TRI-COUNTY — Brian Enlow is much different than his brother Greg was. Greg embraced an artistic world, immersed himself in music and lived off the beaten path. Brian is three years older, more grounded, and as they grew up together in Tyler, Texas, those differences started becoming more and more profound.
“I ended up working for corporate finance, was pretty boring, had a suburban house and three kids kind of life,” Brian said. Meanwhile, Greg left East Texas at 18, took to Bob Dylan songs and started playing guitar in Austin bands. Apart from the rave reviews he got for his mastery of guitar in rock bands like The Strange Boys, he was well-known and loved for his craftsmanship in building and repairing guitars at a shop he owned in Austin.
Greg found his way to Marfa in 2016 at age 29, after Brian said he started noticing all the changes in the “Keep Austin Weird” city, which was maturing into a large, metropolitan area. “Greg was always sort of cutting edge, even in an exodus from Austin,” Brian said. “He knew that he needed a change since he had probably rung every bit of light he could out of Austin.”
In addition to playing with numerous bands, and sitting in with many more in Marfa, Greg worked at El Cosmico doing pretty much everything that needed to be done for the campground hotel and its events. Even though most people know almost everyone else in a small town like Marfa, Greg’s lean figure, big blue eyes and boyish good looks made him even more recognizable. “I know it’s cliche, but he did have a magnetic personality, and people were drawn to him,” Brian said. “And people genuinely loved him. His friendships were rarely, if at all, topical, surface level. All of his connections were very deep-rooted.”
Brian noted how he still can’t shake how different he is than the brother he loved so much. “I still joke to this day, if I died tomorrow, the only people five years from now that will be talking about me are my immediate family. I’ve got some buddies here and there, don’t get me wrong. But I certainly have not had the same impact on the world as my little brother did.”
But Brian, now 41, is remembering Greg fondly today. Greg is gone. He was found dead at age 33 at his Marfa home in March of 2019, a victim of suicide.
As a Marfa musician, Presidio County Commissioner David Beebe — who served as justice of the peace at the time — knew Greg from playing with him at music events around town and said he was heartbroken to have to handle his official duties at the scene of his death. “It just caught everybody by surprise,” Beebe said, not because there were no warning signs from Greg, he said, but because suicide is fairly uncommon in Presidio County and can have a more profound impact on small communities.
Brian said Greg had ongoing mental health issues, including depression and suicidal thoughts at times, and he struggled with substance abuse at several points in his life and had undergone a variety of both medical treatments and counseling. Greg eventually experienced severe emotional distress in Marfa and was trying to find ways to cope with it, he said.
Most anguishing for Brian is that he believes that creative people like Greg are more prone to suicide because of the intensity of the emotion they put into their work. Studies vary in the likelihood of suicide for artists, but many do note a much higher rate than the general public. Greg’s charm and likability also may have masked his troubles to others, he said.
Beebe said he wondered if Greg, despite his natural way of connecting with people, may have felt isolated, like so many others feel out here in a small town, perhaps not knowing where to get help or feeling lost. “I don’t know for sure,” he said, “but I do want to make sure that people know help is available.”
The suicide rate for the U.S. hovered around 14 per 100,000 individuals from 2015-2022 (as did the rate in Texas), and Presidio County averaged under 10 suicides per 100,000. Texas Department of Heatlh and Human Services does not report data on suicides for counties if the number is below 10 per year for privacy reasons, and the tri-county area falls in that category. Beebe said, in his experience, most of the suicide deaths he encountered were with people who had been known to have significant mental health issues and often related substance abuse problems.
Beebe said statistics don’t reveal the impact of suicides, where even one seems devastating in a town like Marfa with only 1,800 people. “Every single one of those people were people who were known to other people, had families and friends,” he said.
A greater need
It’s long been recognized that the isolation of many communities in the Big Bend — while providing beauty and sometimes peaceful living — comes with a drawback of limited resources for healthcare. With a hospital district and new health facilities built over the years, the region has chipped away at providing access to medical treatment. But something often overlooked is the need for mental and behavioral healthcare.
“There’s a shortage of mental health counselors and mental health professionals in the region, and that’s for paid and low-income services,” said J.D. Newsom, executive director of the Big Bend Regional Hospital District. Newsom said it’s typical for rural areas nationwide.
