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B.R. was 12 when she tried to overdose on Midol in her rural Uvalde junior high bathroom last year after the bullying at school had become too much to bear.
The girl’s first appointment with a counselor at the government-funded mental health authority finally came in May — a year and a month after that suicide attempt.
Now her family worries that the limits of the small-town system they rely on make it ill-equipped to meet the needs of children like her — suicidal, isolated and with few things standing between her and another attempt at taking her own life.
“I understand there’s a process in order to get help,” said her mother, a 39-year-old Uvalde resident, who asked that the family’s name not be used in this story. “But we’ve gone through so many things already. It takes so much time to get help that sometimes a family just gives up.”
Despite the teen’s isolation in the South Texas town of 15,000, B.R. is not alone. She is among millions of people scattered across the rural counties of Texas who are vulnerable to higher rates of depression, anxiety and suicide than their urban counterparts — yet they have only limited access to patchwork mental health services from a handful of understaffed or underfunded providers.
The weight of the shortcomings of Uvalde’s mental health system came down hard after a troubled teen, raised in the small southwest Texas town, entered Robb Elementary School a few days before summer break and shot to death 19 children and two adults with an assault rifle.
While many debated the merits of more gun restrictions, Gov. Greg Abbott and other Texas Republicans defended Texas’ lax gun laws and instead blamed poor mental health services in the area, although no evidence has been produced the shooter was ever diagnosed with a mental illness. Their response was to send a wave of state-funded and -organized services to Uvalde, including a federally supported crisis center known as the Uvalde Together Resiliency Center.
While it’s unknown whether the shooting had anything to do with the lack of mental health resources, few dispute that Uvalde has little to offer.
“There’s never enough. There’s never, ever, ever enough in rural Texas,” said Todd Russell, a professor retired from Sul Ross State University Rio Grande College who taught counseling in Uvalde for over two decades.
According to the U.S. Department of Health and Human Services, Uvalde has about 15 mental health professionals based in the town, and those include marital therapists and substance abuse counselors. There is one psychiatrist affiliated with Uvalde Memorial Hospital, where emergency room beds for mental health patients are most often used for drug cases. There is no dedicated mental health hospital or residential treatment facility.
Residents in Uvalde and other rural Texas towns “might as well be living on the other side of the moon” when it comes to mental health access, said Steve Bain, interim dean of the College of Education and Human Performance at Texas A&M University-Kingsville and a counseling professor.
Wait times for services can be months, even for suicidal patients, said Bain, whose research focuses on rural mental health.
“It’s almost impossible to get people in to a psychiatrist,” Bain said. “Often the county mental health services are so backed up, they don’t have the specialized professionals working with them that they need to help these kids.”
The problem isn’t just proximity, but also poverty. Some 30% of the children in Uvalde live below the poverty line, according to health data collected by the Robert Wood Johnson Foundation.
“You have to look at the income in these communities: A large part of them are working at minimum wages, and they don't have the time and the luxury of having health insurance or the ability to take off from work,” said Marian Sokol, executive director of Children’s Bereavement Center of South Texas, which worked with students in Sutherland Springs after a church shooting there in 2017 and is setting up a location in Uvalde with at least one full-time counselor for the next several months. “They might be struggling to meet the basic needs of their family — food and housing — and not be able to focus on mental health as much.”
A narrow safety net
The mental health care services in Uvalde fall to fewer than a dozen agencies, private providers, churches and publicly funded clinics — all of which have a limited reach.
Most mental health care in the region falls to the state safety net, which in Uvalde is Hill Country Mental Health and Developmental Disabilities Centers, the local mental health authority offering treatment to the mostly uninsured and underinsured.
The agency is based in Kerrville but has a center in Uvalde, a collection of tin buildings on a sun-soaked parking lot that serve as a regional hub for the agency.
Known locally as MHDD, the agency serves roughly 15,000 people a year in a 19-county region stretching from the Austin suburbs down to Uvalde and west to the Texas-Mexico border in Del Rio. Its service area is 23,000 square miles, with a population of about 760,000 people.
In Uvalde, about 550 residents receive mental health and developmental disability services through Hill Country MHDD, said Tod Citron, the agency’s chief executive officer. The Uvalde office has 20 employees it shares with two neighboring counties, with a collective population nearing 30,000 people.
Community Health Development Inc. runs a federally qualified health clinic in Uvalde that also offers mental health services to impoverished patients, with a psychiatrist and a licensed social worker on staff.
Republican state leaders have increased mental health funding by hundreds of millions in recent years — with more attention on the issue following the shootings at Columbine High School in 1999 and a 34% increase in funding since 2015 — and yet Texas still ranks 51st among states and Washington, D.C., in per capita state spending.
