Barred Care: Want treatment for mental illness in Houston? Go to jail.

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The place reminds me of junior high. Cinderblock walls are painted glossy white, easy to clean. Voices bounce down long hallways and blend into the constant din—laughter, curses, metal doors, squawking loudspeaker announcements. Each day at about 3 p.m., there’s a vague, familiar smell: cafeteria food. Waiting for the elevator, I watch a guard stacking Styrofoam containers onto a wheeled cart.

“What’s for lunch?” I ask.

“Nothin’ good,” he says. “I think it’s discount taco day.”

We’re chatting on the second floor of the largest mental health facility in Texas: the Harris County Jail. Of the 9,000 or so inmates here, more than a quarter take medication for mental illness, meaning that many days, this jail treats more psychiatric patients than all 10 of Texas’ state-run public mental hospitals combined.

Most of those patients live in the general population and get their psychotropic drugs alongside inmates taking blood thinners or insulin. But some stay here on the second floor, in the Mental Health Unit, an award-winning program that functions as a full psychiatric hospital within the jail. The unit can treat almost 250 inmates at a time for serious mental illnesses. All receive medication; some also attend therapy and visit with caseworkers who help them plan for life after release. Many leave the jail more stable and connected to social services than when they came in.

Outside the jail, Houstonians with mental illness often can’t find those kinds of services. Harris County has one of the most underfunded public mental health systems in a state that consistently ranks last, or almost last, in per capita mental health spending. The Mental Health Needs Council, a policy advisory group made up of mental health practitioners, estimates that in 2012, almost 70,000 adults and more than 14,000 children in Houston with severe mental illness needed help from the public system but couldn’t get any. Hundreds of people are currently on a waiting list for basic mental health services—and that’s progress, down from 1,600 during the summer.

This isn’t because of some inefficiency in the public system versus the jail, but because of who pays for each. Community-based mental health care is funded mostly by state government, and for years, the Texas Legislature starved its public system. Like all public services, community-based mental health care was never flush, but in 2003 lawmakers slashed funding and limited treatment to just three diagnoses. Thousands of people who relied on the system were suddenly ineligible. Many went into crisis and were picked up by police or wound up in emergency rooms, where they stayed briefly, stabilized, and were released, still unable to get treatment in the community.

A crisis-driven system evolved, one that was inefficient, ineffective and unkind. It was also expensive. While the state initially saved money in 2003 and with subsequent cuts, it passed the cost on to counties, which had to deal with the real consequences of untreated mental illness. In Harris County, the number of law enforcement calls about people in psychiatric crisis jumped from fewer than 11,000 in 2003 to more than 27,000 in 2012.

As people with mental illness filled the jails, counties like Harris were forced to act. They added mental health programs to their law enforcement agencies and jails, a humane move, but one that shifts costs from the state to local taxpayers and blurs the lines between institutions designed to punish and those meant to treat. That’s how Texas’ largest jail became its largest mental hospital. And that’s why many Texans can get better mental health treatment inside the jail than out of it.

White men, age 22 to 55, who are medically indigent—meaning they don’t have insurance and aren’t eligible for Medicaid—are the group most likely to end up both needing the public mental health system and, at some point, going to jail. Preston Murski is all these things. He’s a Houston native, 22, blond and chatty, and he slips easily into a grin. But he faces an uncertain future. When we meet in the Harris County Jail’s chaplaincy room—just a concrete floor, plastic chairs, a dry-erase board and a battered wooden podium—he flickers between bravado and worry. Like all the inmates, he wears baggy orange clothes, but a purple hospital wristband signifies that he’s in the Mental Health Unit.

“I started coming to jail when I was 14,” Murski says. “It’s been in and out, doing six months in, a month out, a year in. I’ve been with MHMRA since I was 14.” MHMRA is the Mental Health and Mental Retardation Authority of Harris County, the primary provider of public mental health services for medically indigent Houstonians like Murski.

