Sunday was supposed to be movie night at Candi Garrett’s house in Sweetwater.
Garrett’s oldest daughter, Kinzie, was 16 at the time. Kinzie doesn’t remember what started the fight between her mom and stepdad, Daniel Lee Eller, but it escalated until he was alone in his truck with a gun, threatening to kill himself.
Someone called 911, and according to the Nolan County sheriff’s report, Kinzie came out of the house and talked to the officers, telling them that her stepdad would never hurt her, that he had “mental blocks,” and was a good person. She swore he hadn’t meant to point his gun at anyone. She also told them that if they tried to arrest Daniel, he’d shoot himself.
Over the phone, Investigator James Villanueva tried to convince Daniel to get out of the truck and put down his gun.
But Daniel’s response was insistent and adamant: “He was not going to jail or any mental hospital,” Villanueva later wrote in his report from September 22, 2019. “I told Mr. Eller several times that he needed mental help and requested for him to allow me to take him to the hospital for evaluation and he told me that he would not, again making the statement that he was not going to jail or any mental hospital.”
Kinzie told the Texas Observer Daniel was her best friend, a “dorky little dude,” just 5-foot-2 and bald. In her cell phone, his number is saved as “Daniella,” an old joke she used to tease him. She misses the sound of his black Dodge dually coming up the drive, the same truck he sat in for hours that night, sometimes talking to law enforcement officers and sometimes texting Kinzie, until he got out of the vehicle a little before two in the morning and walked down the driveway, away from the house.
He shot himself at 2:26 a.m.
Daniel’s death report stated he wasn’t intoxicated, but it did say that he exhibited mental health problems. For years, Daniel struggled with depression, and several officers on the scene recorded having had interactions with him. He’d been treated by West Texas Centers, the region’s mental health authority, and had taken antidepressants, Garrett said. After a previous suicide attempt, he spent two weeks at Oceans Behavioral Hospital, in Abilene, the nearest inpatient facility.
Garrett recalls when Daniel got out of Oceans he returned to West Texas Centers for counseling, but it was over a computer, and those sessions didn’t last long. “He’s not electronic. He didn’t care about any of that,” Garrett said.
Sweetwater is a city of about 10,000 surrounded by scrubby Mesquite plains and massive wind farms. It’s 40 miles west of Abilene, more than 200 miles west of Dallas, and part of Texas’ Central Plains. Locals have two persistent concerns: drug abuse, which people attribute partly to traffickers on busy Interstate 20, and the lack of opportunities. For kids and adolescents, that means there’s nowhere safe to play or hang out with friends. For adults, it means no local work.
Five years after Daniel’s death, Garrett has stayed put, but her daughter and oldest son both moved on.“I don’t want my children to move back,” she said. “This town has nothing.”
Kinzie in particular struggled with the trauma and emotional aftermath of Daniel’s suicide. She met with a counselor at her high school a couple of times, but that didn’t seem to help. Mostly, she felt alone, surrounded by family members dealing with their own pain and by classmates who never knew nor seemed to care why she was struggling.
A few people suggested she see a therapist, but, in Sweetwater at the time, that was more of a theoretical possibility than something you could actually do.
After moving to San Angelo for college, Kinzie decided she had to get help and started seeing a campus counselor. She can talk about her stepdad’s suicide now, but she said she’ll never live in Sweetwater again: People there just don’t understand.
“They’re not going to know the four-and-a-half, three-and-a-half-hour standoff that happened. They’re not going to know the words that were used that night. They’re not going to know the things that I went through, nor my family went through. Like, nobody will, because I’m not going to go and say, ‘Hey, you know, what? Did you know that throughout that night, my stepdad had a gun pointed at me? Not once, but twice?’”
The day Daniel died wasn’t a normal day, but a lot of what Garrett and Kinzie’s family has experienced isn’t unusual in rural Texas, where mental healthcare providers are scarce and stigma around seeking help persists. The federal Health Resources and Services Administration designates 192 Texas counties as mental health provider shortage areas. Nolan County, home to Sweetwater, ranks worse than 155 of those.
