Bringing Light to the Shadows of Health Care
New institute, philanthropy lead Duncan's system-wide focus on West Texas' mental health.
The Texas Tech University School of Medicine was created almost 50 years ago to fix a shortage of primary care doctors in West Texas.
The school — now grown to be the Texas Tech University Health Sciences Center — succeeded and continues to do so.
Now there’s a new challenge — an acute shortage of mental health care.
A topic at odds with the region’s culture of bravado and self-reliance, it’s often rarely discussed, if not ignored.
While researchers across the Texas Tech University System wrestle with the topic, much more needs to be done — especially for children.
At the forefront of those efforts is a new Mental Health Institute, created by Chancellor Robert Duncan to increase collaboration and spur faculty innovation on mental health topics.
“They’re not treating patients, but warehousing them.”
Duncan credits Regent Ronnie Hammonds and his fellow board members for challenging the system to do more to address mental health, a topic often overlooked in the shadows of social stigma.
It’s an issue Duncan is familiar with after more than two decades as a highly respected state legislator representing 51 West Texas counties .
“The biggest issue,” he said he heard from county judges and others was “what do we do with our constituents impacted by mental illness?”
It was an issue with substantial consequences.
“It’s the social cost, but it’s also the fiscal cost to the small counties who don’t have a lot of money. They’re not treating patients, but warehousing them,” Duncan said.
The answer he discovered was far from satisfying.
“There is no real system…in the rural areas to be able to deal with this. It was a constant issue,” he said.
For someone who made his reputation in the Legislature by bringing people together to solve the challenges of rural Texas, Duncan looks at this problem unflinchingly. The opportunity couldn’t be better suited to the university system he now leads.
He lists an array of programs Texas Tech already has, but said until they are all brought together, Texas Tech is not maximizing its opportunities, making sure every dollar is invested right and people are working together when it makes sense.
“We’ve already shown that we’re able to excel in a lot of areas. We already have the correctional managed care for the state west of I-35, and that’s a significant population to be able to provide mental health services and to better research and understand mental health issues,” he added.
A collaborative approach to mental health in which universities across the Texas Tech University System contribute their expertise to solve problems in the communities they serve and model solutions for the rest of the state and nation.
“Mental health issues are never going to be addressed without good public policy.”
The newly minted Mental Health Institute is the first step. It’s charge, to coordinate mental health efforts across the Texas Tech University System to avoid duplication and encourage collaboration; serve as a repository of system-wide knowledge on mental health; look for ways to apply research findings in clinical practice and advocate integrating best practices into public policy.
“The institute provides service, research and academic learning for healthcare providers,” Duncan said, adding “it has to be focused on policy. Mental health issues are never going to be addressed without good public policy.”
Duncan sees great potential for Texas Tech to be a leader in mental health, and presidents at the system’s flagship institution and oldest health sciences center share his passion for collaboration and serving their communities.
A challenge unique to West Texas
Across the Marsha Sharp Freeway from Duncan’s office, Dr. Tedd L. Mitchell, president of Texas Tech University Health Sciences Center, understands the challenge of talking about mental health in this part of the world.
“West Texas epitomizes the rugged individualism of the state. Some of that is out of necessity because we have [fewer people] and people, by design, have to be fairly self-reliant. It becomes part of the culture itself. You have somebody telling someone they need counseling, and there’s a sense that ‘if I can’t deal with this on my own, I’m broken or weak or I can’t handle something,’” he said.
“West Texas epitomizes the rugged individualism of the state.”
Transient populations tied to cattle in the Panhandle, cotton on the South Plains and oil and gas in the Permian Basin also create issues.
Many workers suffer chronic pain from those jobs, which leads to pain medicine abuse.
Or issues from children who come to the Permian Basin with their parents who work in the oil fields and who need help coping with anxiety, loss of friends and the other challenges of moving to a new town.
“You do have a large transient population…who never get the ongoing care or follow-up they need,” Mitchell said. “West Texas has very, very unique challenges we face that if you lived in Austin or Houston or Dallas or Denver are different.”