“If you live in a rural area, it’s hard to get access to primary healthcare, but it’s even harder getting access to mental healthcare,” said Dr. Allan Tasman, an emeritus chair of the University of Louisville’s Department of Psychiatry and former president of the American Psychiatric Association. Tasman, who has studied community and social psychiatry in rural areas, said the same conditions that result in a lack of resources can also create a greater need for those resources.
“One of the things we learned from the pandemic is the impact of social isolation on the need for mental health resources,” Tasman said. “It’s magnified in very rural areas … there’s a tight knit community, but usually people’s own circle of relationships is not generally that big. You may know everybody’s name. If you go to the grocery store and you see 20 people you know, it doesn’t mean you’re really friends with them.” Tasman added that rural residents are often “living in environments and in situations which put them at greater risk for health or mental health problems.”
The problem of limited mental health services for Big Bend area residents is compounded by an increase in those trying to access it. “People seeking mental healthcare is much more common now,” said Alejandra Ruiz, an Alpine crisis services supervisor for PermiaCare, a nonprofit that provides healthcare services in the Permian Basin and throughout the Big Bend. “Back in the day, some people were worried about being seen as crazy. Society is much more open to mental health issues, so we’re definitely seeing a greater need for services here.”
While tragic stories like Greg Enlow’s provide an anecdotal example of the need for mental healthcare, statistics for Texas paint an even more alarming picture. An estimated one in five Texans live with some type of mental disorder, and a recent study by Forbes magazine ranked Texas as the worst state in the nation for mental health services. Much of the problem stems from not only limited access to services and a shortage of providers, but the cost to individuals for services in a state that leads the nation for the uninsured. With the Texas Legislature repeatedly rejecting Medicaid expansion, it has turned its head to billions of dollars that would go to medical and mental health treatment for low-income Texans.
Newsom said the importance of mental health services has gotten significantly more attention in recent years because of mass shootings, which have provided the impetus for more state funding and nonprofit grants. “Since the shootings in Uvalde, there has been a greater focus figuring out how to improve access to mental health resources.”
Mental health is often connected to substance abuse. The Journal of the American Medical Association reports that 37% alcohol abusers and 53% of drug abusers also have at least one serious mental illness. “If you have substance abuse in the Big Bend, there are some Alcoholics Anonymous or Narcotics Anonymous groups,” Newsom said. “But there are no inpatient treatment centers. It’s a real challenge.” He noted that the tri-county area is part of Region 10 for the state Outreach, Screening, Assessment, Referral (OSAR) program (located in El Paso), which provides free screening to those in need of help with dependency issues, including referrals to rehabilitation center and detox facilities.
While the Legislature has rejected Medicare expansion, it has devoted more resources for mental health as a reaction to mass shootings in Texas, with a record $11 billion in spending on mental and behavioral health programs, a 30% increase from the previous biennium. However, many school-related mental healthcare initiatives were left unpassed in favor of funding for beefing up school security. The emphasis on mental health is seen by many critics of Gov. Greg Abbott and Republican state leaders as a way to steer the conversation away from gun-access legislation and red-flag laws, which would allow law enforcement to petition judges to take away guns from those they consider a risk to themselves or others.
While suicides, mass shootings, and severe mental illness often are the tragic face of mental health, lack of treatment fuels a variety of issues — substance abuse, unemployment, school dropouts, domestic abuse and incarceration — that are costly to individuals, families and local governments.
Tri-county struggles with mental healthcare services
The tri-county area of Presidio, Brewster and Jeff Davis counties are classified as “underserved” for health services overall, meaning there aren’t enough medical providers for the population. The same is true for mental health providers.
The federal Health Resources and Administration agency scores counties on a variety of attributes for several health-related services. For mental health, all three counties are each classified as a Health Professional Shortage Area (HPSA). While that signals that the counties need significant improvements in providing mental healthcare, it also allows the region to apply for financial assistance and participate in programs that intend to recruit more mental healthcare providers to the area.
