MENTAL HEALTH. The development of professions, institutions, and treatment paradigms for mentally ill citizens in Texas is characterized by three overlapping trends still identifiable in the current period: (1) an early and persistent emphasis on segregating the mentally ill state in eleemosynary institutions, (2) provision of private care beginning at the turn of the century and rapidly diversifying and accelerating after World War II, and (3) the development of state and local cooperation as a result of federal initiatives and public advocacy in implementing comprehensive community-based services beginning in the 1960s. The development of academic psychiatry and clinical psychology and the humanizing influence of psychoanalysis were major influences in the development of mental-health services in the state.
Eighty-three years after the first American institution exclusively for the insane was opened in Williamsburg, Virginia, the first Texas facility for the mentally ill was established by the Sixth Legislature. Legislation signed by Governor Elisha M. Pease on August 28, 1856, called for the establishment of a state lunatic asylum. Fifty thousand dollars was appropriated for land and buildings. The State Lunatic Asylum (now Austin State Hospitalqv) did not open until 1861, when superintendent Dr. Beriah Graham admitted twelve patients. Before 1861 individuals with a mental illness or mental retardation were kept at home, sent out of state for treatment or custodial care, or confined in almshouses or jails. The State Asylum was neglected during the Civil War and Reconstruction.qqv Soon afterward a second facility, the North Texas Lunatic Asylum, was established at Terrell (1883). A third asylum, The Southwestern Lunatic Asylum, opened in San Antonio in 1892. The last institution for the mentally ill established in Texas before the turn of the century represented a conceptual advance in that it separated individuals with uncontrolled seizures from patients with mental illness. Abilene State Hospital, the only institution of its kind in the United States, was approved by the legislature in 1899 and opened its doors in 1904. It immediately filled to capacity with transfers from the three existing state asylums (see ABILENE STATE SCHOOL).
These early asylums were primarily custodial institutions. They emphasized detention, economic efficiency, and behavior management. Superintendents were practicing physicians who called themselves alienists. They were appointed by the governor, usually as a reward for political support, and the asylums operated under independent boards that set their own standards and management practices. As a result, activities of different institutions were not coordinated. Care for those incarcerated in the asylums varied greatly. Mismanagement and mistreatment of patients and staff at times elicited public attention and censure. Some of the superintendents attempted, however, to improve the care of patients. Dr. F. S. White, superintendent at the State Asylum in Austin before the turn of the century, first advocated a cottage system for custodial care. White's alternative provided a semblance of noninstitutionalized life for patients and diminished the effects of the asylum itself on their symptoms. Despite this early proposal, White's concept was not fully implemented in Texas until 1932 at Wichita Falls State Hospital. B. M. Worsham was another doctor who pleaded for "scientific investigation and treatment of the insane." He decried the absence of "a pathological lab or medical department" at the State Asylum in the late 1890s. The most significant of the early superintendents was Dr. David R. Wallace, a friend of Sam Houston. Wallace was the first physician in the state to limit his practice to psychiatry. He was appointed superintendent of the State Asylum in 1874 by Governor Richard Coke, served in that post until 1879, and in 1883 was appointed superintendent of the new North Texas Lunatic Asylum. He retired in 1896. During his tenure as superintendent of the two institutions, Wallace successfully resisted political patronage in the asylums, advocated removal of the "harmless mentally retarded" from them, did away with restraint, introduced occupational and recreation activities as treatment modalities, and utilized furloughing as a prominent part of institutional procedure.