Like most rural counties, not just in Texas but nationwide, Nolan County has no psychiatrists. The lack of providers means that people are more likely to receive care from a general physician with little mental health training, if they receive treatment at all.
Even when counselors or psychiatrists do serve rural areas, stigma around seeking help remains high. That stigma can lead people to feel as if mental health problems aren’t legitimate, that they should avoid or overcome them on their own, and not let others know. Stigma can foster distrust of providers—since if mental health problems aren’t legitimate, then neither are the people who treat them.
Kinzie said the consensus in Sweetwater is that everyone should just grin through hard times. “People in Sweetwater perceived mental health as, like, you’re lower,” Kinzie said. “They always thought you should just be happy.”
For her that was an impossibility: “It was like you had to be a functioning person with depression, and I couldn’t do that every day.”
People in rural areas experience mental health problems at roughly the same rates as those in larger cities, but they are less likely to receive treatment, according to official statistics and studies in Texas and elsewhere. They’re also more likely to kill themselves. The suicide rate in Texas’ nonmetro areas is about 30-45 percent higher than in metro areas, and it’s been increasing faster there, too. White men are the most likely to die by suicide, with rates about three times higher than men in other racial or ethnic groups. Researchers have argued that higher rates of gun ownership in rural Texas play a role in those elevated suicide rates.
Katie Carter, a counselor at Rolling Plains Memorial Hospital in Sweetwater, said financial stress also contributes. “We’re seeing quite a few suicides of people that are struggling economically right now. Things are just hard. It’s a hard place to live.”
Daniel’s standoff with law enforcement and eventual suicide also illustrates a lesser-known problem in rural mental health: the prevalence of crisis. While over 80 percent of the state’s population lives in large urban areas, rural areas see more calls to crisis services and treat more people, per capita, through Local Mental Health Authorities (LMHAs). Adults in rural areas are almost 50 percent more likely to receive treatment than adults in urban areas, LMHA statistics show; rural children and adolescents are about 150 percent more likely. The Texas Health and Human Services (HHS) report on rural mental health suggests that these differences may be explained by greater access to more diverse care options in metro areas.
According to HHS, Nolan County has the state’s highest rate of crisis calls, with 43 calls per 1,000 people, about 20 percent higher than any other county. Of the four counties with the highest rates of calls, three are served by West Texas Centers, a regional mental health authority that covers 23 counties spread over 25,000 square miles.
Rural hospitals, which struggle to negotiate sufficiently discounted rates with private insurers, operate on thinner margins in states like Texas that have opted not to expand Medicaid. The Center for Healthcare Quality and Payment Reform estimates that half of Texas’ rural hospitals are at risk of closing. According to the Texas Organization of Rural and Community Hospitals, roughly 20 percent of rural Texas hospitals have shuttered since 2000, leaving only around 160.
Government-owned hospitals in rural Texas are in an especially challenging position. A recent study by the National Bureau of Economic Research found that privatized hospitals are more profitable—public hospitals lose about $335 per patient, but, if privatized, make about $740. However, the study authors argue that’s a result of “cream-skimming” more profitable patients and admitting fewer on Medicaid.
The financial challenge of running a small, public hospital is top of mind for Doug Dippel, the CEO of Rolling Plains Memorial Hospital in Sweetwater, an 86-bed facility with a 24-hour emergency department. He said some rural hospitals have turned to cosmetic treatments like Botox to help make ends meet, but he thinks publicly funded hospitals should find ways to remain solvent while focusing on patients’ needs.
Before Dippel started as CEO, meeting those needs meant that Rolling Plains created a dialysis center to compensate for another that closed in a neighboring county. And in 2021, when the hospital’s community assessment showed that mental health concerns, as he puts it, “just kind of jumped off the charts,” it meant looking to make counselors available.
“The county hospital should be doing something about addressing the number one need of the county,” Dippel said. “And we’ve been serious about it, and we’ve been willing to put the money behind it.”
