What Does Mental and Behavioral Crisis Response Look Like in Texas?

During Mental Health Awareness Month, conversations around behavioral health often focus on reducing stigma and encouraging people to seek help. But for many Texans, the challenge is not only recognizing when help is needed and finding the courage to ask – it is navigating an increasingly strained behavioral health system, particularly when facing moments of crisis.

Over the past several years, Texas’ healthcare landscape has shifted in ways that are hard to ignore. Years of workforce shortages, inadequate reimbursement, fragmented infrastructure, lack of coordination and rising demand have pushed many hospitals and providers to a tipping point, and these pressures are felt more acutely in mental and behavioral healthcare.

A State of Crisis

Worrying numbers are coming out on the mental well-being of young Texans. Recent data shows that roughly one in five children in Texas is affected by a mental, emotional, developmental or behavioral health condition, and for many, these challenges are not mild or temporary. They are serious emotional disturbances that affect the daily functioning of an estimated up to half a million children between the ages of 9 and 17. Texas adults are also experiencing challenges; in 2023, 36.8% of Texans reported symptoms of anxiety or depression, 4.5% higher than the national average.

Jessica Knudsen, LCSW, FACHE, the CEO and president of Clarity Child Guidance Center in San Antonio, says the facility has seen more acute and earlier onset of symptoms, manifesting as “younger children with active suicidality and more aggressive behaviors across all ages.” That worry transforms into a concerning cry for help when factoring in the lack of resources available to health providers and facilities in Texas to care for people most in need.

“There has been a significant increase in numbers of children presenting in need. We rose from 85% total bed capacity in April 2025 to 92% bed capacity in April 2026,” she shared. “This has resulted in an increase in children sleeping in our Crisis Services department awaiting an inpatient bed either with us or another inpatient provider. This type of volume makes it more difficult for us to take Emergency Room transfers, causing a buildup of behavioral health patients boarding in ERs. At our facility, [the increase in patients] also leads to our need to increase staff per shift to accommodate potential staff burnout and avoid safety issues just based on the physical volume of people in our lobby.”

In a state where 47% of pediatric stays are related to psychiatric conditions, only 10% of Texas counties have inpatient psychiatric beds. And across organizations, workforce shortages often prevent patients from receiving the level of care clinicians recommend. A 2024 projection from the Texas Department of State Health Services placed a shortfall of behavioral health providers in 2022 at 11,449 and predicts a widening gap of 33,558 professionals by 2036.

Meanwhile, the finances underlying care weigh on providers and patients alike. Payer reimbursement – particularly Medicare and Medicaid – continuously runs short of the cost of providing care, making it difficult for facilities to sustain operations. In 2021, Texas adults enrolled in large-employer health plans were tacked with an average out-of-pocket spending of $1476 for mental healthcare, compared to an average of just $730 for physical care.

The barriers to accessing care lead many to delay care until it becomes more severe. Knudsen says that generally, over the last ten years, it has taken an average of eight years between the first appearance of behavioral symptoms and being connected to services.

“There can still be a great deal of denial with these disorders, and folks may wait until symptoms have escalated to the point that emergency services are needed. The deficit of mental health professionals in the state also contributes to wait times for outpatient services, potentially causing issues to rise to a crisis.”

Point of Hospitalization

As psychiatric facilities struggle to meet growing demand with diminished resources, emergency departments have increasingly become the safety net for the behavioral health system.

When symptoms escalate into a behavioral health emergency, patients may enter the system in different ways. Some individuals voluntarily seek help through an emergency department, behavioral health clinic or crisis facility. In other situations – particularly when a patient is considered a danger to themselves or others – law enforcement, emergency medical services or the courts may become involved.

Under Texas law, a person experiencing a severe psychiatric crisis can be placed under an emergency detention order by a peace officer and transported to a facility for evaluation by a physician or mental health professional. Many times, patients are brought to the nearest emergency room, regardless of specialty. The goal is stabilization and assessment, then determining whether inpatient psychiatric care, outpatient treatment or another level of support is necessary.

Emergency departments are designed to provide a broad scope of care intended to stabilize acute medical emergencies. Hospital ERs are being increasingly forced to take on responsibilities traditionally meant for psychiatric facilities. Yet, emergency rooms cannot offer the same depth of specialized care that an inpatient psychiatric facility is equipped to provide. In some cases, patients may have to wait hours in emergency departments for an available psychiatric bed, worsening their condition and overloading staff workload. Agitated patients in crisis waiting too long for care is a recipe for workplace violence to enter the fray.