In 1913 the state legislature attempted to promote coordination among the various institutions by lengthening the terms of individual boards of managers to six years. At the same time, Dr. Thomas W. Salmon surveyed the various asylums and made recommendations to the governor. His report strongly recommended establishment of a common state authority. In the meantime, the governor signed legislation in 1917 mandating two new institutions for the mentally ill. First, prison land at Rusk in east Texas was to be used for a hospital for the "Negro insane." Before it accepted patients in 1919, this institution opened its doors to all races and its name was changed to East Texas Hospital for the Insane (see RUSK STATE HOSPITAL). The second institution, Northwest Texas Insane Asylum, was established to serve the growing population of west Texas and was ultimately built on a site seven miles from Wichita Falls (see WICHITA FALLS STATE HOSPITAL). The need for inter-institutional coordination was more effectively addressed in 1919, when the legislature abolished the various boards of managers and instituted a centralized Board of Control to manage the budgets of most state institutions, including eleemosynary ones. Further reforms of state psychiatric institutions were undertaken by the legislature in 1925. At that time, the words lunatic and insane disappeared from the names of state institutions. The legislature substituted State hospital and a locality name. A mandated mental-hygiene program approved by the same legislature was never funded. These reforms, more cosmetic than substantive, were augmented by legislative provision for two psychopathic hospitals, one in Galveston and the other in Dallas. Only the Galveston hospital was built, and during the 1930s the state system deteriorated and warehousing of patients increased. The Galveston psychopathic hospital opened in 1931 under the direction of Dr. G. W. Day. After a hurricane in 1943, it closed. In 1946 it reopened under the administration of the University of Texas Medical Branch at Galveston with Dr. Jack Ewalt as director. In 1937 the legislature authorized a new state hospital. When it opened in 1939, Big Spring State Hospital was the first state institution designed for expansion and equipped as a modern psychiatric facility.
Overcrowding became a major problem during the 1940s. Public pressure to reduce the lengthy waiting lists for admission to state hospitals and to remove mentally ill individuals from local jails increased occupancy in already overcrowded hospitals. In 1943 the legislature converted the Confederate Home for Men into a hospital for mentally ill male geriatric patients in order to provide beds in the larger hospitals. World War II led to continued deterioration. Because of the war the State Dairy and Hog Farm (later the Texas Leander Rehabilitation Centerqv), established in 1942, was the only new facility opened. In 1945, Austin State Hospital transferred twenty-five to thirty patients to the farm, where they worked as laborers. In 1949 the Fifty-first Legislature established the Board for Texas State Hospitals and Special Schools. Almost immediately the board authorized a study of state institutions directed by Ernst and Ernst Management Firm. The findings, of overcrowded institutions understaffed by poorly trained personnel, were not new. Female attendants received eighty dollars a month, and male attendants, who worked seventy-two-hour weeks, were paid only ninety dollars a month. Large numbers of geriatric patients received only custodial care in the hospitals. To reduce overcrowding, the Kerrville State Home opened as a branch of the San Antonio State Hospital in 1951 to provide care for aged mentally ill patients. This institution later became the autonomous Kerrville State Hospital. Also in 1951 the Vernon State Home opened as a branch of the Wichita Falls State Hospital for the care of geriatric patients who had failed to respond to treatment. The home became an independent state hospital in 1969, a rehabilitation center for drug-dependent youth.
In 100 years the state system for caring for the mentally ill grew to nine state hospitals scattered about the state. Their population had, however, begun to decline as a result of new treatment techniques and changing social ideas about the role of state psychiatric hospitals in caring for afflicted individuals.