Add in other issues, like the older population, who suffer from being alone or struggle to care for a sick spouse, and the need grows.
To fill the gaps in mental health service in the region, Mitchell said family practice doctors need to know more about mental health.
“In a city like Dallas, where they have a ready supply of mental health help, the family physician will be very quick to refer to a mental health professional…If you’re in Plainview as a family physician, you can’t simply say you’ll run them over to see this psychiatrist, because there is no psychiatrist over there. So out of necessity you have to be on the front lines of that therapy as well,” he said.
To meet that need, Texas Tech University Health Sciences Center is considering a combined family medicine/psychiatric residency program.
Adding one more year to the residency requirements, will give the doctors board eligibility in both areas.
But there’s more being done in mental health on across the university’s 6 campuses:
- Psychiatric residency and fellowship programs in the Permian Basin.
- A new residency program beginning soon in Amarillo.
- A first-in-Texas Doctorate of Nurse Practice in Mental and Behavioral Health degree.
- Two new master’s programs focused on counseling — one for general mental health and the other on substance abuse counseling.
And Mitchell is excited about the institute.
“The goal of the Mental Health Institute is to break down the silos, so we can get some synergies,” he said.
“We want to be Switzerland…not seen as taking sides,” he added, hoping the institute can get community health organizations involved.
“We want Covenant and UMC working together. We want Northwest working with BSA in Amarillo,” he said, listing off the major health care providers in the region. “We’re in position to be considered the honest broker.”
At the system’s flagship institution, mental health is front of mind for Lawrence Schovanec, president of Texas Tech University.
“Is there a bigger issue than mental health?” asked Schovanec, who just returned from a recent trip to China where they talked about problems with suicide and anxiety.
“Is there a bigger issue than mental health?”
“It’s a worldwide issue,” he said.
Schovanec is proud of the work done on his campus with addiction recovery in the Department of Community, Family & Addiction Sciences, one of many examples.
“It’s so inspiring and also heartbreaking. I admire the people who can work in that environment,” he said.
Schovanec is also excited Texas Tech brought in Keino McWhinney, the recently named director of the Mental Health Institute.
“We were very fortunate to get someone like him. Hopefully there will be a more coordinated effort. I do see the health sciences center taking a greater lead through clinical services…you’ll see the basic research that’s done here is complimenting that,” he said.
McWhinney returned to Lubbock a few months ago to tackle a massive job — creating and running Texas Tech’s Mental Health Institute.
“Mental health is a complex issue. A big part of the attraction to this job was the opportunity for Texas Tech to play a role in convening and understanding not one sector has the solution,” he said.
McWhinney had been at Texas Tech University Health Sciences Center as special assistant to Mitchell before moving to Missouri where he worked in the population health department at a hospital.
With a background in public policy — instead of clinical or research expertise — he feels he’s the right kind of person to bring people together.
At the top of his to-do list, a mental health assessment for the region to better understand current gaps in treatment and patient care.
“We don’t have enough mental health providers. Eighty-one percent of West Texas are shortage areas. We can provide additional service and use of technology,” McWhinney said.
By working with all parts of the Texas Tech system — medical school and psychiatry, psychologists, social workers, marriage and family professionals, legal professionals and more — gaps can be filled.
“Texas Tech attracts pioneers who do things that can’t be done elsewhere in the United States.”
“I told Keino this is 15-20 years ahead of most of the U.S., said Dr. Michael Gomez, associate professor of pediatrics and director of Child and Adolescent Mental Health at the Center for Superheroes, part of Texas Tech University Health Sciences Center’s Lubbock campus.
Gomez mentioned work already being done at UCLA, Duke and the University of Oklahoma that’s part of the National Child Traumatic Stress Network.
Right now, Gomez is an affiliate member and hopes Texas Tech will move to become one as well.
“There’s no reason we can’t be one of those places,” Gomez said.
“Texas Tech attracts pioneers who do things that can’t be done elsewhere in the United States. We can build a nationally recognized site in a few years for treatment, policy, research and education/training,” he said.
Rising from the ashes of abuse
Every superhero starts out OK.
Then something traumatic happens.
