TRI-COUNTY — Jeff Davis County Justice of the Peace Mary Ann Luedecke picks up her frantically chiming cell phone. “I don’t know what’s going on with our case,” Luedecke says to the person on the other line. “Can you tell me where we are?” She’s speaking to a staff member from PermiaCare, the local behavioral health authority, who tells her they may have found a psychiatric bed for an individual in crisis.
Luedecke has been waiting for the call for over two weeks. The patient in need is a person with an intellectual disability that has repeatedly assaulted their elderly caretakers, a situation which led to their recent detainment at the county jail. “I would hope that we could get intervention before it reached that stage,” Luedecke said. “Unfortunately, it doesn’t always happen that way.”
The patient has been in the PermiaCare system — previously called the Texas Department of Mental Health and Mental Retardation — for over 20 years, she said. “Literally things just don’t get better with time, at least in this scenario,” Luedecke said.
Local jails and police department offices are often the first stop for those suffering from mental health crises, even those who have not committed criminal offenses. Without a psychiatric hospital in the tri-county region and only a few behavioral healthcare providers, law enforcement officers, justices of the peace (JPs) and PermiaCare bear the brunt of the area’s mental health crises, which they say are increasing faster than state aid.
“The state does not really care and does hoist the greatest responsibilities onto the local city and county governments and officials,” said David Beebe, current Presidio County commissioner and former Presidio County justice of the peace.
“Once you get to that level, you’re dealing with bottom of the barrel resources,” he added.
Those who wind up in the underfunded system are often people without the financial resources to seek outside assistance. More often than not, according to local JPs and law enforcement officials, the police are called as a last resort, usually by concerned family members dealing with a relative’s chronic mental health illness. “You’re talking about people living on the very margins of finances, jobs, family life, and their own mental health,” Beebe said.
According to PermiaCare, there were a total of 127 mental-health related incidents — including calls to its suicide prevention hotline, crisis follow up calls and crisis assessments — for Brewster County in 2023. There were a total of 21 in Presidio County in 2023. Numbers are derived from PermiaCare’s clinics, located in Presidio and Alpine, meaning they also include incidents originating in Jeff Davis County.
PermiaCare contracts with Avail Solutions, an American Association of Suicidology accredited hotline service, that helps provide therapeutic interventions and outpatient services to callers. If a call requires a face-to-face assessment, PermiaCare staff go out to help determine whether or not a patient needs to be hospitalized.
Members of PermiaCare’s Mobile Crisis Outreach Team (MCOT) — which are dispatched from clinics in Presidio and Alpine — are often called to local jails and police department offices to perform mental health evaluations if law enforcement officers believe an individual is at risk of harming themselves or others, a determination that allows them to detain someone without a warrant.
In worst-case scenario situations like the one Luedecke is handling, JPs and county judges, who have commitment powers, are required to sign Emergency Detention Orders if PermiaCare determines an individual is a danger to themselves or others and that individual refuses to seek treatment voluntarily.
From there, PermiaCare staff begin searching for an open bed in a psychiatric hospital, which is easier to locate if the patient has private insurance or Medicaid, according to PermiaCare Chief Operating Officer Todd Luzadder, and “almost impossible” if they are considered indigent, due to a shortage of indigent beds available at facilities. The process can take days, or even weeks, Luzadder said, consuming a “huge portion” of their staff’s time “continuing to check back with facility after facility after facility.”
Thanks to a $449,000 allocation from the Texas Legislature received in 2022, PermiaCare is able to subsidize beds for indigent patients at two facilities they contract with, Oceans Behavioral Hospital in Midland and River Crest Hospital in San Angelo. In 2023 PermiaCare spent $40,000 on indigent stays for Brewster County and $18,000 on Presidio County.
