The curved blue wave pattern on the floors of the San Antonio State Hospital is meant to symbolize the River Walk, which runs a few miles to the north. A decorative quatrefoil shape on the exterior of the building honors the city’s historic Spanish colonial missions. These nods might feel like commonsense design for a local museum or hotel, but for a facility meant to house Texans in crisis, they’re downright radical. The brand-new structure, designed by HKS and New York–based Architecture+, is bright and cheery. It’s an intentional change meant to improve upon the original San Antonio State Hospital, which hadn’t been majorly updated since 1892.
The day after April’s solar eclipse, a mariachi band played inside the lobby as part of the ribbon-cutting ceremony for the new three-story, 454,000-square-foot building. Men in suit jackets and cowboy hats and women in casual dresses milled around a table crowded with pan dulce, coffee, and colorful paper flowers. They walked beneath mission-style arched entryways and explore the building’s “downtown” area, which consists of multiple outdoor courtyards, a greenhouse, a canteen, a beauty salon and barbershop, and a general store. Private bedrooms will house three hundred future patients.
Architecture and design can’t mask any pain and suffering that happens within four walls, but mental health advocates believe beautiful structures and fresh air should be part of treatment and recovery. More than a century after several of our state hospitals were built, Texas politicians finally decided it was time to modernize. Since 2017 the Legislature has approved about $2.5 billion in funding for mental health facilities, with the goal to update inpatient psychiatric care and increase capacity across Texas. The new San Antonio and Austin State Hospital buildings opened in April and May of this year, respectively, and the Terrell and Wichita Falls facilities broke ground for major renovations in August and September. Brand-new hospitals in Amarillo and Lubbock are in the works, as are expansions and improvements to existing facilities in El Paso and Harlingen. These upcoming renovations, plus buildings like the new San Antonio hospital, “symbolize a shift in our mindset,” says Kristy Carr, associate commissioner of the state’s psychiatric hospitals.
Airy courtyards, private bedrooms, and colorful walls are a massive improvement in the lives of patients and the people who work in our state hospitals, but is it enough to counter the fact that in a 2022 survey, Texas ranked dead last in states with access to mental health care? Lyssette Galvan, public policy director at the National Alliance on Mental Illness of Texas (NAMI), says, “With the exception of Arkansas, Texas was notably lagging behind its neighbors in mental health spending as of 2022, prior to the eighty-eighth legislative session.” Galvan says that when new data is available, the recent spending figures could show that instead of lagging behind, Texas is moving in the right direction.
Stigma and misinformation about who goes into psychiatric care, and how they should be treated, took hold of the public consciousness long before the state’s first mental health hospital, originally called the Texas State Lunatic Asylum, opened in Austin in 1861. Before America’s first psychiatric hospital, in Williamsburg, Virginia, started admitting patients in 1773, people suffering from psychological illness would “roam the countryside,” according to King Davis, a research professor at the University of Texas at Austin who served for five years as the executive director of the university’s Hogg Foundation for Mental Health. “The question now is: What are state hospitals designed to do? And are they prepared to meet new objectives for old diseases?” he says.
In East Texas, the Rusk State Hospital was built as a prison in 1883 before it was converted to a psychiatric facility in 1919. What’s now known as the North Texas State Hospital, in Wichita Falls, admitted its first patients in 1922, back when its welcome sign read Northwest Texas Insane Asylum. That facility is a 940-acre campus designed using the cottage system, a style that became popular in the late 1800s, when the architecture of psychiatric facilities came to be seen as an important part of patient care. The Cottage Plan had separate, freestanding structures meant to instill a sense of independence in residents and convey the feeling of living in a self-contained town. It differed from the Kirkbride Plan, named for the physician who conceived it, which consisted of a large main building with several attached “bat wings” fanning out from the center, which gave patients a sense of privacy and allowed for more natural light and air circulation. Many of these reforms happened because of mental health activist Dorothea Dix. In 1843 she witnessed and documented horrific conditions in which Americans suffering from mental health issues were kept in cells or chained to walls in prisons and almshouses with no heat or light. Dix advocated for change, and at the time, the new designs inspired by her work were considered revolutionary. Nearly two hundred years later, advocates are still fighting for reforms that grant patients agency and dignity.
Two years ago, I discovered that my great-aunt Inez was sent to that Cottage Plan hospital in Wichita Falls in 1946. She was convicted of arson in Fort Worth after nine people testified that she was “of unsound mind.” She’d set fire to the home of her abusive ex-husband when he wasn’t in the house. From my somewhat more privileged perch as a woman in 2024, I consider Inez to have been brave as hell and of very sound mind. A jury of her contemporaries didn’t agree. When I went to visit the hospital to try and understand what my great-aunt had been through, the stately redbrick buildings and eerily quiet grounds didn’t exactly scream “quaint, happy cottage.” Instead, the place evoked a time when lobotomies and insulin shock therapy were considered cutting-edge, and people were often left at the gates by family members who thought they had nowhere else to turn.
“We’ve been lax in investing, so the need is heavily there,” says Natale Stephens, regional health-care director at the Page architecture firm in Austin. Stephens worked on the Austin State Hospital (ASH) redesign, and she’s now planning the new Wichita Falls build. As opposed to the Cottage or Kirkbride designs, Stephens says that they tried to pull inspiration from college campuses for ASH. They designed it as a place you go to “grow and gain skills, and then you move on. It’s not a detention space,” she says. The architects took input from ASH employees and tried to incorporate updates that would improve the staffers’ day-to-day lives too, such as more color and open-air courtyards.