“When I was in juvenile [detention], they give you one or two free refills of your medication. My medication costs like $800 because I take a lot of Seroquel, and I take a lot of Adderall. So [after] I get that free refill, my dad’s like, ‘I’m not paying this money. I ain’t got the cash.’ And I’m not on insurance, nothing. I’m just walking around. So meds run out. I go to jail. It’s always been the story of my life. If my meds run out, I go to jail.”

Access to services for juveniles is a major challenge in Houston. The Mental Health Needs Council found that in 2012, about 19,300 children and adolescents in Harris County suffered serious emotional disturbance and needed help from the public system. Most had already developed substance abuse problems and 40 percent had been exposed to trauma. But 74 percent of those 19,300 kids received no mental health treatment at all.

Many ended up in trouble with the law. Almost 69 percent of the children referred to the Harris County Juvenile Probation Department in 2012 had a diagnosable mental illness.

One reason so many kids can’t get help is the waiting list for public services, though the waiting list is likely to shrink since the Legislature dedicated funds for its elimination last session. But a child can end up on a waiting list only if his or her parent recognizes a need and knows where to seek help. Cuts to schools have hurt the first line of defense. “We still foolishly think that all schools have counselors,” says Dr. Robbie Sharp, chair of the Needs Council. “They don’t. Some of them don’t even have school nurses. So even the places everybody thinks kids can get help and have someone to talk to, that’s not true.”

Although the Legislature has restored some money for community centers to offer medication, programs that used to provide child therapy and training to help teachers recognize mental illness remain unfunded.

But one place juveniles can still get counseling is the criminal justice system. Sharp says, “Like the adult system, sometimes the first time these kids have gotten therapy services has been once they’re on probation. That’s kind of sad.”

Access to therapy is good, but early contact with police often turns into repeated contact. It did for Preston Murski. Over the years, he’s been in and out of jail for theft and trespassing. This time, he’s in for running away from the halfway house where he was paroled after breaking into his father’s home. He lives with his father intermittently, between bouts of jail or homelessness, but his dad had recently kicked him out.

“When the police arrested me,” he says, “at first he wrote down on the thing, ‘Trespassing.’ Then I shot my mouth off in the cop car and I said, ‘I wanna get 20 years!’ So he ended up putting burglary of a habitation.”

Impulsivity is one symptom of bipolar disorder, which Murski has. He was untreated when he was arrested because he couldn’t afford his medication. But when we meet, he’s getting medicated in the Mental Health Unit’s acute ward. Its dorms are smaller and less crowded than general population, and inmates see a doctor weekly and are supervised by nurses and psychiatric techs. There’s also a step-down unit that’s less intensive, where inmates stay in larger dorms and have more freedom, the idea being to prepare them to rejoin the general population. Some inmates attend group therapy or cognitive behavioral therapy.

Murski is in the acute ward because he hears voices that sometimes tell him to hurt himself. Being in the acute ward makes him feel safe, in part because he can’t get certain commissary items like razors. Down his inner forearm is a long scar from when he ordered a friend to cut him with a carpet knife. “You can see where it was supposed to go down my whole arm,” he says, pointing to where the scar stutters at the end. “But it skipped because I jumped back.”

The voice, he says, is “not bad. It’s not like something’s talking to me right now while I’m talking to you. It’s just every once in a while I hear something in my head that ain’t right. It’s not my conscience and it’s not me. It’s something else.”

Alcohol makes the voice worse. Murski says, “Whenever I get drunk and I’m around different people, I try to show off in front of them. I start listening to my voice. Well, this dude was riding by on a bicycle, and my voice said, ‘Hit him!’ So I said, ‘Watch this.’” He mimes clotheslining the cyclist. “Pow! He got off the bike and started fighting me.” Murski tilts his chin. “That’s how I got that scar right there.”

Like more than a quarter of Houstonians with severe mental illness, Murski has a substance abuse problem. Though drinking makes the voices worse, it also helps his mood. “I self-medicate with alcohol,” he says. “Alcohol seems to level me out. It makes me happy, helps me go to sleep, and it’s cheap. It’s like a big package with a bow on it, wrapped around a 40-ounce.”