For Rolling Plains, addressing the issue first required confronting healthcare workforce shortages that are even worse in rural areas. The hospital previously had one counselor—Dippel said “no other little hospitals even had that”—who left at the start of the COVID-19 pandemic for a higher-paying job in Dallas. (HHS’s annual report on rural mental health notes that COVID-19 exacerbated existing workforce shortages by encouraging many counselors to switch to private, telehealth practices.)
The only other local alternative he found was Katie Carter, a former counselor at the Robertson Unit, the maximum security prison in Abilene.
By the time Dippel reached out, Carter’s “sunshine and rainbow” aspirations had come crashing down: She felt unable to really make a difference with incarcerated adults at the unit, who seemed so deeply affected by how they’d been raised and decisions they’d already made.
“I had always told myself in grad school that I wouldn’t work with kids,” she said, “but I realized working in the prison that if any changes are going to happen in mental health, we’re going to have to [address] the generational issues.”
After leaving the prison, Carter had worked at the Children’s Advocacy Center in Sweetwater, then with the local school district. Even working with children and families, she kept seeing some of the same patterns she’d confronted as a prison counselor.
“Sweetwater is rough,” she said. “They don’t want somebody blowing smoke and having them sing ‘kumbaya’ and all that. They want someone who will sit there and say, ‘You know what? Life is crap sometimes. It absolutely is. But we’ve got to figure out how to work through it.’”
Over time, Carter again began to feel her efforts simply weren’t enough: She was covering five campuses and referring kids to Abilene when she knew their parents couldn’t afford to take a half-day off work to make those appointments.
When Dippel asked Carter to work at Rolling Plains, she agreed—as long as she could build a counseling program, something bigger than just her.
Dippel doubted she could find more help. But in less than three years, Carter recruited two additional counselors, an intern, and a psychiatric nurse practitioner. Many clients are referred to her by doctors at the county-owned hospital, and more than half are children and adolescents. While there’s still a waiting list, it’s shorter than those of other hospitals and inpatient clinics in the region. These days, Rolling Plains is even getting some referrals from Abilene, reversing the typical trend of patients going to bigger cities to find care.
The program isn’t profitable, but it’s not losing money, either, Dippel said. “It kind of feels like we’re maybe the first rural hospital that said, ‘We can do this.’”
John Henderson, president of the Texas Organization of Rural and Community Hospitals, described Rolling Plains’ counseling program as “a unicorn in rural Texas.”
Another difference is that Rolling Plains offers in-person counseling. “I have yet to hear anyone say anything other than, ‘I hate talking to that computer screen,’” Carter said. “So it’s just, in our community, that’s what we see. They want to be face-to-face. They want to be having that human connection and interaction.”
That’s a big change from West Texas Center’s telehealth counseling, which didn’t work for Daniel. That state-run program hadn’t been effective for Garrett’s oldest son, either, who also has mental health issues.
“After a few visits … he just refused to go back. He refused to take his medicine. He said, ‘This place is a joke,’ and he left,” Garrett said.
Garrett’s son eventually moved to Odessa, where he did get care.
According to researchers at Johns Hopkins University, children who have a parent die by suicide are about three times more likely to die by suicide themselves.
Those are frightening numbers for Garrett, especially given the mental health challenges of her youngest son, who was only 5 when Daniel killed himself.
In 2021, a worker at the West Texas Children’s Advocacy Center recommended Garrett take her youngest to see Carter at Rolling Plains. About a month later, they had an appointment. That was a big deal, Garrett said, because they’d been on a waiting list at a clinic in Abilene since 2018.
Six years later, she still gets emails from the Abilene clinic: The last one suggested that they travel to Dallas for treatment. “You’re told to go to Abilene or Fort Worth or San Angelo or Midland-Odessa or Lubbock. Some people can’t. They don’t have a car, they can’t travel. Some people don’t have insurance. Some people don’t have the capability of going to a bigger town.”
The counseling at Rolling Plains was accessible, and Garrett said her son initially trusted Carter with things he said he couldn’t tell anyone else.
She described, too, how different the experience was from the online counseling her oldest son and husband got from West Texas Centers. “You know, [Carter] sees these certain people regularly. It’s not like they’re seeing somebody else every other week, and they can’t and they just give up. She’s here.”