Luzadder said the funds are “not near enough” to cover patient needs across PermiaCare’s service area, which includes the tri-county region as well as Midland, Ector, Pecos, Hudspeth and Culbertson counties. PermiaCare is classified as a Certified Community Behavioral Health Clinic (CCBHC) and is, in part, funded with taxpayer dollars from each of its counties. Of the 39 mental health authorities like PermiaCare in the state of Texas, they cover the largest geographical region.
PermiaCare received initial news that it will be awarded an additional $1.5 million from the Legislature to help cover indigent beds in “frontier” communities, but the funds have not yet been received. Construction has begun on a behavioral health center with 100-plus beds in Midland-Odessa that will serve patients from the Big Bend when possible. The facility, which is being funded by a mix of grants and state aid, is slated to be complete in 2025.
In the meantime, once an open bed is located, entities have to act fast. Local law enforcement officers are tasked with transporting the individual, often to Oceans Behavioral Hospital in Midland or River Crest Hospital in San Angelo, three to four hours away. But sometimes open beds are even farther away, requiring local law enforcement to travel across the state. Alpine Police Chief Darrell Losoya said he has traveled as far as Fort Worth to help place someone in a psychiatric hospital.
During transportation, patients range from violent to cooperative, Losoya said. It is Alpine Police Department protocol to send two officers on the transport, with the patient sitting in the backseat, being restrained by belly chains, handcuffs and a leg iron around their ankles. He said the Big Bend Regional Medical Center sedates patients when needed.
While transports come at the taxpayers’ expense, local officers say they are not occurring frequently. Losoya estimates transports to San Angelo, for example, cost Alpine PD $1,000 when factoring in gas and officer overtime. In addition to the financial strain, transports are difficult for small police departments because they take two officers out of commission for several hours.
“Many of our counties have very small police forces or law enforcement presence,” Luzadder said. “It’s hard for them to transport — if we have somebody in crisis — to a behavioral health facility because they also need to have somebody still there to provide policing for the community.”
Beebe recalled a case where a Presidio County resident had to be transported all the way to Tyler, nine hours away, for placement in a mental health facility. “Police are in a bad place — not as bad as the people experiencing the crisis — but the police don’t have the resources to do this either,” Beebe said.
Before transports are deemed necessary, county sheriffs and local police departments are tasked with caring for mental health subjects while they are in their custody, time periods which vary depending on the availability of PermiaCare to evaluate the individual. If an individual is intoxicated, PermiaCare will not evaluate them, so officers have to wait for the individual to sober up.
Patients may wait in police department offices or in holding cells. The Marfa Police Department office, a small space adjacent to City Hall, includes a holding cell where individuals may wait for mental health evaluations.
“It’s hard for us to see people with mental health issues,” said Marfa PD Lieutenant Nichole Fuentes. “But to us, knowing that we have them here safe is better than the other option of them being out there, a danger to themselves or others.”
Luedecke said Jeff Davis County jailers recently spent four hours attempting to get the individual with intellectual disabilities back into a holding cell after a mental assessment. “They’re not trained for this, they are not a mental health facility,” Luedecke said, adding that employee turnover at the Jeff Davis County Jail is “astronomical.”
Luzadder said calls from law enforcement are priority, and crisis response workers are dispatched as soon as possible to their location, but the area’s vast expanse sometimes poses a challenge. “Getting there in less than an hour is certainly a struggle,” Luzadder said.
At PermiaCare’s Presidio office there is only one employee, who acts as both a crisis response worker and a case manager. In Alpine, there are two daytime workers and two nighttime workers serving on the crisis outreach team. All may be dispatched to calls through the tri-county region, Luzadder said.
The behavioral health assessment PermiaCare crisis workers perform is standardized, Luzadder said, involving obtaining a brief medical history, looking for signs of substance abuse and asking open-ended questions to determine a person’s mental state. An individual will be transported to the emergency room if it is determined they are experiencing a medical or substance abuse issue and need to be medically cleared before entering a behavioral hospital.
When possible, PermiaCare tries to avoid admitting a patient to the ER, he said, so as to not overwhelm those facilities and because it is “an undue cost burden” to patients, who have to foot the bill.