Alcohol is also easier and cheaper to buy than medication. While the waiting list for public services in Harris County has been cut in half thanks to a recent cash infusion from the state, it still has 700 adults at this writing. No one can enter the mental health system unless someone in it drops out or, more rarely, doesn’t need help any longer. Once in the system, if they miss one appointment, they go back to the end of the wait list. Those currently on the list have been waiting an average of about six months for care.

Being untreated makes it harder to stay out of trouble. A six-month study by Harris County’s public mental health authority found that people on the waiting list were three times more likely to end up in the Harris County Jail than their counterparts receiving services.

But once in the jail, help is available. Dr. Scott Hickey, director of outcomes management for the county mental health authority, says that’s both good and a symptom of the public system’s problems. “There are any number of individuals who have dropped out of the treatment system who reconnect through our jail mental health services,” Hickey wrote in an email. “In addition, there are many who received care only through the jail. [T]he root cause of many system problems, including this one, is our inadequate outpatient service capacity.”

The mental health authority estimates it would need a fourfold budget increase to satisfy the current demand in Harris County. But there is a way lawmakers could decrease demand: expanding Medicaid. Andrea Usanga, policy director for Mental Health America of Harris County, an advocacy group, says that had Texas chosen to expand Medicaid under the Affordable Care Act (aka Obamacare), it would have made an enormous difference. “Close to 90 percent of the individuals who are currently served in the public mental health and substance abuse system would be eligible for Medicaid if it were expanded,” she says. Gov. Rick Perry’s choice not to expand it, she says, was “all political. It’s really sad. Ideology hurts everyday people all the time. Everyday people are suffering.”

Harris County’s public mental health authority not only lacks the funds to meet the demand in the community but also can’t offer whole areas of needed services, Usanga says. When I tell her about Murski’s alcohol problem, she nods. “I’m not surprised.” She says that one of the major barriers to effective mental health care is that the public system still treats mental illness and substance abuse separately. “If you have a substance abuse issue, there’s a very, very high likelihood that you’re having some type of mental health issue, too,” she says. “MHMRA will treat the mental health issue, but you can’t go to MHMRA to learn how to safely withdraw from substances. Our system is not set up to do this. So it’s a very ineffective way to be dealing with folks with co-occurring issues.”

In jail, however, Murski is both medicated and forced to be sober. When we meet, he’s clear-eyed and hopeful. He talks about someday going to community college to become a licensed chemical dependency counselor. “Because I’ve been off drugs for a couple of months now,” he says. “I haven’t been drinking or using.”

“Since you’ve been in here,” I say.

“Yeah,” he says, looking down.

Murski will get out of jail soon. When he does, he’ll have a prescription, a bus pass and six weeks of free lodging in a halfway house to finish his parole. After that, he plans to move in with a friend and try to get hired at the labor agency where he used to work.

“I do have a plan on doing the right thing,” he says. “I’m just scared that I’m institutionalized.”

That may sound absurd coming from a 22-year-old, but for inmates like Murski, staying out of jail is hard. He doesn’t have stable lodging. So if his plan to stay with a friend falls through, he’ll be homeless again. Being homeless makes it harder to keep psychiatric appointments and stay medicated, which puts him at risk for having his symptoms return. And a young homeless man in psychiatric crisis is likely to end up back in jail.

In 2011 and 2012, some 920 people were booked into the Harris County Jail five times or more. Formally, they’re known as “chronic consumers,” but behind closed doors they’re called frequent fliers, people who use hundreds of thousands of dollars in public services cycling through jails and emergency rooms for years. Well over half of chronic consumers have a mental illness; almost two-thirds are homeless.