Private psychiatric services began developing at the turn of the century. Dr. David R. Wallace opened an office in Waco after retiring from his post as superintendent of the Terrell Asylum. He advertised his specialty in the Texas medical journals of the 1890s. In 1892 Dr. John Pope opened the state's first private psychiatric hospital, in Marshall. The hospital, called Valleloma, had a twenty-bed capacity. After four years, Pope's failing health forced him to close the facility. Several hospitals were established for the care of individuals with alcohol and drug addiction. They included the Hogg Institute, established in Austin in 1893, the Matheus Home, opened in San Antonio in 1899, and the Preedy Sanitarium, established in Houston in 1906. Two brothers, Dr. George H. Moody and Dr. T. Lawson Moody, established Moody's Sanitarium, a seventy-five-bed general psychiatric hospital in San Antonio in 1903. The San Antonio facility was the first of several private hospitals of which George Moody was a principal promoter. For example, Arlington Heights Sanitarium in Fort Worth, partially underwritten by him and directed by Dr. John S. Turner, opened in 1906. It had a twenty-five-bed capacity. In 1925 Dr. Greenwood's sanitarium opened in Houston with George Moody and Dr. Marvin L. Graves as partners. Other early private hospitals in Texas included Dr. Thomas Dorbandt's Lampasas Sanitarium (1905), Dr. V. P. Armstrong's Westmoreland Sanitarium in Dallas (1906), Dr. W. C. Rountree's Sanitarium in Fort Worth (1907), and two psychiatric hospitals that opened in 1909, Glenwood Sanitarium in Amarillo and William L. Barker's Sanitarium in San Antonio. In 1911 Dr. Thomas Dorbandt moved to San Antonio and opened Lakeside Sanitarium with fifty beds. Dr. Ralph E. Cloud established two early hospitals, the Height Sanitarium in Houston in 1912 and the Oaks Sanitarium in Austin in 1917. Dr. James J. Terrill and Dr. Guy F. Witt opened Timberlawn Sanitarium near Dallas in 1917 with Dr. George Moody as a principal stockholder. Timberlawn opened with fifteen beds and had expanded to forty beds by 1927; it is the oldest private psychiatric facility in the state. The first recorded private facility in the state for children, the Elm Grove Lodge, began operating in Austin under the direction of Dr. Margaret Holliday, who had served as an assistant superintendent in the state system. Her hospital with twenty-five beds opened in 1906 for the treatment of children with nervous and mental disease and physical defects. The facility closed by 1912. During the first two decades of this century, private psychiatric hospitals served only limited geographical areas, and were usually located in the most populous sections of the state. As psychiatrists established private practices in rural areas where no psychiatric hospitals existed, they were forced to find ways to provide residential care for disturbed patients. Typical of such arrangements were those of Dr. Arlen Cooper in El Paso, who in the 1940s boarded patients in private homes, and Dr. Winston Cockran in Beaumont, who rented rooms in nursing homes for his patients. Psychiatric care in the private sector was to some extent modeled after the state system. In its early years it was based on small hospitals or sanitariums where patients were housed in order to receive treatment.
A significant impetus in the development of private psychiatric services in Texas was the organization of psychiatry as a specialty in the state's medical schools. Dr. Marvin Lee Graves joined the faculty of the University of Texas Medical Branch in Galveston in 1905 as a lecturer in nervous and mental diseases. He previously had served as the superintendent of the state hospital at San Antonio. When Graves retired in 1926, a new department of neurology and psychiatry came into being separate from general medicine. Dr. Titus Holliday Harris, who had received training in neurology but not in psychiatry, assumed the appointed chairmanship of the new department and served in that position for thirty-six years. He insisted that psychiatry be taught in all four years of the medical-school curriculum. Shortly after the organization of the department, postgraduate training began. Dr. Abe Hauser, the first physician to take advantage of this training, moved after completing two years of training from Galveston to Houston and entered the private practice of psychiatry. Dr. Hamilton Faith Ford, who succeeded Harris as department chairman, accepted the second position available for psychiatric residency. For many years, the University of Texas Medical Branch had the largest percentage of medical graduates entering psychiatry of any school in the nation. Other medical schools subsequently initiated specialty training in psychiatry-Baylor medical school in July 1951 and Southwestern Medical School in 1952. At present, state medical schools at San Antonio, Lubbock, and Houston also provide psychiatric residencies (see BAYLOR COLLEGE OF MEDICINE, and UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER, DALLAS). Psychiatric training programs were also established in nonuniversity settings. For example, Timberlawn established a psychiatric residency in the early 1920s as did Austin State Hospital in 1958. A residency program begun in 1977 at the Texas Research Institute for Mental Sciences (now the University of Texas Mental Sciences Instituteqv) in Houston was absorbed into the pre-existing program of the University of Texas Medical School at Houston when the institute was transferred to the school in 1985. Departments of psychiatry in the post-World War IIqv era became important resources for training psychologists, social workers, and nurses. Special programs and new treatment techniques were developed by interdisciplinary staffs. Notable in this regard was Multiple Impact Therapy, developed in Galveston to serve the mental-health needs of rural families.