Losoya and Fuentes said frustrating situations arise when law enforcement believes a person is a danger to themselves or others and needs to be transported to a psychiatric hospital, but PermiaCare determines they can be released. Fuentes said that scenario can put cops in a difficult position because community members don’t understand why the person is back out “causing disturbances.”
Fuentes and Losoya said many who are released often wind up back in police custody. Losoya said his main concern about the release of certain individuals relates to their access to guns despite one or more mental health episodes. Under federal law, if an individual is involuntarily committed they can no longer possess firearms in perpetuity, according to a public information officer from the Bureau of Alcohol, Tobacco, Firearms and Explosives.
But it is not illegal to show signs of mental illness, Luzadder said, and PermiaCare cannot involuntarily commit someone to a psychiatric facility against their will — an extreme action — unless they “meet the criteria for imminent risk.”
“When you’re assessing an individual, and you’re looking at doing something like putting them in a hospital against their will, you are making a decision that impacts that individual’s right to freedom of movement,” Luzadder said.
Many on the forefront of rural mental health crises agree mental health patients are unduly intertwined with the judicial system, where many people they encounter are not properly trained how to handle those suffering from mental illness.
The passage of SB 1849 in 2018 raised the minimum requirements for individuals seeking to obtain a Texas peace officer license from 16 to 40 hours of training on “de-escalation and crisis intervention techniques to facilitate interaction with persons with mental impairments.” Additional eight-hour crisis intervention training may take place every four years, and continuing education classes on mental health are available, according to a spokesperson from the Texas Commission on Law Enforcement (TCOLE).
Fuentes said Marfa PD officers are well-trained in their response to mental health calls, but situations can vary widely, presenting challenges for officers. “We can go to a residence where we know that somebody does have mental health issues. One day we can go and they can be pleasant, then one day we can go and they’ll fight us.” Fuentes said. “There’s no way for us to determine what we’re going to walk into.”
Losoya said his officers at Alpine PD could use more mental health training. “We don’t have enough training on it,” Losoya said. “It’s something that we definitely need to seek other resources for.”
While there is increased national awareness of the dangers armed law enforcement officers pose as first responders to mental health crises, Losoya said, due to Alpine’s small size, those experiencing mental illness are often familiar with the officers, especially if they have been called out to their residence before, which typically plays to everyone’s advantage. “We have patients that know us from these calls and they react to us positively so it’s easy for us to de-escalate,” Losoya, who has worked for Alpine PD for nearly 30 years, said.
Losoya recalled responding to a call involving a supposedly suicidal man who had locked himself in a room of his house with a gun. He realized he knew the individual and was able to talk him down. Losoya learned there was actually no gun, and that the man made the suicidal comments to an ex-girlfriend to try and get her to feel sorry for him. “We don’t recommend it. We don’t want the officers to put themselves in danger,” Losoysa said. “But I knew that I could talk him down.”
In a recent hospital district meeting Brewster County Judge Greg Henington said he is seeing an increase in mental health cases, which he said he is “ill equipped to deal with” due to a lack of training. “They don’t belong in the justice system, in fact it’s a very inefficient, poor way of treating mental health,” Henington said.
Beebe echoed Henington’s sentiments, stating he may not have been technically qualified to talk someone down, but he had to learn the skill on the job as a JP. When someone with mental illness is facing criminal charges and upcoming court dates it only exacerbates their situations, he said. “The judicial system is a bad place for them to be because it compounds their problems.” Beebe said. “It’s the lazy way to fix it. The lazy way is to put them in a cage.”
Much of the work to address rural mental health crises falls on PermiaCare staff, which has experienced a high turnover rate in the past — something both law enforcement and JPs noted — but Luzadder said, due to new sign-on bonuses, raises and stipends for rural workers, the situation is improving. “I would say our turnover is definitely a barrier,” Luzadder said. “But we’ve been — I’m knocking on wood here — relatively stable over the past two years in our ability to maintain staff.”