The orphaned Peter Parker became Spider-Man after a bite from a radioactive arachnid. The mercenary Elektra was assaulted as a girl. Young Bruce Wayne became Batman after his parents were gunned down.
At the Center for Superheroes in Lubbock, children who are victims of abuse learn their trauma is no different than the challenges those comic book legends faced and overcame.
They see that they can be a superhero, too.
“There’s a loss or trauma that initiates the hero’s journey. But they find a mentor or a friend who helps,” Gomez said.
The center is the only mental health facility in West Texas and Eastern New Mexico designed to provide comprehensive medical and mental health services for victims of childhood trauma and their families.
Children who’ve been abused need help sorting out what has happened to them.
“A kid thinks there are ten things wrong with them. They can’t sleep. They don’t want to play football. They don’t want to talk to their mom. They’re angry. But it’s all one problem tied to post-traumatic stress disorder,” Gomez said.
“Trauma disconnects; healing connects,” he added.
Gomez and his team encourage the child to stop asking “What’s wrong with me?” and replace it with “What happened to you?” and “What were you supposed to have that you didn’t get?”
There’s a misconception that the center just works to make children happy and avoids having the children face the trauma.
“You have to feel it. After feeling and tears, you find your peace. We can’t take away what happened, but we can take away the ability for it to harm you again,” he said.
Gomez believes strongly in the center’s trauma focused cognitive behavior therapy.
“It worked in the Democratic Republic of the Congo and Zambia. If it works there, it’ll work in Slaton,” said Gomez, referring to the thousands of children who fled inter-ethnic clashes in the African nations last year.
“Kids come in and get better. We deal with the hardest kids in the region who are not hospitalized. We’ll have families tell us they have a totally different kid, or tell me ‘we thought we lost our kid.’ These treatments get kids better,” he said, adding they usually see improvement after four sessions, eight at the most.
Children have their pick of rooms when they visit the center. There’s a Star Wars room, a Star Trek room, a Disney princess room and a Guardians of the Galaxy room.
“Whatever works for the kid — Harry Potter, Elliott in E.T., for one young girl it was Oprah Winfrey,” said Gomez.
It’s part of empowering children to pick a space where they feel safe — a place where they can begin to heal.
Dr. Patti Patterson, professor of pediatrics at TTUHSC and a child abuse specialist coined the term superheroes.
She has been focused on child abuse for ten years.
“What I saw was we were pulling kids out of the fire, but they were still a mess. We didn’t have mental health folks in town who would see Medicaid kids, and they were not necessarily trained to work with traumatized kids,” she said.
Patterson sees victims of sexual abuse who are cutting — a form of self-injury — and say they’re suicidal.
She sees teen parents who are more likely to not have coping skills and mistreat their children.
Three years ago she recruited Gomez to treat patients and help build the center.
Besides addressing the here and now, she also knows the center is fixing the future.
Victims of childhood abuse have higher rates of health issues later in life because of the earlier traumatic stress.
“We see a bear and cortisol shoots up,” said Patterson, explaining how the stress hormone creates the “fight or flight” response people feel when threatened.
Leading the statewide conversation on school safety
Dr. Billy Philips and his team don’t look for students planning a school shooting.
“That’s a needle in a haystack. It can’t be found,” said the executive vice president for rural and community health and director of the F. Marie Hall Institute for Rural and Community Health at
Texas Tech University Health Sciences Center.
Instead, they look for kids with mental health issues and help them long before those problems develop into something serious — and potentially deadly.
His work on the Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR) has been cited by Texas Governor Greg Abbott as a model of how to deal with rising violence in Texas high schools following the May shooting at Santa Fe High School.
The center works with junior high school and high school students to identify those at risk to commit violence and get them help.
“The governor placed it in his 40-point school safety plan. Since then our life has been quite different,” Philips said. “There has been interest from schools, politicians and interest groups.”
TWITR started in Lubbock shortly after the shooting at Sandy Hook Elementary School in Connecticut.
Rick Perry, then governor of Texas and now U.S. energy secretary, was aware of work Philips had done at The University of Texas Medical Branch at Galveston.