Harris County launched a program in 2009 to identify chronic consumers who had frequent run-ins with police and to connect them with services. It’s been successful; the county has reduced its clients’ contacts with police by about half. A new pilot program, funded by the state, will target 500 chronic consumers and do even more, providing medical, psychiatric, substance abuse and housing services in Harris County during their first weeks out of jail. The goal is to save money in the long run by breaking the crisis cycle, preventing re-incarceration and re-hospitalization. But are the millions appropriated for it well spent?

Usanga, of Mental Health America, is among those with doubts. “If you look at these folks that we’re targeting in Harris County,” she says, “[who have] 20 or 30 years of criminal justice involvement, saying that some months or even a year of case management is going to break that cycle—that’s very, very difficult. The Legislature invests a lot when we’ve already gotten to the point where it’s most difficult to treat something.”

The Harris County pilot program, for example, got $10 million to address the needs of between 500 and 600 chronic consumers for the next two years. That’s about $9,000 per person annually—considerably less than the price of a year in jail, but far more than outpatient care. The problem is that even with the new efforts, Usanga says, chronic consumers are likely to spend time in jail.

“With this program, they’re going to have to determine what success is,” Usanga says. “Again, you can’t say that success is the person’s never going to come back [to jail], especially when you have somebody with histories as complicated as many of these individuals. It may just be like, well, it’s better if instead of coming back after one month, they come back after two.”

Community-based care, however, is downright cheap. In fact, an entire year of outpatient care costs less than the average jail stay of 40 days.

Mental Health America believes that’s where state money should be going. Usanga says that the last legislative session, when lawmakers added $350 million for various mental health programs, was a start, not a solution. “It’s like, we appreciate what you’re trying to do,” she says. “You’re trying to make up for years and years, decades of ignoring us. But we can’t fix it in two years.

“Since 2003,” Usanga says, “you’ve had a lot of people who for the last 10 years have made jails their home, who are caught up in that system. Can you just undo that in the next year, in the next two years? If you look at those folks who were doing fine before 2003, and now have been living in the jail, can you undo it for them? I don’t know. I don’t want to say no. I say it would be very difficult.

“But can we, moving forward, prevent a whole other generation from being lost in that manner by putting money into community services, by ensuring they don’t have to wait five months just to receive services? Hopefully. That’s the goal. But if the thought is that miraculously, because an additional $300 million has been appropriated to mental health and substance use services, they can turn back the clock on all the damage that’s been done over the past 10 years, I think it’s going to take a lot more from the Legislature than that. And not just in money, but in their policies. I think the Legislature still has some work to do.”

Part of the problem is that Texas has a chronic shortage of mental health professionals. “That [new] money, for the most part, has to pay for staff,” Usanga says, “but we don’t have the workforce.” Harris County’s mental health authority “can post all these positions—they need X number of psychologists, X number of psychiatrists, X number of social workers—but if no one bites, they’ve got $10 or $20 million that they can’t do much with. If they can’t do anything with it, they still have their waiting list.”

The staffing issue is statewide, but Usanga says it’s especially bad in Houston because of competition from medical centers. “Would you choose going into the public mental health system over MD Anderson or Methodist, one of those hospitals?” she asks. “Unless you have a heart for a certain population, I don’t know.”

Dr. Sharp of the Needs Council sees the same problem. “We have to have bodies,” she says. “Now everyone that got those funds is competing for the same psychiatrists, psychologists, social workers and counselors. But you can’t just wiggle your nose and have a mental health clinic set up and staffed.

“My concern is, [lawmakers will] say, ‘Well, we gave you the money and what did you do with it?’ I think that’s all our concerns. How do we demonstrate that we can use these funds we’ve been begging for?”

While community clinics have gone begging for years, the Harris County Jail has become only more sophisticated as a provider—and it will continue to do so. In November, Houston voters approved a new joint city-county inmate processing center to be built across the street from the jail. One selling point to voters was that the center will include dedicated space for mental health providers to identify and divert people who need services, not jail.

Unfortunately, even the new processing center is managing, rather than fixing, the crisis-driven system. Getting help on the way into jail is better than being helped in jail, or not being helped at all, but it still means a person has been picked up by police while in psychiatric crisis.