Counties are scored for HPSA on mental health from 1 to 25, with the higher the number indicating the greater need for providers. The scores are 17 for Presidio, 11 for Brewster, and 9 for Jeff Davis. The scores are based on the ratio of providers to the population, federal poverty levels, and the time needed to access care outside of the area. Lack of providers isn’t unique to the Big Bend –– 98% of Texas’ 254 counties have designations as “mental health professional shortage areas” –– but the region’s distance from major urban areas makes it a challenge to attract new professionals to the area.
Tri-county patient services
Access to mental and behavioral health services for the tri-county region consists of several entities –– all of which assess clients for mental health needs and do referrals to licensed professional counselors (LPCs) serving the Big Bend.
PermiaCare, which started out of Midland-Odessa in 1969 as the local authority for the Texas Department of Mental Health and Mental Retardation, has since grown to serve a wide swath of counties in the Permian Basin and throughout Far West Texas. Ruiz, the Alpine PermiaCare supervisor, said clinics in Alpine and Presidio assess clients on a wide spectrum of health needs and then refer them to appropriate providers. PermiaCare relies heavily on telehealth but offers those services in their clinics and has nurse practitioners and other health professionals ready to supplement the remote consultations and work to fill prescriptions if needed.
PermiaCare has a 24-hour “Crisis Intervention/Suicide Prevention Hotline” (844-420-3964) for those “experiencing emotional crisis situations, including possible suicide.” The hotline is answered by staff trained in crisis assistance, and “staff is available to provide face-to-face intervention including mobile assessments by our Mobile Crisis Outreach Teams (MCOT) and emergency hospitalization.”
PermiaCare started a new initiative this summer to help coordinate resources for dependency. “We are the link for those needing help with substance abuse, whether it’s alcohol or narcotics or illegal drugs,” said Ruby Losoya, the Alpine Rural Border Intervention team lead for PermiaCare. “If it’s stemming from maybe a mental issue, we can do a referral to try to get them some help [for what] may be causing them to lean more towards substance abuse. There’s always a route to address the problem, and we want to help them find it.”
Preventative Health Care Services (PCHS) is a federally funded nonprofit that concentrates on preventative care, but provides a variety of other services — maintaining clinics in Marfa, Presidio and Alpine. Three years ago, PCHS began a Behavioral Health Program, and it now refers adult and children clients to two LPCs that provide in-person and remote services at those clinics. PCHS is designed to never turn anyone away for lack of money and accepts Medicaid and Medicare along with sliding-scale fees for those not covered under those programs.
Marfa Country Clinic founder Don Culbertson PA-C started a new partnership in November with Agno Health, which promotes a “collaborative care model” that seeks to close the gap between healthcare providers and mental healthcare practitioners. “Primary care providers are usually their first front line mental healthcare,” said Dr. Jane Himmelvo, Agno Health founder and chief executive. “Patients are sitting there talking to their doctor who is asking, ‘How are you eating? how you doing?’” The doctor can then ask about everything from anxiety and depression to eating disorders and work with Agno Health to find the right person to help them — whether that’s a counselor or psychiatrist or other mental healthcare specialist, she said.
Himmelvo said the idea is then to break down any walls between mental and physical healthcare so that the doctor is in constant communication about their patients’ mental health treatment and any medications they may be taking. Marfa Country Clinic also makes a space available for remote counseling. She said Agno Health also has a poster advertising the services at the Marfa Public Library and that a sliding scale flat flee is available for those who face financial hardships.
The Family Crisis Center of the Big Bend refers clients to two LPCs under contract to provide free in-person and remote services, although the number of sessions is limited to 12 to 15 before the center refers the clients to PermiaCare. The center’s mission is to empower people traumatized by abuse and provide safety for those who have suffered domestic violence, sexual assault, violent crime and dating violence, and it provides walk-in and scheduled services along with two emergency shelters.
“With abuse, especially emotional and psychological abuse, the whole point of it is to wear down a person’s self esteem,” said Gina Wilcox, a center program director based in Alpine. Wilcox said they refer clients to LPCs to teach clients “healthy coping skills to deal with trauma, grief and loss and to regain a positive sense of self esteem and self worth. “And most of our clients need that rebuilding of their self esteem. Because it’s just been destroyed, and they don’t believe they’re good for anything or anybody. They need help getting out of that hole.”