Others in Sweetwater told similar stories about care that meets them where they live and offers more consistent support. A woman in her 30s who has experienced paranoia and anxiety for more than a decade said her counselor at Rolling Plains got worried after hearing she was driving herself to appointments on no sleep, so the counselor found a bus service to pick her up.
Seeing Carter helped Garrett’s youngest son, but it didn’t completely stop his crises. In spring 2024, he began experiencing psychosis following a medication change and ended up in the Rolling Plains ER. There were no available beds, and Garrett didn’t want to take him home in an unstable condition. At 4 a.m., a judge signed an order to admit him to a children’s facility in Fort Worth.
The next week, back in Sweetwater, Garrett said her son was still “up and down.” On Wednesday, he had a counseling session with Carter, but on Friday morning, when Garrett tried to get an emergency appointment, she was told that Carter wasn’t available until the following Monday.
Garrett said she started calling nearby inpatient centers to see if anyone else could help when her son got out of school. “I was trying to prepare myself for when I picked him up,” she said. “If he was in a crisis mode, I wasn’t taking him home. I was driving him somewhere [for help].”
That afternoon she got a call from Child Protective Services saying that a medical neglect charge had been filed against her.
Garrett said the allegations included things that her son had only told Carter. The medical neglect case was eventually closed, but the process took six weeks, and she was embarrassed because the investigator contacted her son’s doctors and she felt like she’d been accused of faking his illness or of being an unfit mother.
Garrett took her son back to see Carter twice after the CPS allegation, but she said he no longer trusted her. He took his dog the second time and refused to go inside because he said there were cameras there.
Steve Bain, founding director of the Institute for Rural Mental Health Initiatives at Texas A&M University-Kingsville, said he’s too often seen patients lose trust in their mental healthcare due to lack of accessibility. Sometimes wait times are too long or a judge who has ordered state funding for a person needing mental help decides that court-appointed counseling has run its course—or the timeline of a crisis doesn’t match the working hours of a counselor.
Even the Rolling Plains counseling program isn’t big enough to have someone always available, so after-hours calls usually just get referred to the ER. “It’s like if you went to the hospital with a heart attack,” Bain said, “and you get there and there’s no one there who is a cardiologist, no one there who can take care of you. If you survive, you’re going to be like, ‘Don’t ever go to that hospital again.’ Because what does that signify? It signifies a lack of trust. I came to you. … Or maybe you bring a loved one there and there’s no cardiologist and they die. What the heck are you gonna do, you know? How are you going to be able to trust anybody after that?”
Crisis makes it even harder to maintain trust around mental healthcare. In part, that’s because crisis response typically involves law enforcement and a trip to the ER for evaluation. From there, people experiencing crisis might end up stabilized and with a care plan or a referral for counseling—but they can also end up at an inpatient facility or in jail. That’s the path that Daniel told officers he would rather die than go down.
Even when a crisis doesn’t end in jail or hospitalization, there are other ways that unpredictable situations can go wrong, and in rural areas, stories get around.
“That’s a very hard part of being in a small town,” said Carter. “Because you’ll really quickly get those moms who are like, ‘Don’t go to them. They called CPS on me.’”
Carter declined to comment on Garrett’s or any other individual’s case due to patient confidentiality. She did say she is legally required to notify CPS in some cases.
In a town like Sweetwater, patients don’t have many options if they lose trust in a provider. One route is to just stop counseling, and Dippel said he imagines that’s what usually happens if someone doesn’t want to see Carter or one of the other counselors—then some later hit a crisis point and end up in the ER.
The other option is to get help outside of Sweetwater. Sometimes that happens naturally, like when Kinzie left for college and started seeing a therapist in San Angelo. But for others, getting help is more disruptive—and often means a lot of driving.
For Garrett, it means four-hour trips to Abilene, where her youngest son has started seeing a new therapist. She had to buy a car that gets better gas mileage, and she’s scared that she’ll lose her job because of taking time off for appointments, but she also said her son’s doing better.