Preserving the histories of past eras influences the design process as well. In Wichita Falls, they’re using the same Acme mix to match the redbrick shade of the buildings from over one hundred years ago. At ASH, they used wood from pecan trees on the property to make furniture, and they discovered a section of the foundation from one of the original patient bedroom wings and made that a feature of the new building. Instead of burying a reminder of an era when dormitories were often dirty, dark, and overcrowded, Page exposed the slab for future generations to see. “When you have so much history, and all that history is not necessarily positive, the challenge is to not gloss over that but to acknowledge it,” Stephens says.
This effort to preserve the past is spearheaded by D. D. Clark, historic preservation and grant coordinator for the Texas state hospital system. When I first met Clark, at the San Antonio ribbon-cutting event, she was showing people a stained glass window hanging in one of the hallways. It had been salvaged by a maintenance director at the old building. When Clark searched through boxes and drawers at ASH, she found old spoons from the early years before the name was changed. The utensils had “SLA” (for State Lunatic Asylum) engraved into the metal.
“It was not doing them any favors,” she says of the impact the engravings likely had on patients who already felt shunned by society. Clark can rattle off dates, names, and facts like a walking, talking, blond encyclopedia of Texas state hospital history. She’s worked with the Bullock Texas State History Museum on exhibits that highlight children’s mental health and the history of electroconvulsive therapy machines in the state. She takes her job seriously and believes that those spoons, and that stained glass, are as crucial to the story of Texas as a statue commemorating a battle or an artifact from a 1960s NASA mission.
In late September, I meet Clark at ASH’s old administration building. Built in 1857, before the hospital officially opened, it’s an impressive structure that employees call the “white house,” because it looks stately enough for a president. It has a neoclassical portico, and the ceiling of each porch is painted light blue. The color is a Victorian design touch thought to either keep insects away or ward off evil spirits. The building is from a time when people were sent to state hospitals for things like addiction, epilepsy, liver disease, menopause, and senility. The white house is on the National Register of Historic Places and is designated as a State Antiquities Landmark. UT’s Davis believes that it should be converted into an official state hospital museum. As I walk through the quiet building with Clark, it’s hard not to imagine all the people who passed through the hallways and wonder what became of them. Did they, like my great-aunt, eventually get released and go on to marry and have children, all the while keeping their time at the state hospital a carefully guarded secret? Did they get out at all? Did they ever find a kind of peace?
Clark shows me artifacts displayed along the corridors. There are glass bottles labeled “opium tincture,” a curling iron that looks more like a torture device than a beauty tool, and a bone chisel. (Clark is quick to explain that the chisel was used not as a horrific form of psychiatric treatment, but for autopsies.) She shows me wooden crutches that a child used long ago, ledgers that document patients putting away twenty or thirty cents toward their retirement, and a 1924 hospital cafeteria menu. “There was a lot of beef stew,” she says.
If not for her, these relics would likely have been lost to history. Clark travels all over the state in her quest to salvage artifacts from state hospitals. It’s not exactly dainty work: She puts on hunting boots, gloves, and bug spray and spends hours in abandoned structures. She encountered one of her most interesting finds at an old creamery in Terrell, just east of Dallas. She squatted down to peer under a giant cauldron and pulled out small, dirt-stained paper ice cream cups with red and blue cowboy clowns and the words “Mr. Fun” printed on them. The patients would gather at the spot for ice cream socials, and a few of the paper cups had remained hidden under that cauldron for decades.
“These objects tell a story of resilience,” Clark says. They illuminate the fact that during their time in the state hospitals, patients ate ice cream together, painted pictures, and planted vegetables. They had dances and celebrated birthdays. “It’s important to share the human side so people don’t perpetuate the spooky. I’m here to help debunk myths.”
I encountered one of those myths while researching the history of the Wichita Falls hospital and looking for information about great-aunt Inez’s time there. Several websites declared that the abandoned “M” building on that campus was haunted. In the 2010 Texas Monthly essay “Patient Observation,” Skip Hollandsworth writes about growing up in Wichita Falls in the late 1960s and peering at the hospital’s “cluster of dignified, red-brick buildings trimmed with limestone. Some of them were three stories high, as big as oilmen’s mansions.” Local kids shared stories of homicidal maniacs with hooks for hands and beautiful nymphomaniacs in those redbrick structures, but once Hollandsworth stepped inside the buildings and met some of the patients, he stopped, as Clark says, perpetuating “the spooky.”
Elizabeth Stauber, archivist and records manager at the Hogg Foundation, says the new buildings are a sign of positive change, and Clark’s work to preserve the history of mental health care in Texas is crucial. “State hospitals across the country have not been perceived well because a lot of bad things have happened in them in the past, but hiding the history from the public or minimizing it does not help us calm the stigma.”
On the day of the ribbon-cutting ceremony at ASH in May, a tour guide showed us a makeshift apartment where patients can practice social skills and prepare to reenter society by throwing a Super Bowl party or hosting a Thanksgiving dinner. While I walked through the kitchen, I noticed a woman filming the surroundings with her phone. To me, the room looked a little boring, but she was crying and whispering, “This is amazing. This is amazing . . .” She told me she was a peer-support specialist at ASH, and that she was crying because she knew the impact the building, apartment included, would have on the people she worked with every day. “It’s very emotional,” she said, before heading out into the hallway, her phone still recording the tour. I’d just perceived a simple room, but this woman had noticed something more. What she’d glimpsed was a little bit of hope.
