Senator Eliot Shapleigh - El Paso, Texas

Renee Carver sits in a small, pink room with two rocking chairs, a tiny window and a hospital staffer who watches her every move.

How did she get to here? The Austin woman -- who has schizoaffective and borderline personality disorders -- doesn't really know. She's been here before, lots of times, and the days have morphed into a hazy montage of jingling keys, slamming doors, screaming patients and the pervasive smell of urine and cleaning solution.

But how did she get here this time? She can't remember.

Wait.

It was the parakeets. They were talking to her, calling her names: Fat. Stupid. Worthless.

She wanted to kill them. Instead, she fled to her parents' house and wandered the streets in her nightgown and socks at 2 a.m. It was 42 degrees.

"The next thing I remember," Renee says, "I woke up here."

Here is the Austin State Hospital, and this is Renee's seventh visit in 11 months.

Renee is among the thousands of people trapped in the revolving door of Texas' psychiatric hospitals. At any given time, more than half the patients in the 10 state-run facilities have been there before.

In 2004, there were 18,479 admissions to the state hospital; 10,482 -- 57 percent -- had been hospitalized at least once before. About 8 percent have been hospitalized three or more times in six months.

The fact is that Texas' psychiatric hospitals are not designed to heal people. Instead, they are psychiatric pit stops. Most patients are medicated, stabilized and sent back to their homes within two weeks.

The real healing is supposed to occur through state-funded community mental health centers. But those centers, struggling with too many patients and too little money, refuse care to thousands of people a year. Even those who do get help face waiting lists and limited care. At Austin Travis County Mental Health Mental Retardation center, for example, patients wait up to four months for an appointment with a psychiatrist.

The result: The sick get sicker -- or they cycle between stability and sickness -- and end up back in state psychiatric hospitals, the most expensive and least effective long-term treatment Texas has to offer. It costs about $419 per day to house patients at Austin State Hospital.

"The system is cracking," said Kenny Dudley, director of state hospitals for the Department of State Health Services.

Renee is luckier than most people in the public system.

The 44-year-old goes to a well-regarded mental health center. She sees a psychiatrist once a month and visits with a caseworker three hours a week. She has a family that loves and supports her.

And yet, she returns to ASH again and again.

But Renee's seventh trip to the hospital will be different from the others. During this visit, Renee, who agrees to stay at the hospital voluntarily, will be selected for a new program focused on positive reinforcement and behavior modification -- a huge leap from the medication-only regimen most patients receive.

The program, spearheaded by ASH psychologist Joe Pacini, acknowledges that mental illnesses can't be treated solely with drugs. Some behaviors are simply that, behaviors. And so people need additional tools to cope in the real world.

Pacini knows Renee is one of those people. So for two months, ASH staffers will try to help Renee change the behaviors that lead to her frequent breakdowns.

The goal: To keep Renee out of the hospital for at least several months. Will it work?

On a mid-February afternoon, just days after her admission, Renee can't imagine it. Instead, the full-figured brunette with the gold-rimmed glasses and pecan-colored eyes slams her back against a heavy rocking chair, her face contorting with anger and grief.

She is broken. She thinks she can't be fixed.

That night, she tries to cut her wrists with a plastic spoon.

The Texas evolution

On Guadalupe Street, far past the Texas Capitol and the University of Texas, stands a Hyde Park institution surrounded by a chain link fence crawling with rose bushes.

When it opened in 1861, it was called the Texas State Lunatic Asylum. Today it is Austin State Hospital.

This is the public safety net, a facility intended for Texas' indigent and uninsured. But these days, poor people aren't the only patients at ASH. Professors, athletes, architects and nurses live among the homeless and jobless.

They may have insurance, but Austin only has one private psychiatric hospital -- Shoal Creek -- and the 151-bed facility is often full. So, when it all falls apart, they come to Austin State Hospital.

The lush campus is dotted with buildings, but most patients are housed in a one-story, utilitarian building on the property's south side.