When Tina Cudd couldn’t find the help she needed in Sweetwater, she felt like she had no choice but to move to a city with more resources. Her 14-year-old son has been diagnosed with a range of conditions, including ADHD, autism spectrum disorder, and bipolar disorder. Like Garrett’s son, he’s had multiple crises, starting when he was very young, some of which have involved the police or the ER. He’s been treated by West Texas Centers and nearby inpatient facilities, but it’s been years since Cudd felt like the right solution, or even an acceptable way of managing his crises, could be found in her hometown or anywhere nearby.
Last April, Cudd moved to Dallas so her son could attend a school that specializes in helping teens with mental health disorders. He’s had crises there as well, including one that kept him in the hospital for about two weeks. Cudd had to leave her job in Sweetwater to live with him, first in a hotel, then in an apartment.
Her son is making some progress, but it’s been hard on Cudd. She drives home some weekends. Sometimes she picks up shifts at her old job. Her relationship with her husband, who still lives in Sweetwater, has suffered.
“The most important thing is there are no resources,” Cudd said about Sweetwater. “Everything that we did, we had to travel for.”
In rural areas, mental health crises are both the rule and the exception. The rule because statistics show they’re just more common there, likely due to a combination of longstanding stigma, lack of access to care, and financial strain. For some families dealing with more severe forms of mental illness, crisis isn’t something that happens once or twice in your life; it can come every few weeks.
But, however frequent, crisis is also the exception by definition. It falls beyond the bounds of normal care. Outside the ER and the inpatient clinic, crises are never adequately prepared for. They happen at home and on the street, on the weekends and at night. They’re the images that stick with you: the man in the truck who won’t put down the gun, the broken window and the trail of blood, the kid on the roof with the machete.
Reflecting on the counseling clinic that he and Carter have built, Dippel finds questions about crisis disheartening. “I think we have a great deal of trust with patients who are in a state of mind that can seek us out,” he said. “But when it comes to the patients in crisis that are out of options, that’s when it really gets tough.”
Drugs are a contributing factor in many of the mental health crises that Rolling Plains confronts, according to Loran Hendrix, the director of the hospital’s emergency department. She estimates that as many as 80 percent of these cases that come into the ER involve drug-induced psychosis.
Carter remembers a woman who told doctors that she was schizophrenic, but during her evaluation Carter also learned that she had recently started using methamphetamine after being off the drug for 15 years. She had also stopped taking her antipsychotic medications, setting her withdrawal on a collision course with her reignited hallucinations. She was sent home as soon as she could take care of herself, in part because the hospital doesn’t have any psychiatric beds, and there’s often no other open bed.
“So they do a safety plan, and they send them on their way,” Carter said. “In those cases, I would love to see if we can’t get them stabilized over a day or two while we’re waiting for a bed, instead of just having them sign a piece of paper and say, ‘Promise you’re not going to do anything.’”
But building a new unit with psychiatric beds is a completely different financial proposition than staffing a counseling clinic—and it doesn’t seem like a real possibility considering that rural Texas hospitals are struggling just to stay open.
The term mental health means so many things: depression and suicidality, anxiety and paranoia, psychosis brought on by schizophrenia or drugs. There is no one solution. So it’s discouraging, Dippel noted, that someone might view Rolling Plains’ counseling program, which is for non-acute patients, as insufficient because it can’t fully address the region’s more acute crises of drug addiction and suicide.
Something that Sweetwater makes clear is how acute and non-acute mental health needs are related—and how crises reverberate through families and through the community. Kinzie and her younger brother both continue to deal with trauma from their stepdad’s suicide. Their mother, Garrett, worries that she might lose her job driving to Abilene to get care for her son after a crisis eroded their faith in the counselors at Rolling Plains. And generations of older Texans continue to live with experiences from the past, when stigma was greater and care was even harder to find.
Carter said she’s surprised that the clinic has started to bring in a few of these older patients, too, some who have mental health needs stretching back decades.
“We are having people coming in saying, ‘I watched my daughter drown when she was 15, and I’m not OK. And I’m 70 now, but I need help.’”