That resulting safety net is so narrow that it catches only patients with the most complex or dire mental health issues, leaving out vast swaths of people who urgently need care before their problems escalate into major life issues, suicide or — in the rarest cases — mass violence, Heinz said.
And while that is a problem in cities large and small across Texas, she said, mental health care access shrinks even further in small underserved towns like Uvalde, where 20% of residents live in poverty and nearly a quarter have no insurance.
A new state program designed to help at-risk youth through early intervention had not reached Uvalde by the time Salvador Ramos killed 21 people with an assault rifle he purchased legally as soon as he turned 18 in May.
That program, run by the Texas Child Mental Health Consortium, is funded at $25 million per year to serve 40% of the students in the state, much of that through federal COVID-19 money.
So far, the two-year-old program has served more than 6,000 children, a number that would have been higher had the pandemic not stymied its growth, officials said. The consortium’s leaders say they expect that number to increase exponentially as the program takes hold in more districts.
When demand for services provided by a separate program, Communities In Schools, the largest provider of school-based behavioral health services for students in Texas, was at an all-time high in 2021 because of mental health issues brought on by the pandemic, its request for additional federal funding was denied by the Texas Legislature last summer. That program was not in Uvalde at the time, although it has responded to the Robb Elementary shooting.
This health access gap disproportionately impacts communities of color, who make up the vast majority both of residents in the Uvalde region and patients without insurance.
Alicia Ramirez, a registered nurse with Methodist Healthcare Ministries of South Texas, Inc., said many of her patients have language barriers or lack the information necessary to recognize a mental health problem and seek care. It’s also a cultural issue, she said.
“It’s a stigma,” Ramirez said. “They don’t like to talk about those things sometimes, especially in our culture.”
Family Service, an organization that partners with schools to provide mental health counseling as well as drug prevention and after-school programs, opened its first Uvalde offices 20 years ago in Robb Elementary, though it has since moved.
The San Antonio-based organization serves much of the Hill Country through its rural area services program and is one of about half a dozen small private or nonprofit agencies operating in Uvalde and the surrounding area. Many of them are charity- or grant-based with oft-changing missions or based in churches. Nearly all of them are either based somewhere else or covering several rural Texas counties.
None of it comes close to meeting the demand, said Mary Garr, Family Service’s chief executive officer.
“The resources needed are much greater than what Uvalde currently has,” she said.
But of all the medically underserved areas in the region, in fact, Uvalde has historically been better off than its counterparts.
Of six counties that border Uvalde, with a collective 125,000 people, not one of them had a working psychiatrist full time in 2020, according to DSHS.
Statewide, some 61% of adults with some form of mental illness reported that they weren’t treated. About one-fifth of adults with mental illness are uninsured in Texas, according to Mental Health America’s recent survey, twice the national average.
Texas ranks in the bottom fifth of states when it comes to youth mental health services.
The Texas Department of State Health Services predicts that with population and health projections, South Texas will need 50 more psychiatrists in the next 10 years — but is on track to add only 10.
Experts fear a powder keg in rural Texas, where residents are lucky to have more than one stoplight, let alone an army of therapists and intervention specialists waiting to intervene in a crisis. Where the state’s gun restrictions for people with legal indicators of severe mental illness ring hollow without ways to identify those people to begin with.
“We are a desert in more ways than one,” Russell said.
Debate continues over whether a stronger system in Uvalde could have prevented the Robb Elementary shooter from committing such an atrocity — if his early problems of truancy, cruelty to animals and violence at home and at school that appeared to raise few red flags in his hometown might have been recognized in a system set up to intervene with people just like him.
There is doubt that Uvalde’s gunman could have received the treatment he needed even if he had been diagnosed because so little help was available before the shooting.
The majority of individuals diagnosed with mental illness do not engage in violence against others. But people who commit mass murder are also apparently experiencing some kind of mental or emotional episode or break, doctors say, even if it’s not a diagnosable mental illness. If and when it might cross the line into violence is impossible, usually, to predict.
But Ramos’ actions on that day in May — as well as the experiences of B.R., the teen who waited for a counselor for a year after her suicide attempt — open a window into the dangerous gaps in health care. While these gaps may not be unique to rural America, they are especially difficult to solve there.
Holes in critical points of treatment leave vulnerable the 15 million Texans living in mental health shortage areas across the state — including the Robb Elementary victims. Ramos had warning signs that might have been recognized had more services been available — but he likely didn’t have those professional mental health supports when he needed them, said Tammy Heinz, senior program officer at the University of Texas Hogg Foundation for Mental Health.