Perry called Kent Hance, the TTU System’s chancellor at the time, to see if technology could help find an answer.
Philips was asked what could they do.
“Not much without being invited into schools,” was his reply.
Conversations with school administrators followed, and it became obvious to Philips that most rural school districts had a “profound shortage” of counselors.
Licensed professional counselors started “riding a circuit of schools” in 2013.
“Mental illness is just another illness. Let’s take care of it and prevent it.”
Today, the program is in 15 school districts around Lubbock, and a state grant will allow them to expand into Amarillo.
“We don’t look for violent kids,” said Philips, who added they work with students referred by teachers who have seen something that gives them concern.
“Studies show one in five kids have issues. The vast majority of kids don’t have serious mental illness, they have a situational disorder — a divorce is disturbing — and it’s taken care of at the school level,” he said.
“We will screen them and do a clinical interview for two hours. The student and parent have to agree,” he said.
Then a child psychiatrist interviews the patient using secure video conference technology, which cuts wait times, eliminates travel and allows each mental health professional to serve a larger geographic area.
The psychiatrist does a diagnosis and prescribes a plan for care. If there are further concerns more tests can be done.
“TWITR has led to care for kids who were suicidal, maybe homicidal,” Philips said.
Philips agrees with the governor’s plan for school safety, emphasizing the need for more behavioral-trained counselors in schools.
“But it’s a very expensive fix. You have to be efficient and use technology in a smart way,” he said.
He hopes schools can learn from the program and Texas Tech University Health Sciences Center can train and give technological assistance.
“We’d be willing to license TWITR,” he said.
Philips hopes to see proactive approaches like Texas Tech’s make a difference across the country.
“If people with serious mental illness can be identified and cared for in a proper way, we’d see a dramatic decrease in all kinds of things like homelessness, violence in schools and public places, and a healthier society,” he said.
It would also help if the shame associated with mental illness could be erased.
“Mental illness is just another illness. Let’s take care of it and prevent it,” he said.
Decoding the addict's brain
Sterling Shumway knows about addiction.
He’s director of Texas Tech University’s Institute for the Study of Addiction, Recovery & Families and chair of the Department of Community, Family & Addiction Sciences.
He knows addiction is a disease in the brain, and that addiction and mental health co-occur in about 40-60 percent of patients.
He also wants to see people who help addicts team up with people who help the mentally ill — so everyone can be more effective.
“It can make a much bigger difference. I’m interested in lasting recovery, ” he said.
The institute is home to the Center for Collegiate Recovery Communities, led by Director Thomas Kimball, the George C. Miller Family Regents Professor of addictive and recovery studies. The first-of-it’s-kind program was created in 1982 and has grown to be the largest in the country.
“It’s a safe place for students to support each other,” said Shumway, who added recovery is a team sport, requiring peers and families in the process.
“If we don’t include mental health, we won’t keep them sober — it can cut the relapse rate in half,” he said.
A recent project linking disease and mental health is part of the work Shumway, Kimball and their teams are doing to uncover parallels between the brains of addicts and their family members.
“I’m interested in lasting recovery.”
Brain dysfunction in an addict works like this.
A part of the brain called the frontal cortex is responsible for helping a person say no.
But when an addict sees their drug of choice, part of the brain called the midbrain feels that if it doesn’t get the drug, the body will die. So the impaired midbrain overrides the frontal cortex, resulting in the addict’s decision to use the drug.
In family members of addicts, Texas Tech researchers have uncovered a similar behavior.
Family members often make terrible choices to enable an addict. The same midbrain impairment is at fault.
“You’re trying really hard to save your loved one,” said Shumway. “You give your son $20 to get drugs so he won’t get them somewhere else. You keep giving them a place, loaning them money.”
A wife may call her husband’s employer and tell them he’s sick and cannot come in to work.
“The classic way it works,” said Shumway, “mom, dad and son are getting out of treatment, and mom is so happy. They go to a family reunion, and there’s alcohol there. Mom says ‘I am his sober buddy and won’t let him drink.’ But smelling it and being around it can cause the brain to crave it as much as using.”
