Ronald Singer was arrested and charged more than a year ago for the murder of his ex-wife and the kidnapping of their child. He remained in the Denton County Jail all that time, unable to be tried for the crime because a judge found that he was mentally incompetent, meaning he is unable to fully understand the charges against him and assist in his own defense.

More than 2,500 mentally ill defendants are in a similar predicament. They wait in Texas county jails for months and sometimes more than a year for the kind of intense therapy and medication treatment available only through the state’s psychiatric hospital system. And while they wait, their conditions, if not treated locally, deteriorate.

These long wait times continue despite the fact the state has poured millions of dollars into upgrading state psychiatric hospitals, adding what are referred to as “forensic” beds so those jailed individuals who are seriously mentally ill can receive the treatment that will allow them to be competent to stand trial. The beds are ready and open. But state officials can’t take this specialized group of patients, they say, because they don’t have enough workers to manage them.

“We simply have significantly more people who need treatment than we can currently provide for, and the involuntary inability to comply with that order is a complete defense to contempt,” said William Wassdorf, an assistant attorney general who was representing Texas Health and Human Services during Singer’s case, told the judge, according to a Dec. 9 transcript.

Over the past 20 years, the state has reported a 38% increase in people who are found incompetent to stand trial.

The rise is anything but a surprise.

In fact, Texas Health and Human Services warned in 2017 that the state psychiatric hospital system’s reduced capacity, an increase in demand, and staff recruitment and retention challenges were leading to lengthy waits for these beds and were putting pressure on jails, emergency rooms and community-based psychiatric hospitals.

What officials did not foresee was a global pandemic, which not only exacerbated mental health workforce shortages but also kept those with serious mental illness from treatment. Experts agree that mentally ill individuals are not more violent than the general population but even so, they can be arrested for more minor crimes like loitering.

When these same individuals can’t understand the charges against them, they might be locked up longer than what their eventual sentence might have been due to a lack of available beds in the state hospital. And in turn, their detainment can now last months or even a year before they enter a courtroom because of a lack of treatment.

By the beginning of this year, the state’s nine psychiatric hospitals for adults had 5,987 full-time employees with approximately 1,805 jobs vacant. A shortage of attendants and other staff who supervise and treat patients at state hospitals has kept more than 800 of the system’s 2,351-bed capacity — slightly more than a third — unavailable for patients.

“If someone is bleeding and they go into the emergency room, the physicians aren’t going to tell them, ‘We will get right to you in a year or two years,’” said Keith Hampton, Singer’s attorney. “These are emergencies and they have been deemed emergencies by the court. They aren’t getting better in the jails. They are getting worse.”

Before the pandemic, the state started spending more than a billion dollars to expand and renovate its aging psychiatric hospital system, which dates back to the 1800s. Texas added 434 beds since 2012 along with new facilities and renovations, but workforce issues spawned by the pandemic have made the impact of these upgrades negligible.

Hampton said his client’s competency was eventually restored with medication inside the Denton County Jail after he argued in court that the state of Texas should be held in contempt over the psychiatric hospital’s refusal to admit Singer, but Hampton doesn’t think it should have taken this long. He said he has been fighting in court on cases like Singer’s for over 20 years and the lack of urgency by the state to solve the problem has been exasperating.

“Why isn’t this emergency legislation? The governor should make this an emergency,” he said. “The governor made the situation at the border a state emergency and this is equally as important.”

Impact on jails

The impact of such delays go beyond the individual inmate. This large waitlist at the state level has forced county jails to become almost secondary mental health facilities. While inmates wait for a spot in the state psychiatric hospital, jail workers are pressed into service as makeshift social workers to help prevent the mental and physical health of detainees from degrading, to the extent that is possible.

The amount of treatment a mentally ill detainee might receive while in jail varies from county to county, based on available resources. Some jails have taken to creating their own mental health teams to deal with the waitlist.

In Dallas County, there are mental health diversion teams who track and monitor individuals who enter the criminal justice system and are identified as homeless, pregnant or have veteran status. They aim to identify trends and to connect these people to assistance.

“The problem is not everyone has the capacity to do this,” Rep. Toni Rose said. “There are 254 counties in Texas, and every county doesn’t have the resources to conduct their business like Dallas County, so that is where the problem is.”

Rose, who used to work at the Dallas County Jail as a mental health liaison, said at the end of the day the No. 1 priority for those who work in the jail is security. Everything else is secondary.

“The jail is not a therapeutic environment,” she said. “The officers in these county jails are not mental health professionals.”