Wilcox said providing mental health services to Terlingua continues to be a challenge for the center because it has no LPC providers in the area and its facility is limited for remote sessions because it lacks privacy. Trying to find time for their contracted LPCs to help clients has been a continuing problem, she said, and the center is looking to contract another provider.
The Marathon Health Center is a good example of how telehealth can work to provide remote mental health therapy that goes beyond someone simply trying to access a provider through their phone or computer. “We have a dedicated room in the health center here that we call the ‘Zoom Room,’” said Daniel Gallo, the center’s manager. “It’s available for community members who do remote counseling if they want to have a space where they’re not at home. They can come and log in and link up with their personal therapist or other providers. It’s free of charge.”
Jeff Davis County may have more services available soon if it gets the $6.5 million in funding it’s seeking from a federal grant for a local “federally qualified health center” in Fort Davis. Although primarily a preventative care clinic, officials said they also would look at providing mental healthcare services.
Private practice
Only a handful of private LPC providers work out of the Big Bend, with most offering only online sessions. (Note that providers are often licensed with other designations, such as licensed chemical dependency counselor and licensed clinical social worker, as well as specialties like marriage counseling, grief counseling and family therapy.)
Carolyn Hanesworth and her husband moved to Alpine last year after living in New York City the past 15 years. As a licensed clinical social worker, she consults remotely on homeless issues and provides online therapy. “But when I got here, I knew that I’d want to contribute to the community in some way,” she said. “And I thought I’d volunteer, because there’s such a need for mental healthcare providers that I just couldn’t say ‘no’ to a request to do some in-person work here.” Hanesworth volunteers for in-person counseling one day a week at the Marathon Health Clinic. “I have someone from Fort Davis, someone from Alpine, and a few people from Marathon Center that come and see me there.”
The Big Bend does not have any in-patient facilities, which are needed for more significant treatment for patients with psychosis, those at risk for suicide, and other situations that require individuals to be treated in a safe, secure environment. Those patients are usually placed in El Paso, Midland-Odessa, Big Spring, San Angelo and other larger cities throughout West Texas, depending on availability. However, grants from the Permian Strategic Partnership and other foundations, along with state money, have funded a new Permian Basin Behavioral Health Center in Midland-Odessa — with more than 100 beds — planned to open in 2025. The facility will accept patients from the Big Bend if space is available.
Professionals needed
While the isolation many suffered through in the pandemic was a root cause of many more people needing mental health services, it also spurred an incredible growth in online opportunities for therapy and treatment. But there’s still a huge need for professionals to staff those online services, and remote sessions don’t work well for some people, so even more providers are needed on the ground in shortage areas.
After PCHS began its Behavioral Health Care program, it began looking for ways to increase the number of mental health professionals in the Big Bend, said Dr. Adrian Billings, who serves as the chief medical officer for PCHS and an associate dean of rural and community engagement at the Texas Tech Health Science Center. Billings helped launch a collaborative partnership with master’s degree programs for LPCs at Sul Ross State University and University of Texas at El Paso. The partners then won a four-year Behavioral Health Workforce Education Training (BHWET) grant from the federal government. The grant, which is renewable, pays a stipend to 24 student “fellows” seeking a master’s degree in licensed professional counseling who will then work in areas from El Paso to the Big Bend, including possible placement at the PCHS clinics in Alpine, Marfa and Presidio.
Billings said the students work alongside the clinic primary care providers in the beginning. “When these LPC students graduate, they’re almost like a medical student. They have to do 3,000 hours under supervision.” While under supervision, they are called LPC associates, and “once they’re done with these 3,000 hours of supervision, which usually takes 18 to 24 months, then they are completely independent. And so the whole idea of this kind of pathway is to bring these students in when they’re students and support them with a BHWET grant, and then when they graduate, we bring them on board as a mental health fellow from Texas Tech and then when they finish that supervision, we then retain them in these underserved areas.”
Another significant benefit of the grant program, Billings said, is integrating the LPC students with the health clinics to help identify patients — who while seeking physical health care — may need mental health services. A PCHS federal grant for indigent care requires that the clinics do depression and anxiety screening periodically for all patients. “They come to see you because they have a cold or they have hypertension, but they also have comorbidities of behavioral health issues that if you don’t ask about it, they often don’t bring it up. So, it’s so important to screen for it. And then from the provider perspective, it’s nice to have another healthcare professional on your team like a licensed professional counselor that can help with the behavioral health issues.”