“The family member can be a big part of the solution or problem,” he added.
Shumway said time, coping skills and helpful family members are all needed.
“The first thing we tell family members is to get well yourself. By the time we get done with them, the scales come off their eyes,” he said.
Then they can be part of the recovery.
Brian Shannon wrote the book on law and mental health used throughout Texas for one reason.
His mother told him to.
The journey began when his brother, a senior at Sul Ross State University in Alpine, started having mental breakdowns. His roommate got scared and called Shannon’s parents in San Angelo.
The family brought Shannon’s brother home and “the odyssey of learning about mental illness was brought home to our family,” said Shannon, a Horn professor at the Texas Tech University School of Law.
The Shannon family got their son help and medications.
Eventually his life improved, before dying of a hemorrhage at 53, the result of drugs he had to take in order to live.
From the day the Shannons got that panicked phone call, they decided to do something about mental health.
“It impacted everyone in the family — my mom, who was an elementary school teacher, and my dad, who was a coach and college professor,” Shannon said.
His parents visited Shannon when he was serving as a lawyer at the Pentagon.
They talked to people at the National Alliance on Mental Illness (NAMI) and asked if there were any chapters in Texas.
The family started one in San Angelo.
Shannon’s mom retired early to become a full-time mental health advocate and eventually became NAMI’s national president.
When Shannon came to teach law at Texas Tech 30 years ago, he started and facilitated a Lubbock NAMI chapter.
His mom was president of NAMI Texas when she asked her son if there were any books about mentally ill people in the criminal justice system.
Shannon told his mom that book did not exist.
“Why don’t you write one?” Shannon recalled his mom asking. “Isn’t that what you’re supposed to do?”
NAMI Texas got a grant to publish “Texas Criminal Procedure and the Offender with Mental Illness” in 1993. More editions followed.
It quickly became required reading among his peers. Shannon recalls an insanity defense trial where the judge, prosecutor and criminal defense attorneys all had copies of the book.
In the 25 years since the first edition, Shannon hears from attorneys who have questions not addressed in the book, and he takes notes for the next edition.
“There are not a lot of resources out there on these issues,” he said.
Shannon’s seen the widespread impact of his writing.
During the 2001 Texas legislative session, Duncan, then a state senator, led a task charged with rewriting criminal competency statutes.
“He did a masterful job,” Shannon said.
The biggest impact?
At the time, every criminal competency case needed a jury trial, which Shannon said was a waste of time and resources in 90 percent of the cases.
Now, the default rule is a hearing in front of a judge.
Shannon has also seen changes to intercept people with mental illness before they become a danger to others or commit serious crimes.
Treatment is better, but getting people into treatment is still a challenge — sometimes taking up to a year, he said.
Shannon has served on the Texas Judicial Mental Health Commission and the board of StarCare Specialty Health Systems — the state designated mental health and mental retardation authority for the Lubbock area — since 1991.
Appointed a Horn professor in 2015, Shannon uses funds from the award to bring in national speakers for mental health symposia. The next is in November.
Morning sessions are for law enforcement. Judges and lawyers attend in the afternoon. The split gives opportunities for all parts of the criminal justice system to broaden their knowledge of mental health issues.
It’s yet another way Shannon and his family continue working to address mental illness in their communities and across the nation.
But challenges remain.
“There’s lots to be done,” he said.
With the critical need for mental health treatment and care and widespread potential for impact across two universities, Duncan isn’t wasting time.
Investment in mental health efforts across the system has already started.
In June, Midland Development Corporation announced an $8.4 million economic development incentive for Texas Tech University Health Sciences Center at the Permian Basin that will provide much needed psychiatric services for the Midland-Odessa area and all of West Texas.
“This will help us recruit more faculty who will treat patients and train other doctors,” said Dr. Bobby Jain, chairman of the TTUHSC Department of Psychiatry.
Jain praised the incentive as “generous,” one of the most significant investments since Texas Tech opened its regional campus.
“I commend leadership of the Midland Development Corporation for their foresight and vision to fulfill the mental health need. The benefits will percolate across all West Texas areas,” he added.