Usanga wants help to be available before emergencies arise. She says getting the community system to that point will be slow going. “[2003] was a big cut in funding. Even if you put it all back, it does still take time.”

Deputy Edwin Long watched the consequences of those cuts firsthand. He’s worked in the jail’s Mental Health Unit for almost two decades and sees the same faces again and again. Tall and imposing with an exceedingly gentle face, he embodies the unit’s strange blend of caretaking and punishment. Like all staff in the unit, he wears a navy blue polo shirt rather than a deputy’s uniform, a gesture toward his mixed role.

“There are always going to be mentally ill people in jail,” he says. “Always. But right now there’s too many.”

Long says the number of inmates needing psychiatric care has grown dramatically since 2003 because people can’t stay medicated in the community. “When they stop taking their medication, that’s when they get into trouble and end up coming back to jail. They’ve told me they have trouble affording it, or they don’t have transportation.”

Getting to and from psychiatric appointments can be a major problem in Harris County, which has little public transportation and sprawls over 1,178 square miles. Long says the lack of enough clinics has a direct impact on how many people with mental illness he sees.

“The more facilities they have outside, the less the mentally ill population will be inside the jail,” he says. “That’s clear.”

Besides its overwhelmed community services, Houston suffers from a shortage of state-funded inpatient beds for people in need. Last year, the Mental Health Needs Council found that Harris County had fewer than nine public psychiatric hospital beds per 100,000 residents. Experts recommend seven times that many for a county Harris’ size (the national average is 17). While Harris County is allocated some beds in Texas’ public mental hospitals, about 70 percent of them go to forensic cases—patients sent from the Harris County Jail for what’s called “competency restoration.”

Competency restoration is another place Texas’ criminal justice system and anemic public mental health system collide. When someone is arrested and charged with a crime but found incompetent, or too mentally ill to assist in their defense or stand trial, they’re sent to one of 10 state-run mental hospitals for treatment until their competency is restored. If no beds are available, inmates can languish in jail, untried—and, depending on the jail, potentially untreated. The state has taken several steps toward ameliorating the problem, including dedicating more public beds to forensic cases. And in 2012, a Travis County district judge ruled that inmates couldn’t be made to wait more than three weeks for competency restoration.

But every bed used by someone from a jail is one less available for people in emergency rooms. In other words, Texas reduced the number of beds for those in crisis who asked for help before committing a crime.

Usanga, of Mental Health America, says this exposes the state’s flawed priorities. “You can’t get in there if you need services unless you’re coming in through the criminal justice system,” she says. “So what we’re doing is telling people, in order for you to get help, in order for you to go to the state hospital, you have to commit a crime. That’s not right.”

Deputy Long says this is sometimes literally true. He knows some inmates who’ll violate the law and intentionally get caught just to access the treatment in jail that they can’t get outside.

“I have one [inmate] that would break windows, is what he did,” Long says. “So whenever he was depressed, had no place to stay, he would break a window and sit down and wait for the police to come.” Long shakes his head. “If they had enough places outside where they could go when they got into trouble, they wouldn’t have to go break that window.”

He acknowledges that, in the absence of community-based care, the jail has assumed more of a caretaking role.

“We have people here because they committed a crime,” he says, “and we have people here that we like to say are being rescued. If somebody did not arrest them and pick them up, they would probably be taken to a hospital extremely ill or die from exposure.

“They’re going to come here, they’re going to get fed, they’re going to get showered and clean. They’re going to see a doctor. If they need to see a dentist, they’re going to see a dentist. …They’ll come here and stay for a few months and get well, actually. So they feel good about themselves when they get released. But they’ll be back.”

Murski is one of the youngest people in the Mental Health Unit’s acute ward. “The rest are in their 30s, 40s and 50s,” Murski says. When I ask whether he sees himself in them, whether he expects to still be in and out of jail at their age, he says, “Nah, not really.” But he looks worried.

This story was originally published in The Texas Observer.