As it has statewide, the length of time mentally ill inmates at the Bexar County jail languish on wait lists to be treated at the state hospital so they can stand trial has increased in recent times.
Across Texas, 143 inmates — all charged with nonviolent, misdemeanor crimes — currently sit in county lock-ups for an average of 34 days as they await “competency restoration,” or treatment that addresses their mental illness and prepares them to go before a judge or jury. When felony defendants are added to the mix, the number jumps to more than 370 inmates on the waiting list.
Some inmates have waited as long as eight or nine months to get competency treatment before their criminal charges can be resolved, officials said.
To deal with the growing glut and ease wait times, the Texas Department of State Health Services, which oversees the state’s mental hospitals, recently reallocated space in those facilities to provide more beds for misdemeanor offenders and take them away from nonoffenders whose mental illness is so severe that a judge has determined they pose a danger to themselves or others.
At the San Antonio State Hospital, or SASH, 32 spaces for adults in an acute-crisis unit were switched to low-level defendants on the inmate waiting lists, raising the number to 112 inmate beds. The move has some local mental health officials up in arms.
“Thirty two beds may seem like a low number, but that represents the loss of one-third of our acute (civil) crisis care capacity,” said Bexas County Associate Probate Judge Oscar Kazen, who oversees cases involving people who are mentally ill and may need to be committed but are not criminals.
In a civil commitment, a judge has determined that a person’s mental illness requires longer-term treatment at a state hospital— on average 44 days — than is generally available at private psychiatric hospitals. State hospitals also typically treat people who have no private treatment options because they are poor or indigent, according to officials.
The number of inmates awaiting treatment to become competent for trial at the Bexar County Adult Detention Center wasn’t immediately available, Kazen said, but of the last 50 or so such inmates, the average wait time for misdemeanor offenders was about 25 days — not including the weeks it typically takes for an inmate to be assessed and for a hearing to be held.
“What kills us are the felony offenders, who face an average wait time of 150 days,” or five months, he said.
The reallocation of space does not affect felony offenders across the state. They are assigned to “maximum-security” beds at two other state hospitals, North Texas State and Rusk, which together have a capacity for about 300 inmates.
National studies show jails and prisons have become the de facto institution for the mentally ill, warehousing hundreds of thousands of inmates each year who need treatment.
Bexar County Sheriff Susan Pamerleau welcomed the state’s recent action, saying it’s crucial to reduce the number of nonviolent defendants who are mentally ill and waiting in jails and prisons while their charges are pending. Their behavior generally gets worse while incarcerated, she said.
But others say the reallocation will cause a domino effect: hospital emergency rooms in San Antonio and South Texas could overflow with psychiatric patients who truly belong at the state hospital, costing millions more in medical care and robbing hospitals of beds needed by those suffering dire crises, such as heart attacks.
Dr. Sally E. Taylor, chief of behavioral medicine at University Health System, said that with the reallocation of beds, the San Antonio State Hospital has space for only 80 adults who have been civilly committed by a judge. The rest of the 192 so-called “civil” beds are reserved for geriatric, adolescent and “step-down,” or residential patients. (Of those 192, 15 beds are currently out of commission because they pose strangulation dangers, state officials said.)
The state hospital in San Antonio serves an area of 55 counties across South Texas, she said, a population of about 4.2 people, according to Kazen.
“Bexar County uses those state hospital beds for patients who really need more intensive care than a community hospital can provide,” Taylor said. “With that back door shut off, it means the length of stay at any of our four or five (hospital) inpatient psychiatric units will be increased.”
An imperfect solution
This is the second time the state has reduced space for noncriminal patients and added it for inmates in order to deal with long waiting lists. In 2012, a state judge ordered Texas to reduce competency restoration waits to no more than 21 days, in response to a lawsuit brought earlier by Disability Rights Texas on behalf of inmates.
That finding was later thrown out, said Beth Mitchell, senior attorney for the advocacy group. Nonetheless, for a time, the state did well to adhere to the 21-day rule, she said. By early 2014, the average wait had dropped to about 20 days for misdemeanor offenders.
But wait times have been rising again, as the population in Texas burgeons but the number of allotted state hospital beds hasn’t grown with it, Mitchell said.
