Mental healthcare has been an area of contention among East Texas civil servants and residents. In response, elected officials, organizational leaders, healthcare providers, social workers and law enforcement are streamlining each organization’s functions and improving overall partnerships.

“As we began our quest to improve the mental health care in our amazing community, we were essentially all in silos,” Smith County Judge Neal Franklin said. “We’ve come a long way … and our communication among the players has dramatically improved. We’re all focused on the same goal, which is improving our mental health care delivery.”

In September 2022, stakeholders met to work through the Sequential Intercept Model (SIM), a model communities use to assess available resources, determine service gaps and plan for change. The model identified several areas of strain, including the interactions between people in mental health crises, the legal system, and the collaboration between mental health and law enforcement.

Since January, quarterly meetings have been held to discuss Emergency Detention Warrants (EDW). The latest meeting was on Aug. 10 at the Andrews Center. Franklin and Keisha Morris, Andrews Center Chief SIM Officer, led county judge offices, assistant district attorneys, local Emergency Room heads and other community stakeholders in legislation updates, jurisdiction scenarios for cities and counties, voluntary versus order or protection and group discussion.

According to the Texas Health and Safety Code, under an emergency detention statute, a person with mental illness or who, because of mental illness, is at risk of serious harm to themselves or others may be detained by a peace officer or through a court-ordered warrant.

“Today’s meeting was about EDWs, but it’s about mental health in general. This is, to me, what I wanted to get across was Smith County is working hard. We’re all coming together. We even had people from other counties and cities come in today to see what we’re doing,” Franklin said.

Clinical Director Danny Sammons, of Avail Solutions Inc., attends the quarterly meeting to discuss Emergency Detention Warrants on Aug. 10 at the Andrews Center.

Katecey Harrell/ Tyler Morning Telegraph

Thomas Wilson, Smith County Assistant District Attorney, told the group about Senate Bill 2479 updates regarding procedures regarding people with mental illness or intellectual disabilities.

There were five amendments to SB 2479 following the 88th Texas Legislative Session.

Section 1 allows licensed mental health professionals with advanced training and education to request electronic warrants requests from a judge for emergency mental health detention and allows for including Class C misdemeanors in the early identification process.

Section 2 reconciles conflicts inadvertently created between offenses that permit release on personal bond. This law resolves the conflict and allows for the clear resumption of the release of people charged with certain non-violent crimes and eligible for a mental health personal bond.

Section 3 clarifies a law enforcement officer’s duties upon presenting an individual for mental health services. This law states that law enforcement officers do not have a duty to remain at a healthcare facility or emergency room once the officer responsible delivers someone under a warrant for emergency detention.

Section 4 allows blood draws for patients receiving court-ordered medication. Medical personnel must monitor the medication level of a patient receiving involuntary medicines to determine whether the dosage is correct when patients are unable or unwilling to consent. This law permits blood draws for people subject to involuntary psychoactive medications.

They also discussed jurisdiction scenarios for cities and counties.

Three main scenarios are happening where protocol needs to be clarified; hypothetical scenarios include:

Lieutenant Stuart Alexander, of the University of Texas at Tyler, University Police talks about the procedure and policy for voluntary, versus order of protection.

Katecey Harrell/ Tyler Morning Telegraph

A person is picked up in the City of Tyler and transported to a Tyler hospital.

A person in a rural area like the City of Whitehouse is transported to a Tyler hospital.

A person is picked up in Cherokee County and transported across county lines to Smith County.

Area law enforcement agencies engaged in honest, open and transparent dialogue about their policy for handling similar cases. Through conversations, everyone becomes aware of the reasons behind each department’s processes, and solutions can be reached.

Wilson talked about the judicial role in voluntary versus order of protection custody.

An order of protective custody may be issued by a judge upon the request of a county or district attorney to continue to hold a patient in a mental health facility pending hearing on an application for court-ordered temporary mental health services.

“The individual can sign it voluntarily. To be honest, once that happens, that brings us in my office out of the loop of that process,” Wilson said. “You’re no longer involved in that unless the person decides they don’t want to be in the hospital any longer, but the hospital says they do.”