There are plenty of doors between the main entrance and the adult psychiatric wards -- all thick, heavy doors connecting a coral-colored maze of hallways, visiting rooms and offices. It is a Wonderland rabbit's hole, an intentionally puzzling structure designed to contain and confuse escape-prone patients.

Unlock one door, lock it again. Unlock, lock. Unlock, lock.

Welcome to Unit One.

It is just after 8 a.m. on a typical weekday, and Leticia Aguilera stands by the large color television in the common room.

"Excuse me," the mental health worker supervisor says. "Hello. Some of you are new, so I just want to explain what's going on."

Twenty-one patients -- Unit One's maximum capacity -- gather around the institutional-style room. The paranoia-prone stand in the corner, their backs safely guarded by light green walls. The manics excitedly comment on everything, while the depression-plagued slump in 115-pound rocking chairs.

Heavy furniture is harder to throw.

Unit One's routine goes something like this: breakfast at 7:15 a.m., lunch at 11:30 a.m. , dinner at 4:30 p.m. Classes -- everything from yoga to medication management -- are held every hour. There's free time, outside time, medication time, health check time.

And please, Aguilera says, don't clog up the toilets with paper towels when you're upset. It just makes the place stink.

A 50-ish woman with a sweet face and baby-doll voice raises her hand.

"Yes?" Aguilera says.

"What do you do when you feel like you're going to jump on somebody?" the woman asks.

Aguilera doesn't blink.

"Oh you definitely talk to the staff," she says. "Definitely."

Two weeks from now, most of these patients will be gone. The average length of stay is 22 days.

Texas' psychiatric hospitals didn't always operate this way. For years, patients spent decades in institutions with little hope of returning to society. In the 1970s and '80s, conditions improved after advocates sued the state for abusing, neglecting and overmedicating patients.

During the last decade, Texas' psychiatric hospitals transitioned from long-term facilities to crisis centers. The idea was to get people out of hospitals and serve them through community mental health centers, allowing them to work or be near family.

Lawmakers increased spending on community centers by 35.8 percent. Even so, many have waiting lists and limited services. And at hospitals, which saw a 16.1 percent funding increase during the last decade, admissions continued to soar. Between 1994 and 2004, admissions to the state psychiatric hospitals increased 47.5 percent. And Texas still ranks 49th in the country in per capita mental health spending.

Renee is tired of hospitals.

Her first psychiatric break came on Dec. 24, 1977. The then-16-year-old was in a therapist's office when she rammed her fist through a window and intentionally cut her arms.

"She's been in and out of group homes and hospitals ever since," said her father, Andy Carver.

In 2004, Renee moved here from Corpus Christi to live near her parents, triggering a series of hospitalizations that has left her and her parents emotionally drained.

Renee's medications occasionally stop working, causing her to hallucinate or act out. But the real problem is her borderline personality disorder, the part of her that uses manipulation and self-mutilation to get what she wants.

That's not something that medication can cure, doctors say. It's a behavioral problem that's difficult to treat.

But Unit One is going to try.

The front lines

The scrawny blonde paces across Unit One in bare feet, spewing obscenities with every step.

She's fine, she yells. Perfectly fine.

In fact, the new patient is running on cocaine fumes. She's a drug user and has schizo-affective disorder. Her teeth are gray and rotting; her hair is long and ratty. Mental health officials brought her here this morning after plucking her from the Galveston jail.

Staffers want to medicate her. She is wild, slamming furniture and potentially violent.

"If you cooperate, it will be a lot easier," nurse Judy Sharpton tells her.

"I hate all of you," the woman screams.

Another patient huddles in a nearby rocking chair, holding his hands over his ears.

Eventually, four staffers follow the woman into the room she shares with three other patients. Kicking and screaming, she fights as they hold her down and inject her with medication.

Most people settle down within minutes of a shot. Not drug users. The woman rages for another 15 minutes before she sits down to eat a bologna sandwich on white bread.