To accommodate the expanded scope of patients and extensive resources required to care for them, hospitals and psychiatric facilities are increasingly forced to absorb the costs of preventable crises. Strengthening behavioral health infrastructure before patients reach a breaking point – and ensuring they remain connected to care afterward – can reduce repeat emergency visits, ease pressure on overcrowded emergency departments and lower long-term system costs.

The Continuum of Care Gap

Even after a patient is stabilized, the next steps in treatment are not always clear or accessible. Mental and behavioral healthcare depends on a continuum of services – crisis response, inpatient treatment, outpatient therapy, medication management, peer support and long-term community care – and patients can “step-up,” or “step-down” through the levels of care they need. But state behavioral health planners have identified continuity of care as one of the most significant gaps in Texas’ behavioral health system.

For patients leaving the hospital, follow-up care can be difficult to secure. Nationwide, Texas ranks at the very bottom in mental health provider availability – appointments with psychiatrists or therapists may take weeks or months to obtain, particularly in rural communities where behavioral health professionals are scarce.

“Investing in workforce development for behavioral health professionals would assist in addressing the shortages of psychiatrists, therapists and crisis counselors. There have been strides made in loan repayment and training pipelines that could be expanded,” recommends Knudsen.

One of the largest breaks in the continuum exists between crisis stabilization and long-term recovery. THA has advocated for expanded coverage of “step-down” services – including partial hospitalization and intensive outpatient programs – which can help patients transition out of intense inpatient care while still receiving structured support at a fraction of the cost.

Without accessible follow-up care, many patients cycle repeatedly through emergency departments, law enforcement interactions or short-term inpatient psychiatric stays without receiving sustained treatment. The result is a pricey and painful cycle in which hospitals repeatedly stabilize patients only to discharge them back into communities where follow-up care remains inaccessible – driving repeat emergency visits, prolonging psychiatric boarding and increasing strain on an already overwhelmed healthcare workforce, all of which adds to the overall cost of healthcare.

Investing in behavioral healthcare is not just a commitment to better care and access for patients but is a long-term strategy for decreasing hospital financial burden, system strains and ensuring that proper care is provided in an appropriate timeframe.

Prevention as Intervention

Research points out that improving mental and behavioral crisis responses in Texas will require more than addressing emergency intervention alone. Increasing inpatient capacity, strengthening outpatient and “step-down” services, expanding health plan coverage and investing in workforce development are all part of building a behavioral health system capable of meeting the behavioral health needs of Texans. The upfront investment to strengthen the behavioral health system is one that over time will not only improve quality of care, but ensure patients are seen and treated in the right setting at the right time. Providers also point to the success of the 988 hotline system in decreasing suicide rates, and encourage strengthening its infrastructure.

What’s also emphasized is the importance of early intervention and prevention — identifying mental health concerns before they escalate into crisis situations.

“My favorite Frederick Douglass quote is ‘It’s easier to build strong children than repair broken men,’” says Knudsen. “Early intervention matters because it takes advantage of a critical developmental window.”

Advocates say investments in youth mental health services, school-based programs, telehealth access and community support systems could help reduce pressure on emergency departments while improving long-term outcomes for patients.

Mental Health Awareness Month serves as a reminder not only to recognize behavioral health needs, but to confront the lack of infrastructure and evolving strain placed on the providers and facilities responsible for responding to them. There is still hope on the ground; “More people – families, schools, employers, and policymakers – are openly talking about mental health than ever before, which contributes to earlier help-seeking. I am also hopeful that despite the workforce shortage, the individuals who are going into this field are fiercely mission driven and deeply committed to change,” says Knudsen.

As Texas takes steps in to expand behavioral health resources, providers say significant gaps remain. For patients and families navigating mental health needs, timely access to care can mean the difference between stabilization and a complete crisis.

“Improving behavioral health in Texas ultimately comes down to treating it as essential, not optional healthcare,” says Knudsen.

“That means continuing to invest consistently, designing systems that are accessible to our most vulnerable, and listening to those with lived experience. The strongest future system will be one that integrates behavioral health into the broader ecosystem of care and is delivered with compassion and trauma informed intention.”