improved since this report was released in 2011. One of the most respected health care groups in Texas just released a report this January that echoes many of the same concerns. In an interview with Houston Public Media, Code Red’s task force chair and former state demographer Steve Murdock discusses the situation with behavioral health:

Maggie Martin: Medicaid wasn’t the only issue or concern that was raised in this report and something maybe especially raised for Houston, being the home of the Texas Medical Center. What are some of the issues and concerns the task force found within the health care profession itself?

Steve Murdoc: Well, I think that’s one of the things that we found is of course In areas, particularly in behavioral health, we are very short in terms of personnel. We have a wonderful medical center and it does lots of things very well but when it comes to behavioral health we lag behind many other states. I gave you the earlier example of 49th in terms of psychiatry in the country and so certainly we have areas in our health care system where we need to provide more physicians. We have for years, for example, lacked enough residencies. Now the reason that is so important is that one of the best predictors of where a physician will end up practicing is where he or she does their residency and we actually export people to residencies in other states which means that they are likely or less likely to come back and practice in Texas. So a number of things about our program are such that indicate we can also do a better job of ensuring we can get as many of those excellent students that we produce from our medical schools to stay and practice in Texas …

The good news is the Legislature is paying attention. In fact, during the last legislative session in 2013, Republican Representative Cindy Burkett from North Texas, and Democratic Representative Carol Alvarado from Houston co-authored a bill calling for a study of the Texas Mental Health Workforce Shortage and possible solutions.

The final report was issued in the September of 2014, and as you would expect, it confirmed the very serious problems Texas will face without immediate investment. Out of the five themes discussed in the report, the first recommendation is the most important in addressing this problem. Quoting from the report:

At its core, the mental health workforce shortage is driven by factors that affect recruitment and retention of individual practioners. Chief among these factors, as studies and stakeholders suggest, is that the current payment system fails to provide adequate reimbursements for providers, especially in light of the extensive training necessary for practice.

Furthermore, more students may be attracted to the mental health professions by strengthening graduate medical education and by exposing them to opportunities in the mental health field earlier in their education.

Like a lot of public policy, it boils down to money. Our state has failed to invest in this area, and unless we start making a down payment for our mental health workforce, we will undoubtedly suffer the consequence that a lack of access brings.

That’s where Sen. Charles Shwertner comes in. The new Texas Senate Chair of Health and Human Services is tackling the issue of mental health workforce for the full spectrum of providers. The Texas Tribune’s Alana Rocha reports:

Bluebonnet officials say that a bill by health and human services committee chairman Charles Schwertner could elevate the prestige of the profession and help workers balance their desire to serve the mentally ill, make ends meet, and pay off their loans. Schwertner filed a bill Monday to create a grant program to repay loans for licensed professionals, social workers, psychiatrists and psychologists.

“Money spent on mental health is money that is effectively spent. It keeps people out of the emergency room, it keeps people out of the jails and also the school resources that are spent on individuals that need help. If you can catch someone early, get them the right treatment in the right setting that’s the way to handle mental health. It’s cost effective.”

“There’s a huge return on investment for this.”

Andrea Richardson knows first-hand as the executive director of Bluebonnet she worked with Senator Schwertner, himself a practicing physician on developing the bill that creates a commitment from professionals seeking loan reimbursement. The percentage of the loan repayment grows with each year they work in the field.

“It recognizes the value of mental health. It allows for mental health to become a part of the health care system. You know so often we disconnect the mind from the body when in reality it’s the mind and the body working together that keeps us healthy.”

An integrated approach to addressing a growing need.

So, how did this trained orthopedic surgeon suddenly becomes one of the leading advocates for mental health in the entire Texas Legislature? Well, as the Houston Chronicle Editorial Board writes in support of his bill, he might have just been listening to mother:

MASTHEAD-Houston-Chronicle

Each of our incoming legislators will bring varied life experiences to the next session and its upcoming debates over spending and priorities. That’s certainly true of state Sen. Charles Schwertner, R-Georgetown. Schwertner, one of the few doctors in the Legislature, is not only an experienced orthopedic surgeon but also has some familiarity with mental health care. Schwertner’s mother spent over 25 years as a nurse in Texas’ mental health system. The state senator has a habit of saying that he knows firsthand what impact a dedicated mental health professional can have on the life of someone suffering from mental illness.