The Texas Legislature passed a bill last spring that provides repayment of school loans for students who become mental health professionals and meet certain requirements — such as working in a Health Professional Shortage Area.
While it’s clear that building a significant workforce of mental health professionals in the Big Bend will be a long-term process, the recent grant funding and additional initiatives launched by local healthcare organizations and the Legislature are providing a more solid foundation for progress.
Despite the opportunities developing for more mental healthcare professionals and resources in the Big Bend, that current situation is still unacceptable to providers like Wilcox at the Family Crisis Center. Currently there are numerous entryways for people to get referrals for help, but a bottleneck when they actually try to get that help –– especially clients needing bilingual services. “We desperately need more Spanish-speaking counselors,” she said. “And sometimes no one is available or it’s hard to find a time with someone.”
There’s also a gap, she said, between people that qualify for free or sliding-scale care at area services and those that don’t qualify but can’t afford counseling. “Counselors are expensive,” she said. “If you don’t have an insurance plan that includes counseling, it’s out of reach for a lot of people.”
Encouraging those struggling to reach out
All of the area providers noted that outreach to the community is critical regardless of how many resources are available, since many people struggling with mental health need encouragement to get the help they need.
Brian Enlow said his brother Greg did reach out to him in the weeks before his suicide, but he wasn’t sure if he sought any other help when he encouraged him to do so. Brian said Greg realized things were “spiraling out of control” in his life and that he needed to work on his wellness, which included cutting back or quitting drinking. “He was starting to read,” Brian said. “He was starting to meditate. All great things, but all individual activities that don’t involve vulnerability, that don’t involve communicating your feelings and what’s going on. I encouraged him to continue doing all of those things. But if he had a chance, find a group, regardless of the type of group, and try to use that as much as you can.”
Brian said Greg seemed to be on the right track, but in hindsight, he wasn’t. “He was doing all the things that people who are in severe distress should do, and it would probably be enough for most people. But in the severe distress that he was in, it obviously wasn’t enough.”
Note: This is the first in a series of articles on mental healthcare funded by the Presidio County Community Fund. Check back next issue for more articles.
Providers:
PermiaCare
Alpine and Presidio
844-420-3964
PermiaCare assess clients on a wide spectrum of health needs for referrals to appropriate providers. PermiaCare is available to host a free “mental health first aid” training course for school districts, law enforcement, medical providers and other private entities. For more information, visit permiacare.org/mental-health-first-aid-training/
Preventive Care Health Services (PCHS)
Family Health Services of Alpine: 432-837-4555 • Marfa Community Health Clinic: 432-729-1800 • Presidio County Medical Clinic: 432-229-3030
PCHS is a federally-funded nonprofit that concentrates on preventative care, but provides a variety of other services such as a Behavioral Health Program, and it now refers adult and children clients to two licensed professional counselors. PCHS is designed to never turn anyone away for lack of money and accepts Medicaid and Medicare along with sliding-scale fees for those not covered under those programs.
Big Bend Regional Medical Center in Alpine — Senior Solutions
432-837-0455
The hospital contracts with the Senior Life Solutions program that offers psychiatry sessions and remote counseling for seniors as part of an overall wellness program.
The Big Bend Regional Hospital District
432-837-7051
The district, which primarily is intended to provide healthcare to indigent and low-income residents, also refers patients to mental health counseling services to eligible clients through its Big Bend Health Medical Program, and it administers the Presidio-Brewster County Indigent Healthcare Program.
The Family Crisis Center of the Big Bend
Alpine: 432-837-7254 • Terlingua 432-371-3147 • Presidio 432-229-4297
The Crisis Center refers clients to two LPCs under contract to provide free in-person and remote services.
Marathon Health Center
432-244-8446
The Marathon Health Clinic’s “Zoom Room” is available for community members who do remote counseling if they want to have a space where they’re not at home.
Substance Abuse: Outreach, Screening, Assessment Referral program (OSAR)
(Contact PermiaCare: 844-420-3964)
Free screening to those in need of help with dependency issues, including referrals to rehabilitation centers and detox facilities.