Psychology first appeared at the main campus of the University of Texas at Austin in 1898, when a research laboratory was established. In 1908 a new chairman of the Department of Philosophy and Psychology was appointed at UT, Dr. Clarence S. Yoakum, who was a psychologist. Under his administration young scientists were trained who made major contributions in the fields of learning theory and behavior. In 1927, psychology became an independent department. Between 1949 and 1951, Wayne Holtzman, Ira Iscoe, and others went to UT and began developing a nationally recognized program in clinical psychology. Other programs were soon developed at the University of Houston and Texas Tech. Clinical psychology developed rapidly after World War II. The Texas Psychological Association was established in 1947. Of its first twelve presidents, only two described themselves as clinical or counseling psychologists. Of the twelve presidents of the Texas Psychological Association after 1976, ten described themselves as clinical psychologists. In 1969 legislation was passed mandating statewide certification and licensing for psychologists. Psychologists who have had a major influence on mental health care in Texas include Dr. Wayne Holtzman, who followed Robert Lee Sutherland as head of the Hogg Foundation for Mental Health; Dr. Ira Iscoe, who was a leader in developing a clinical training program for psychologists at the University of Texas at Austin; and Dr. Harold Goolishian, who was head of a division of psychology at the University of Texas Medical Branch at Galveston for many years and later founded the Galveston Family Institute. All three served as presidents of the Texas Psychological Association.
Psychoanalysis as an organized influence in Texas appeared after World War II with the establishment of the Houston-Galveston Psychoanalytic Institute, first under the auspices of the New Orleans Psychoanalytic Institute and, after 1974, as an independent organization. Early analysts practicing in Texas included Maudy Marie Burns and Bob Webb in North Texas and Harlan Crank and Robert White in the Houston-Galveston area.
In the 1940s and 1950s, despite the increased availability of private mental-health services and the expansion of the state hospital system, the general low quality of mental-health care in Texas was a source of increasing professional and public concern. The Texas Society for Mental Hygiene, organized in 1934, was reorganized in 1950 as the Texas Society for Mental Health and subsequently became a strong advocate for reform. The establishment of the Hogg Foundation at the University of Texas at Austin and the fortuitous appointment of Sutherland as director of the foundation in 1940 provided a source of funds and an organizational focus for reform across the state. Sutherland's importance in influencing legislative action and mobilizing resources to restructure the state's system of mental-health care was crucial. After the 1949 legislative reforms in state system administration and the subsequent survey of state institutions, the United States Public Health Service reported that no other state fell as far below the American Psychiatric Association standards of care as Texas. A subsequent survey in 1954–55 to determine the progress made since the 1949 legislative reforms emphasized the need for additional administrative changes. At that time chlorpromazine became available for the treatment of psychiatric disorders. Dr. V. J. Kinross-Wright, faculty member of Baylor Medical School in Houston, was the author of the first publication in the United States on this new drug. Chlorpromazine, together with the reform movement, set the stage for a major restructuring of the state system for delivering mental-health services. In 1957 House Bill 6 incorporated a new mental-health code drafted by the University of Texas Law School faculty. House Bill 906 revised the manner in which the criminally insane were to be committed. This bill provided that individuals not be held responsible for acts committed during periods of insanity. Hogg Foundation support, combined with the support of public advocacy groups, helped achieve passage of this legislation. In the same year, the State Psychiatric Institute for Research and Training was established and temporarily quartered at M. D. Anderson Hospital in Houston. National concerns paralleled state concerns. In 1961 Action for Mental Health was published. The principal author, Jack Ewalt, had previously served as director of the State Psychopathic Hospital at Galveston. In 1962 Congress appropriated $4.2 million in grants to states to provide for comprehensive community-based mental-health treatment centers. Subsequently, Texas began the process of developing a statewide plan necessary to obtain these federal funds. One hundred and sixteen citizens participated in thirteen task forces with the purpose of preparing a Texas plan. Initially, Dr. Spencer Bayles directed the effort. Dr. Moody Bettis succeeded Bayles as director. Relevant state agencies, mental-health professionals, medical schools, universities, and foundations provided input to the task forces. The business community and elected officials were also represented in the group's deliberations. Uncharacteristically, the state provided a large support staff for this effort.