Christine Mann, a DSHS spokeswoman, said inmates getting competency treatment now make up more than half the state hospital population, at 1,226. (By contrast, there are now 1,118 patients in state facilities who are not criminals but have been ordered committed by judges.) She couldn’t provide the exact number of beds converted to use for inmates by DSHS’ recent action because it’s “too early to tell.”
In the last legislative session, she said, lawmakers provided $50 million in the current two-year budget to add 100 “community beds” — space in private and public hospitals — across the state to alleviate the shortage of space for patients civilly committed to state hospitals by judges.
Between 2010 and 2014, the state added 218 state-funded psychiatric beds in communities across Texas, she said.
“We’re doing the best we can with the resources we’ve been given,” Mann said. Inmates getting treatment to become competent to stand trial are “complex” and have longer hospital stays.
After arrest, defendants are given a mental health assessment to see if they’re well enough to understand court procedures, such as working with an attorney. Those who fail are placed on the state hospital waiting list.
The average stay for an inmate being restored to competency is 217 days, Mann said, compared to 44 days for patients who are civilly committed by a judge.
Taylor said that because of inadequate facilities, psychiatric patients sometimes stack up in emergency rooms, which isn’t an appropriate place for them.
Taylor said the Bexar County jail has room to handle 232 mentally ill inmates — although they don’t receive competency restoration care — and the jail also provides psychiatric medication to inmates who need it in the general jail population.
Taylor said inmates shouldn’t sit in jail for weeks or months to await being made competent.
“At the same time, stealing those beds from the civil side just pushes the balloon on one end and it pops out the other end, with the patient caught in the middle,” she said.
The shuffling of space at state hospitals, she said, is part of a larger issue: “It’s a lack of mental health funding all across the continuum of care. We need more beds and more access to outpatient care. More funding is at the core of the problem — we need to stop robbing Peter to pay Paul.”
Not enough state-funded community beds.
Leon Evans, CEO of the Center for Health Care Services, the local mental health authority that provides services to low-income clients, said the previous increase in the number of community beds funded by the state to deal with the inmate glut has “worked fairly well, but there’s just so many people with mental illness.”
The center screens inmates and advises judges in competency hearings and is essentially the gatekeeper for the state hospital system, Evans said.
In Bexar County, the added state funding provided room for 30 more patients who had been civilly committed by judges, Evans said, at psychiatric units at either Nix Hospital and Southwest General Hospital. But it’s not enough, he said, especially with the state once again allotting more space for inmates at state hospitals.
Kazen, the judge, said that even though the county operates an innovative outpatient competency restoration program, diverting some mentally ill offenders from the jail altogether, the loss of one-third of the space for noncriminal patients in state hospitals is likely to cause a backlog in emergency rooms.
Mitchell, the lawyer with Disability Rights Texas, said her group is contemplating filing another lawsuit over the growing wait times, but will likely hold off to see if DSHS’ action will resolve the problem.
“But this is really not a fix,” she said. “People on the civil side need a place to go, so what happens is folks who need a civil bed have to commit a crime to get that bed. That’s what our mental health system has turned into, and it’s absurd.”
The whole criminal justice approach needs to change, she said.
“These (mentally ill inmates) are being incarcerated over stupid charges, like trespassing,” she said. “The (district attorney) can dismiss these charges right away and send people to treatment instead. That would free up a lot of beds. But we need to overhaul the entire system — increase community beds, provide more housing and employment for people with mental illness and provide services in the community.”
Trying other options
Bexar County has a number of innovative diversion programs that seek to reduce the number of mentally ill people in jail. In one, a specially trained police officer, rather than arresting mentally ill misdemeanor suspects, takes them to emergency rooms or a facility called the Restoration Center to be assessed, after which they may be placed in a treatment program that bypasses jail and court altogether.
Since its inception in 2003, some 20,000 people have been diverted from jail, said county official Mike Lozito.
For suspects who are arrested, a program at the Central Magistrate’s booking office uses a legal team approach from the start to determine if indigent, often homeless mentally ill offenders are better served with treatment rather than jail, again with a goal of keeping sick, nonviolent nuisance lawbreakers out of incarceration, Lozito said.
“We still need more buy-in from judges, however, to truly break the stigmas surrounding mental illness,” Lozito said.
Yet another program allows mentally ill misdemeanor defendants to have their charges dismissed before they serve jail time, with a mental health court placing them in in-patient or out-patient treatment, although this program is still in the fledgling phase and has served only a handful of people, Kazen said.