Due to minimum required qualifications, it can be hard to hire new employees as well, Luzadder said. PermiaCare’s entire coverage area is classified as a Healthcare Provider Shortage Area (HPSA).
Luzadder, who has worked at PermiaCare for 26 years, said they have definitely seen a rise in mental health calls and incidents in recent years. The number of mental health related incidents across PermiaCare’s service area rose 25% in the past 10 years, from 1,908 in 2013 to 2,443 in 2023. He attributed the uptick to more people reaching out due to increased mental health awareness, and the rise of substance abuse.
Both Losoya and Fuentes said substance abuse cases have increased, and sometimes it can be hard to determine whether an individual is suffering from a mental or a drug-induced episode. “Now we’re having this crisis where these people are on narcotics, and they start having hallucinations, paranoia or whatever, and then we have to deal with them,” Losoya said.
This year PermiaCare began participating in Texas Health and Human Services’ Rural Border Intervention program which provides “community and home-based substance use prevention and intervention services in remote rural border areas.”
Luzadder said the local Rural Border Intervention team is based out of Alpine and is focusing on meeting with clinics and at-risk individuals with the goal of engaging them in services before crises happen. Narcan is also distributed through the program, he said.
“Our hope is that at some point, they’ll reach out, and they’ll agree to participate in services, and we’ll actually engage them in treatment, hopefully reduce their reliance on emergency rooms, reduce recidivism to the jails,” Luzadder said.
Local police officers said the majority of mental health calls they triage do not involve substance abuse and criminal activity. “We have a lot of mental health calls, and our guys end up even having to, basically, be social workers,” Losoya said.
Because there is no local nursing home, many situations involve elderly individuals who are “on their own and just trying to make it,” he said. Alpine PD officers receive routine calls from an elderly woman living in an apartment complex who claims Hillary Clinton and Donald Trump are fighting in her basement.
Officers are aware she has no basement, but are still dispatched to check on her. “We check to see if the cleanliness in her apartment is good, if she’s able to care for herself, if we see anything in danger,” Losoysa said.
Seniors may also sign up for the department’s free RU OKAY program, which involves weekly wellness check-in calls, or more as needed, from Alpine PD dispatchers.
Alpine PD’s situation is further complicated by the fact that the Big Bend Regional Medical Center is in their jurisdiction but does not have its own security staff.
Per state law, officers are not required to stay with a patient once they are passed off to a healthcare facility, but Losoya said he instructs officers to stay as long as they can. “This is still my hospital,” Losoya said. “I have a responsibility to the doctors and the staff and the nurses to make sure that they’re safe.” He recalled at least one situation where a patient escaped the ER and officers had to track them down.
Another issue Alpine PD faces are troubled Amtrak passengers being ejected in Alpine. Losoya said because Amtrak is a private business they have the right to refuse service to anyone, and customers causing issues on the train, whether because they are suffering from dementia or are on drugs, are often dropped off and left in Alpine.
Beebe said it is unfair to saddle the responsibility of both locals’ and visitors’ mental healthcare onto local police officers and JPs, and the state needs to invest further in mental health resources that can “actually help people out on a daily basis” as opposed to border security initiatives like Gov. Greg Abbott’s Operation Lonestar.
“The state safety net is so deficient it barely functions,” Beebe said.
“It’s not like you can just throw money at it and it fixes itself,” he added. “I’m certain that’s one of the reasons it hadn’t been dealt with, much easier just to put a bunch of guys in Tahoes sitting on their cell phones every quarter mile down on the border waiting for nothing to happen.”
Luedecke said the current process of attempting to locate services for an individual experiencing a mental health crisis needs to be streamlined and sped up, to avoid people falling through the cracks and never getting the help they need. “We’ve got to do better than this,” said Luedecke. “We’ve got to.”
This story is part of a series on mental health in the Big Bend funded by the Presidio County Community Foundation.