In 1965 the Fifty-ninth Legislature passed House Bill 3 almost unanimously. This law incorporated the recommendations of the Texas Plan. At the heart of this plan was the establishment of Comprehensive Community Mental Health-Mental Retardation Centers. House Bill 3 instituted the Texas Department of Mental Health and Mental Retardation, which was to oversee the implementation of the Texas plan as represented in the enabling legislation. Dr. Cyril Ruilmen was appointed acting commissioner. By May 1966 all state hospitals had been inspected for compliance with standards required for Medicare payments. Eleven cities had appointed boards of trustees, a step necessary in the process of requesting funds for local community centers. In 1967 the Houston State Psychiatric Institute for Research and Training was renamed the Texas Research Institute for Mental Sciences and given a broader mandate in the implementation of House Bill 3 (see UNIVERSITY OF TEXAS MENTAL SCIENCES INSTITUTE). In 1969 nine community mental health-mental retardation boards of trustees received state grants. This number increased to twenty-one by the end of the fiscal year, with another six centers scheduled to begin operation in the next fiscal year. The state hospital population declined from 14,921 in 1964 to 9,477 by August 1973 and to 8,000 by 1975. The number of admissions to state hospitals had actually increased, but this was largely because of a new policy of committing alcoholics to these institutions. The net decrease in hospital population was a direct result of three factors: development of community centers, use of new medications, and the availability of Medicaid funds for nursing home care. In 1992, the TDMHMR operated nine state hospitals. There were fifty-seven outreach clinics mandated by the state hospitals and ten outreach clinics under the jurisdiction of state centers. Thirty-five local comprehensive MH-MR Centers operate under local boards of trustees in Texas. In the fiscal 1990 year, the average state hospital census was 3,475, and the number of clients served in community mental health-mental retardation centers was 125,277. The Harris County Psychiatric Center, a 240-bed hospital established in October 1986, jointly funded by the state and Harris County and under the direction of the University of Texas Health Science Center-Houston, served an additional 195 individuals.
After federal block grants given to states in 1980 provided more state control in distributing federal funds, Texas (like other states) placed a high priority on severely and chronically ill patients in community programs. This re-allocation of resources resulted in an exacerbation of conflicts caused by different local and state agendas, legislative concerns for cost effectiveness and advocacy groups' agendas for expanded services, as well as professional territorial battles and an expanded definition of what constitutes mental illness. Lawsuits have further complicated the matter of organizing, implementing, and administering the state system while compelling needed reforms. Significant in this regard in Texas was RAJ v. Jones, filed in 1971. Major issues in the case included individualized treatment, patient rights, use of psychotropic medications, and adequate community aftercare services. Morales v. Turman, filed in 1971, resulted in increased quality and availability of mental-health services for juvenile offenders held by the Texas Youth Council. Ruiz v. Estelle did much the same for adults in state prisons and provided impetus for a new prison psychiatric hospital currently under construction in Sugar Land.
Both the state system and the private sector are in a period of major transition. The Texas Department of Mental Health and Mental Retardation was placed by House Bill 7 under the auspices of the Commission on Health and Human Services, a new umbrella agency established by the legislature in July 1991. How this new structuring of the administration of state mental health care will ultimately affect the delivery of mental health services remains to be seen. Major issues to be addressed include the special needs of minorities, the rise in homelessness, and the rapid increase of individuals with mental illness complicated by drug and alcohol abuse. Private mental-health services in the state have been affected by increasing restrictions on third-party reimbursement for mental-health services and reported abuses by proprietary psychiatric hospitals. The certification of social workers and licensed professional counselors in 1981 and marriage and family therapists in 1992 has increased the general availability of mental-health services and led to increased competition for the available dollars. This, in turn, has led to fierce territorial battles between the various professional groups. A continuing restructuring of the private sector appears inevitable.
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