The question of how long county jails can sustain this workload while dealing with their own workforce shortage and strained resources is at the heart of the tension between the state and sheriffs, who oversee the state’s county jails.

The situation has escalated to the point that Dallas County sent a letter earlier this year to the Texas attorney general’s office threatening to sue the state if it didn’t help reduce the county’s 300-person waitlist of people who need to be transferred from jail to state mental health facilities.

Texas Health and Human Services have estimated the average wait time for all forensic admissions is about 323 days, but in Dallas County, the wait can reach up to 831 days for male inmates and 413 days for females.

The FBI recently announced a civil rights investigation into the state’s largest jail, which is located in Houston, after two men — including one who had mental health issues — were found dead in their cells after altercations with jail staff.

Brandon Wood, executive director at Texas Commission on Jail Standards, said every sheriff in the state will say one of their top challenges is dealing with detainees with mental health issues.

“An individual that is determined to be incompetent to stand trial should be transferred to a state hospital as quickly as possible. So that competency can be restored and justice can be served,” Wood said. “Having an individual languishing in the county jail for over a year before they even arrive at a state hospital for competency restoration only delays the whole process.”

Jail-based competency programs have been encouraged by the state as a potential solution, but the long-term viability of this idea has been questioned.

“Jail is not the appropriate environment for mental health treatment for individuals that don’t need to be in jail,” said Wood, who has been in his role since 2012. “If it’s a situation in which these individuals are taken to jail because that’s the only resource that local law enforcement believes will provide them with medical care, then that is not a good outcome.”

The purpose of the state hospital system

Krish Gundu with the Texas Jail Project worries the state has forgotten the purpose of its psychiatric hospital system.

“The state hospital system is our public health system, but the road to that is going through jails,” Gundu said.

The state hospital system for many decades accepted patients who came through the civil court system, where relatives or others petitioned the court to commit them to hospitalization because their illness presented a risk to themselves or others. This changed in the early 2000s when forensic admissions continued to climb.

This year, the state health and human services agency told legislators in a committee meeting last month that nearly 60% of state hospital beds in Texas are used by the forensic population.

House Bill 3396 and House Bill 2733 are both measures authored by Rep. Richard Hayes, R-Denton, to address the forensic patient waitlist. The former measure calls for the Texas Health and Human Services Commission to develop and implement a plan to ensure that each state-funded forensic bed is usable no later than Aug. 31, 2024. The latter requires the health agency to take on a detainee who has been deemed incompetent no later than 45 days after a judge’s order is issued. If the state doesn’t take custody of the detainee within that time then the county will be compensated.

Texas Health and Human Services officials have acknowledged the backlog. The agency has increased salaries and starting pay at state hospitals to help with crucial staffing needs.

“At this time, we are working to fill positions in order to bring beds back online, increasing the number of people we can serve,” said Tiffany Young, spokesperson for Texas Health and Human Services. “Additionally, we are working with the Legislature on increasing total capacity across the state by building new hospitals.”

David Lakey, the state’s former top public health official, said he has seen significant investment by the state to address the state psychiatric hospital waitlist, but the health care workforce shortage happens to be pronounced in these facilities, which are often located in mostly rural areas where it is harder to recruit staff.

“The psychiatrist pay in state hospitals is actually probably higher than most academic institutions throughout the state. It’s all the other staff you need in order to manage the facilities that are having trouble,” Lakey said. “If you can get the same pay and benefits working in retail without the stress of working in the hospitals then you are more than likely going to work someplace else.”

New questions

Lakey said one question that needs to be asked is if the state hospital should be the de facto place where competency restorations are done. The state psychiatric hospitals are home to people who have both an intellectual disability and have been diagnosed with a mental health issue. A patient with such a dual diagnosis will often spend their life inside the state hospital. And they’re home to people who were deemed so dangerous at one time that a judge might never feel comfortable releasing them.

“How do we protect those limited resources, our hospital beds?” Lakey said. “We have to think of a front door and back door solution. We need to find a way to do competency restorations outside the state hospital and that will free up space for those in need of long-term stay. We’ve got to divert some people from going to jail in the first place and we need to find a way to let some of these people who are now too old or sick to hurt anyone out.”

Finding and using these community resources will be key as the state doesn’t seem to have a quick solution to the waitlist problem.

“I think we are going to be behind for a while as we try to meet the growth in Texas because we were behind to begin with,” Lakey said.

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2023/03/10/texas-state-hospitals-mental-health-workforce-shortage/.

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