Keith Stretcher, MDC’s first vice chairman and a Texas Tech University School of Law graduate, said the organization wanted to replicate what they had seen other West Texas communities do with Texas Tech.
Midland leaders, including Stretcher and MDC Chairman Brent D. Hilliard, saw Amarillo and Abilene work with the university successfully.
“We met with Chancellor Duncan and President Mitchell. They said the most pressing need in the Permian Basin and West Texas was psychiatric services for children and adolescents,” Stretcher said.
A partnership was set up between Texas Tech, Midland Development Corporation and the state of Texas, which added another $2.1 million after help from state Rep. Tom Craddick and state Sen. Kel Seliger.
In addition, the Midland-based Scharbauer Foundation contributed money to remodel the building where the program is based.
“We knew it was a huge need in our area. This center will be a hub for West Texas, and we estimate we’ll see more than 9,000 patients a year,” Stretcher said, adding that approximately 40 percent of patients outside of Midland County will eventually be served through telemedicine.
Jain said the project will start in September so that results can be seen in the next year or two.
“We knew it was a huge need in our area.”
“We don’t have enough doctors. There’s a long waiting time. So patients use emergency care, and they are getting inappropriate and inadequate care,” he said.
The program will add four fellows and up to 16 medical residents to help fill the gaps.
Admitting that it’s hard to recruit mental health professionals to the area, Jain expects those who train here will stay.
“Doctors tend to stay close to where they were trained,” he said.
The Permian Basin faces high rates of depression, teen pregnancy, substance abuse and school dropouts, according to Jain.
Part of that is because of the transitory nature of the oil economy.
Many families relocate during boom times and uproot their families, which contributes to metal health issues, he said.
Texas Tech has a clinic in K-12 schools to help families when a parent cannot take time off from work to take their child to a psychiatrist.
For Jain, the new fellows would play a big role doing more with the schools.
While some parents do not want their children to receive care because of negative associations with mental health, the West Texas shortage of mental health professionals is so acute, Jain’s team struggles to meet the overwhelming demand of patients.
“We can’t even get to the ones where parents want their child to be seen,” he said.
But Texas Tech is hard at work. An existing adult mental health program has reduced waiting times from three-to-four months down to a couple of weeks, he said.
With so much potential, Jain is excited about what MDC’s investment will do.
“This will make West Texas more attractive to many other families with better quality of life and retaining better manpower. It’s a very good investment in the future of West Texas,” he said.
Fueled by philanthropy
For Duncan, the investment in Midland is the latest evidence of an crucial source of the system’s success.
“We wouldn’t be as advanced as we are today without philanthropy,” said Duncan, pointing out that only 24 percent of Texas Tech’s budget comes from the state. “Without foundations, groups and individuals, this would not happen.”
Duncan talked about the “Texas Tech model,” a phrase coined by Chairman of the Board of Regents L. Frederick ‘Rick’ Francis to describe how Texas Tech has partnered with West Texas communities to develop innovative and much needed academic, research and patient care opportunities in Amarillo, Abilene, El Paso, Lubbock and the Permian Basin.
While the system is based in Lubbock, it was created to serve all of West Texas, a promise the chancellor says it has delivered on even as its grown to more than a dozen campuses.
“These communities have seen we’re a good investment,” Duncan said, adding Texas Tech brings good, steady jobs to each community’s economy.
Mitchell emphasized that the recent investment from Midland Development Corporation is a prime example of how philanthropy pays dividends far beyond the initial investment.
“That will impact Midland and Dimmitt and Alpine.” he said, adding that technology will provide the platform to link healthcare professionals with patients in underserved small towns all over the region.
And as the new Mental Health Institute takes shape, everyone — from Duncan to university faculty — are focused on one outcome: making a difference in people’s lives.
That’s the biggest motivator of all explained Schovanec, who recalls the times that philanthropic investments in Texas Tech have come from donors who saw the university system impacting people and were inspired to give.
“That’s what distinguishes the American system,” he said. “There is not a tradition of philanthropic support for universities in Europe and Asia as there is in the United States. That’s part of the reason higher education in the United States is still the envy of the world.”