"Where's the salt?" she demands. "What, we can't afford salt anymore?"

Then she glares at Sharpton.

"You have problems," she sneers. "You need a psych evaluation."

Sharpton rolls her eyes and walks into the nursing station. "I need a psych evaluation."

"We've been saying that for years," a co-worker teases.

Sometimes humor's the only thing that keeps them going.

The nursing station is the heart of Unit One, the gateway to computers, offices and patient records. Around the corner stands a refrigerator, sink and counters usually covered with doughnuts or chips. It's where staffers come to take a breather from a job that often leaves them frustrated.

Most state workers make less than they would in the private sector -- by at least 10 percent to 15 percent -- said Carl Schock, ASH superintendent. ASH employees haven't gotten a raise in four years.

The worst pay goes to the staffers who have the hardest job: mental health workers.

These are the folks on the front lines with patients, the ones who take them to the cafeteria and to classes, who sit with them in the common room, who hold them down for shots. They come face to face with psychotic and sometimes violent people every day.

Their starting salary: $18,732 a year.

"Basically they have to decide: Is it worth getting spit on and kicked or should they go sling fries?" Schock said.

Some people quit to make more money elsewhere. But staffers who stay say they love the excitement, the lack of routine and the potential to help people.

Psychologist Joe Pacini has worked for ASH for more than 20 years. He started as a volunteer, then became a mental health worker, occasionally chasing runaway patients through nearby Hyde Park neighborhoods. Today he works with adults, holding group therapy sessions, assessing patients and devising treatment plans. He generally juggles around 40 cases at a time.

Shortly after Renee's arrival, Pacini decides to give her some extra attention. He devises an incentive program that rewards good behavior. Renee must go to classes, stop hurting herself and stop disrupting the unit with screaming and threats.

For each goal she meets, she will be issued "ASH Cash," paper tickets made just for her. When she collects enough, she can use them to buy treats: trail mix, flavored water, stickers, Arby's cheddar roast beef sandwiches, anything her parents are willing to bring her as positive reinforcement.

She'll also get individual therapy with Pacini, something she otherwise would not receive. Within days Renee is noticeably brighter and going to classes.

The court system

The cheerful psychiatrist with short, frosted hair and a long, floral skirt walks down a winding hall toward Austin State Hospital's makeshift courtroom.

Dr. Lynne Inman is queen of the Unit One kingdom. The 54-year-old doctor decides who gets what medications. She plays a large role in determining who stays and who goes. She also attends mental health court several times a week.

About 90 percent of all patients at the state's 10 psychiatric hospitals have been committed against their will by a judge. Patients can appeal their commitments and often do.

Court comes to ASH twice a week. A judge decides whether patients must stay based on this question: Is the patient a danger to himself or others?

Sometimes, it's an easy call. Sometimes it's not.

The easy call of the day comes with a schizophrenic man who has been admitted to and run away from ASH dozens of times. He's the reigning champ of the "unauthorized departure" or U.D.

And so the staffers call him "Udini," a nod to Houdini, the great escape artist.

On a typical weekday, Inman sits at a long conference table and tells a probate court judge that Udini needs to stay hospitalized because he is violent, paranoid and psychotic.

Udini, a tall, thin man with scraggly hair and a jumble of rotting teeth, disagrees.

"I'm just trying to figure it out," he says. "There's a whole lot of people trying to deprogram me."

Udini stays.

The next case is a schizophrenic woman with a history of violence. But inside ASH, she is quiet and docile. She doesn't hurt anyone. She doesn't threaten to hurt herself. That's all the judge needs to know.

"She'll end up back here," Inman says dully. "She'll probably be back tomorrow."

The woman is released that afternoon. She attacks her husband several hours later. The police bring her back to ASH that night.

The road to healing

Renee sits in art class, clutching a dull crayon.

Classical music fills the background as nearly a dozen other patients sit in a sunny, Spartan classroom, coloring pictures of Easter.