After reviewing many of the same statistics cited in the previous studies, the Chronicle concludes:

The Legislature should make Schwertner’s mother proud and act to pass his bill, a good first step in heading off this growing crisis.

So we’ve heard from the Hogg Foundation for Mental Health, the medical experts at Code Red, a workforce shortage study of House Bill 1023, and the newly filed mental health loan repayment bills and we hope our Legislators listen to Senator Schwertner’s mom.

But what happens when we don’t listen? In this case, what happens when we fail to provide access for mental health services? Quite simply, we face the same health challenges but we face them in a criminal justice setting. More on that next time.

From Minding Houston, I’m Bill Kelly.


This weeks episode includes “Dirty Night,” “Settling In,” and “Slow Motion Strut” by composer Dexter Britain and “Ego Grinding” by Megatroid. Hear more of Dexter Britain’s music at DexterBritain.co.uk and Soundcloud and listen to “Ego Grinding” at FreeMusicArchive.com

View the 2011 Hogg Report here and read Code Red: The Critical Condition of Health in Texas for detailed information about the Texas mental health workforce shortage. Listen to the full Houston Matters interview with Code Red’s task force chair and former state demographer Steve Murdock and hear more about Charles Schwertner’s loan reimbursement bid at the Texas Tribune website. 

Minding Houston Episode III: The 1115 Medicaid Waiver in Houston

What if I told you the State of Texas and the federal government are working together, on an $11.4 billion partnership to help increase access to care for Texans? There are no lawsuits, political posturing, or name calling. The program is praised by Republicans, Democrats, and every healthcare organization across the state. Sound impossible? Well, let me tell you: it’s all true. And when it comes to increasing behavioral health services, it’s even better.

This is Minding Houston, I’m Bill Kelly. 

Today, we wanted to talk about the biggest expansion of behavioral health services in Texas. Ever heard of the 1115 Waiver? Well, if not, maybe it’s because it hasn’t generated the, let’s call it the “heat” that other federal initiatives have here in Texas.

So first things first, what is the 1115 Waiver? Simply put, it is a 5 year agreement between the federal Center for Medicare & Medicaid Services, or CMS, and the Texas Health and Human Services Commission, or HHSC. Together, CMS and HHSC have negotiated a plan to combine state dollars spent on healthcare to draw down matching federal funds all in an effort to expand the footprint of healthcare services in Texas.

1115 Medicaid Waiver made easy

       1115 Medicaid Waiver made easy

So what does this really mean for us in Greater Houston? As it turns out, quite a lot. Over our nine county Regional Health Partnership (one of 20 organized throughout the state), we stand to gain over $2.3 billion dollars in expanded healthcare services.

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So, what do these programs look like? Well, let me introduce you to two programs funded
by the 1115 Waiver. First, in a report by Houston Public Media’s Carrie Feibel, is a look at Mental Health Crisis Clinics set up by Memorial Hermann.

Now, as we’ve noted before, the lack of access to mental healthcare leaves an increasing number of cases to be handled by law enforcement. That’s where our second example, the Crisis Intervention Response Team comes in. In this story by KHOU reporter Jeff McShan, you can see first hand the difference having both a mental health professional and law enforcement training has in dealing with a mental health crisis.

Both the Memorial Hermann mental health crisis clinics and three CIRT details are funded by the 1115 Waiver using Delivery System Reform Incentive Payments, or DSRIP funds. In our area, there are 55 projects specifically for Behavioral Health totaling $457 million dollars. Now, remember from last week, our state spends just over 1 billion a year in mental health services through DSHS for the entire state, and DSIRP dollars put almost half a billion right here in our own backyard.

This badly needed expansion of access for mental healthcare represents a huge step forward for the State of Texas. But it also brings a number of challenges. Like, do we have enough of a workforce to staff this expansion? What is the mental health workforce shortage and what we can do about it? More on that, next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.


Music from this episode: “Rollin at 5 – 210” by Kevin MacLeod and “Sand Castle” by Pitx.

To hear Carrie Fiebel’s full report about the Humble Crisis Center, listen here at Houston Public MediaTo hear more about the HPD Crisis Intervention & Response Team (CIRT), watch here at KHOU.com.