“I do not in any way want to minimize the 21 victims and their families,” Heinz said. “But there’s also another person in this. Somewhere along the way we — the societal we — we missed something. This was a child up until a couple of months ago. And somewhere along the way he didn’t get something he needed.”
Early intervention
Early intervention, whether through mental services or even family counseling, can help turn troubled youth away from suicide or violence, experts say. When a child is at risk of dropping out of school or is sent to an alternative school program for acting out or has a history of police visiting the house on domestic calls, those can signal problems that a mental health professional, family counselor or social worker may be able to help solve.
In communities with stronger systems, those youth are often identified in the courts or at school for help before their problems turn into bigger issues. But in Uvalde, as with other underserved places, there are no formal mechanisms in place to do this. There are no automatic referrals to counselors for truancy, for example, or for alternative school placement.
The Uvalde school district has 18 counselors, but many of them must split their attention between academic duties and support for a student population of more than 4,000 — two thirds of whom are considered at high risk of dropping out.
Hill Country mental health’s CEO said early intervention plays a critical role in managing the mental health of a community, and particularly before crises reach a point at which someone is hurting themselves or others. But there is no room in the budget for any of those programs.
“We are very supportive of early intervention, but with the limited funding that we have historically received, that funding has had to be dedicated to serving those individuals with the greatest need and in the communities that have the greatest risk,” Citron said. “That has not left resources on the table for a lot of early intervention services, which we believe is one of the ways that we can truly address the mental health crisis in Uvalde, in our service area and across the nation, for that matter.”
This past spring, about year after B.R.’s suicide attempt, her mother noticed her daughter withdrawing again, refusing to come out of her room. In May, the two were poolside when the mother noticed the cuts on B.R.’s thigh.
She brought it up to the pediatrician two days later at the annual visit, and the doctor sent them immediately to the emergency room. They spent the next five hours waiting for a mental health assessment that would eventually lead B.R. to be accepted into counseling through the Hill Country center.
Days later, the pediatrician was in the same emergency room — saving the lives of children who had been shot at Robb Elementary.
B.R.’s mother wonders if help would have arrived too late for her daughter had she not been paying such close attention, or if the help she can get will be enough.
More care now than ever
In the wake of the Robb Elementary shooting, the mental health landscape is changing for Uvalde.
Help is pouring in from across the state. There’s a new state-supported crisis center. A child bereavement group is setting up for at least the next six months. There’s trauma counseling for the students and offers of partnerships from statewide health and advocacy groups.
Communities In Schools — which responded to the tragedy with licensed mental health clinicians from across the state arriving in Uvalde within 24 hours — will stay for trauma and crisis support and “psychological first aid” during summer school for students, faculty and staff at five schools, organization officials said.
Hill Country MHDD is working with the 38 other local mental health authorities to open up appointments “for anyone who walks in the door,” not just the severe cases it’s been limited to in the past, Citron said. It is also running a telephone hotline for Uvalde residents who have been affected by the shooting.
And in partnership with the city, the agency is attempting to move forward with plans it has had for years to build a 48-bed psychiatric hospital and crisis center to be owned by Hill Country Mental Health. The city is donating several acres for the site, which would include 16 beds for child and adolescent mental health services. The holdup has been getting the funds to move forward, Citron said.
Hill Country Mental Health officials plan to ask Texas lawmakers for about $12 million per year to fund the facility, which has the support of Uvalde city and county officials, Citron said.
“Our need in the community is exploding and we know this will be a long-term recovery process,” Citron said. “This will be a generational recovery for this community.”
The Uvalde Consolidated Independent School District has been invited to join a statewide youth telemedicine mental health program through the Texas Child Mental Health Consortium, which focuses on teaching education professionals how to identify children who may be in crisis and work with their families to get them expert-level treatment in areas where there is little access to mental health services.
And earlier this week, House Speaker Dade Phelan urged support for another $37 million annually to take the program statewide, as well as $30 million per year to increase state-funded pediatric mental health beds.
The trauma left behind in the wake of the Robb Elementary shooting will take years to unravel, doctors say, and likely will affect most of the town’s residents — the majority of whom are multigenerational, born and raised there, with plans to raise their children in the same neighborhoods and schools they grew up in.
They hope the help sticks around.
“There’s a number of us local providers that are here for the long run,” Citron said. “There is some anxiety over what’s going to happen after all these community services leave, after the funerals are done and the TV cameras leave, what kind of void is going to be left in this community. … We are here for the long haul and there are many other agencies that are, and we are all working in collaboration.”
Disclosure: Hogg Foundation for Mental Health and Texas A&M University have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.
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