A Troup Police Department officer said often, a person goes voluntarily and then changes their mind. Officers don’t have first-hand knowledge of what occurred if they go voluntarily and law enforcement isn’t notified. He said signing a protective order without first-hand knowledge is tricky. This is a prime example where inter-organizational communication is critical.

When someone hears how one department is handling things, they’ll take that information and take it back to their community and put it in place, Franklin said.

Morris said people spoke frankly and had solid questions about the barriers to receiving treatment, access to care and the desire to change.

“We’re working together, and we’re working hard to improve the mental health delivery service; we want to make a difference there for our citizens,” he said.

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The delivery of health care services overall during the past three years of the coronavirus pandemic has presented an enormous challenge for providers and patients, necessitating adaptations to the delivery of care model. This has been key for persons who have mental illness—research data show that the number of those in the United States who have experienced depression and anxiety has risen from approximately 16 million per year in 2016 to 21 million persons per year in 2020.

One thing we’ve learned during this global crisis is that many, but not all, of us can successfully receive health care services by using electronic information and communication technologies that support remote, or virtual, clinical health care. This, of course, depends on the nature of the visit and the need for physical examination and being physically present.

Technology use has become an indispensable clinical tool. Let’s begin by defining a few terms:

• Telehealth refers to the use of technology for any remote (virtual) clinical encounter or any remote nonclinical services such as patient education and monitoring, provider training, and administrative uses.
• Telemedicine refers specifically to remote clinical services, meaning virtual appointments in general medicine or mental health.

The use of technology and the ability to have virtual appointments can increase a person’s access to general health care and mental health care services, especially if you live in a faraway or remote geographic area. One advantage of technology use in health care is that it’s more flexible with respect to our time and requires no travel and less time off from school or work.

Dramatic Increases in Use

The US Government Accountability Office (GAO) has reported dramatic increases in the use of telehealth services in the general Medicare and Medicaid populations during the pandemic as compared with before the pandemic (5 million telehealth services increased to more than 53 million services one year later, and 2.1 million telehealth services rose to 32.5 million one year later).

Similar increases in technology use in mental health care delivery were reported in a cross-sectional, national online study of 2,619 licensed psychologists practicing in the United States, where researchers reported that 7.07 percent of clinical encounters were virtual before the pandemic, and this rose to 85.53 percent during the pandemic. Two-thirds of the psychologists surveyed reported conducting all of their clinical work using telemedicine. This trend in the use of technology is expected to continue.

Barriers to Telehealth

Unfortunately, although technology can promote access to clinical care, some of us who experience mental illness have limited access to or barriers to the use telehealth services and virtual appointments. For example, a person may lack a stable residence; have limited access to smartphones, computers, or broadband Internet connectivity; or lack the confidence or required technical training and skills to use these resources. These challenges are more pronounced in those of us who have serious mental illness or are psychotic.

Substantial obstacles also exist for older adults, such as lack of technological literacy, hearing loss, and lack of comfort or desire to see providers virtually. Language barriers in those who are non-English-speaking present another barrier to telehealth access. One proposed solution has been to engage health care extenders, such as mental health aides or peer supporters, who can reach out to vulnerable persons and problem-solve. Research is ongoing in this area.

There has also been an enormous effort to develop technology apps for use in mental health support, education, tracking of symptoms and illness, and as an augmentation to clinical care. Some, but not all, of these have been useful and popular, particularly among the younger generations. The advantage is that one can use these apps anonymously, without friends or co-workers finding out— thus, diminishing the stigma of mental illness. They are also flexible with respect to time and require no travel and less time off from school or work.

Online Therapy Essential Reads

The downside is that one misses the interpersonal interaction with and valuable guidance and support from a professional mental health care provider—part of the therapeutic recipe for success. The burden is also on the user to evaluate and choose those programs that provide reliable information and direction, and this can be difficult to do.

Mental health apps and online education materials are limited to those persons who are without the barriers to technology use that I mentioned earlier. Unfortunately, these barriers create a technology gap that disproportionately places some vulnerable persons who have mental illness at increased risk for inequities in health care. This must be addressed by researchers and technology developers, with input and pressure from users and our communities.

Stay Well!

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