This class feels like high school detention. Some patients quietly follow teacher Steve Ruud's instructions, heads bowed over their colorful creations. Others giggle, talk and flirt. One patient, a beautiful woman on a manic high, oozes sexuality as she hangs all over a nearby male.

"I think we met like ships in the night going from Venus to Mars," she purrs.

Patients are forbidden to "date" while in ASH. It's a way to protect the emotionally fragile from themselves and others, a way to force people to focus on their psychiatric recovery and to protect the hospital from liability.

But some illnesses, such as bipolar disorder, can cause hypersexuality. So things happen. Romances are born.

So is violence. In 2004, the hospital system -- which took in 18,479 admissions -- had 5,686 injuries behind its doors. It also had three deaths: two self-inflicted and one murder.

Less than half of the injuries, 2,009, were determined to be accidents. Another 1,203 were self-inflicted and 1,202 were caused by other patients. The remainders were attributed to causes including medical conditions, visitors or alleged abuse or neglect.

Aaryce Hayes of Advocacy Inc. -- a federally funded group that advocates for disabled people -- reviews a portion of those incidents each month. The number of injuries doesn't concern her, she says, because most are minor and very few are abuse complaints. Renee has no interest in fighting or making friends at ASH.

After more than a month, she is starting to heal. She has not tried to hurt herself in weeks. She attends classes, takes her medication and works with Pacini on ways to change her behavior. For the first time in months, she has hope.

"I want to leave part of me behind here," she says, rocking gently in a chair. "The part of me that's hurt. The part of me that's afraid to try. The part of me that wants to give up on life.

"I want a new Renee."

A new beginning

Renee has that look: bright eyes, nervous smile, the anxious demeanor that heralds something big.

They call it the discharge look.

On a perfect day in early April -- sunny, blue skies and puffy, white clouds -- Renee walks into the Unit One conference room to discuss her discharge with Pacini and social worker Barbara Clark.

"Can you believe we're doing this?" Clark coos. "This is you, leaving!"

Over the last few weeks, Clark has done for Renee what ASH social workers do for all departing clients: scheduled follow-up care at the local mental health center, secured her two weeks of medication, arranged for transportation to take Renee home.

Renee is scared.

What if she can't do it? What happens when the depression comes? What if she has a panic attack at the grocery store?

Baby steps, Pacini emphasizes. Practice buying small things at the store: a pack of gum, a piece of candy. Go through short lines. Take deep breaths. Think positive thoughts.

"That way, you enjoy going to the store," Pacini says. "You enjoy your life. You've got a challenge, but you can do this. I have no doubt in my mind."

"But it's so hard," Renee whines, clutching Clark's arm.

Dr. Inman walks into the room and grins at her departing patient.

"Big day, huh sweetie?" Inman says.

Renee nods and tries to blink away her tears.

"The experience doesn't have to end here," Pacini tells her.

Despite her fear, Renee is excited. She has celebrated the occasion by making the hospital staff cards adorned with colorful cotton butterflies and original poetry. She's also given Inman a framed, earth-toned collage made of fabric and seeds.

"Dr. Inman, will you hang this in your office?" Renee says.

"I would love to," Inman answers.

Renee is stalling now, lingering to stave off the inevitable.

With a final few hugs, a wave and a little sob, she walks out of the conference room.

"Bye," she says. "Thank you. Bye."

As soon as she leaves, the staff ponders her chances of long-term recovery.

Not great, Inman says. Five or six months without a hospitalization would be a victory.

"I think she'll be OK for a little while," she says.

But for now, it's out of their hands.

And then, as if they have silently closed the book on Renee, the Unit One treatment team moves on.

"OK," Inman says. "Let's do report."

"We have 21 today."

"Full house."

"What else is new?"

And as they talk, another day at ASH begins against the backdrop of jingling keys, slamming doors, screaming patients. Just like every other day.

Renee returned to Austin State Hospital 20 days later.