UVALDE, Tex. — In the days since a shooter killed 19 students and two teachers at an elementary school here, Enedelia Soto-Quintanilla has barely been able to keep up with the stream of residents who want to talk.
“This whole town is heartbroken,” she said. “Everyone is suffering from surviving guilt, anxiety and some kind of post-traumatic stress.”
Soto-Quintanilla thinks healing will take years of sustained attention from professionals like her. But she and other experts warned that limited mental health resources and insurance access could keep such care out of reach for much of the town.
“It takes time and we know that this is going to be a long journey,” said Alejandra Castro, the rural services manager of the Family Service Association, a San Antonio-based organization that has operated in Uvalde for 22 years. “We know that our services are going to be here long term.”
Since the shooting, therapists have flooded the town, offering counseling to grief-stricken residents. But most of those support organizations will leave in the next few weeks or months, Castro said. And while several public and private practices in the town offer behavioral and mental health services, experts say Uvalde lacks inpatient treatment options, and enough psychiatrists specializing in children and adolescents.
For years, local officials have been fighting to fund an inpatient psychiatric facility in the region, City Manager Vince DiPiazza said. Currently, patients in need of hospitalization or long-term care must drive hundreds of miles across the state to find an available bed, he added.
Mental health experts, advocates and clinicians interviewed by The Washington Post said workforce shortages, language barriers and cultural stigma among the predominantly Hispanic community have created other obstacles.
“The school districts do have a little bit of mental health counseling … but it’s woefully underfunded and not sufficient numbers across our state to meet the needs within the schools,” said Mary Garr, CEO of Family Service, which works closely with school districts. “There’s much more that needs to be done, but we can’t grow mental health counselors overnight.”
In news conferences after the shooting, Texas Gov. Greg Abbott (R) promised to boost mental health resources in the region, saying that the state needed to “do a better job with mental health.”
Abbott has pledged significant support to the community to address the “magnitude” of mental health challenges, including a 24/7 counseling line and providing a temporary family resource center for Uvalde residents seeking mental health and other services.
Ramping up those state resources could be a challenge in Texas. A recent report by the nonprofit Mental Health America ranked the Lone Star State 51st in the nation on access to mental health care — a ranking that weighs access to insurance and treatment, quality and cost of insurance, access to special education, and mental health workforce availability.
According to another report by the Hogg Foundation for Mental Health at the University of Texas, 173 Texas counties did not have a single licensed psychiatrist in 2019, meaning more than 2.7 million Texans lived in a county without one.
Lack of insurance makes it worse. Texas leads the country in both the number and percentage of uninsured residents. Nearly 1 in 4 residents in Uvalde county lack health insurance, according to the Census Bureau. Latino children have the lowest rates of insurance in the state, the Hogg Foundation reported.
And even once the state creates a new program, it can take time to develop.
In 2019, Texas launched a youth mental health program for students with mental and behavioral issues. But the state-funded program has not yet reached Uvalde because it is still “ramping up,” said David Lakey, presiding officer of the Texas Child Mental Health Care Consortium — which was created in 2019, a year after a shooting that killed 10 at Santa Fe High School, to increase access to mental health services for children.
“It takes time to go from zero to statewide, not only moneywise but developing the workforce and community relations,” he said, adding that the Texas Child Health Access Through Telemedicine program offers a network of doctors, counselors and other professionals to more than 300 school districts across the state and covers about 40 percent of the student body.
In the meantime, the need here is acute.
Nine-year-old Jaydien, who said he survived the attack by hiding under a table so the shooter would not see him, told his grandmother he wanted to attend the funerals of his classmates. But as he sat in the car on the way to the church last week, he suffered an anxiety attack and begged his mom to take him home, his grandmother Betty Fraire said.
“It is slowly starting to hit him,” Fraire said. “It is so hard, but he wanted to attend all the funerals because they were all his classmates, so instead we went for him.”
Right after the shooting, Jaydien spoke to a counselor who told his family he seemed to be coping well, Fraire said. But as days pass, the trauma seems to be surfacing, little by little.
Jaydien — who is being identified only by his first name because he is a minor — used to love math lessons but does not want to go to school anymore. When he hears a loud bang, he gets anxious and scared and struggles to sleep, his grandmother said.
To help him, his family plans to take him back to therapy. “He will need counseling for a long time,” she said. “And so will we.”
And as the grief-stricken community collectively mourns their dead, the crisis has left few in this small town untouched.
At Uvalde Memorial Hospital, the emergency staff members who treated the 15 patients from the shooting, including seven children, are struggling to process the trauma of that hectic, terrible day, said Tom Nordwick, the hospital’s CEO.
The intensity of the crisis and the close connections with the victims hit the nurses, doctors and technicians hard.
“You have staff that have friends who were here who may have lost someone, others that had family members in the police department,” he said. “You have a lot of involvement, a lot of close relationships, and so there is trauma of going through something like this and knowing that your friends and neighbors are hurting.”
One staff member admitted not knowing how to talk to his grandson who had lost a dear friend, Nordwick said.
To assist those who are struggling, an in-house counselor and an array of other organizations have stepped in to help and are providing counseling to the hospital’s employees, Nordwick said. One of them is Family Service Association.
But even those not directly affected are grappling with secondhand trauma.
Soto-Quintanilla, who is originally from northern Mexico and bilingual, admitted that the task of helping others has come with a toll, prompting her managers to consider hiring outside PTSD services for the counselors themselves, she said.
For now, she is determined to keep supporting the community through the arduous process of healing.
To help children process the wave of emotions, Soto-Quintanilla used a drawing of a heart with different parts, to illustrate how a human has the capacity to feel many emotions, sometimes at the same time.
“This side is anxious, this side is sad, this is space for angry,” she told the children, some of whom had witnessed their friends and teachers being killed. “And then there is a small space for happy, too,” she said.
She also helped them come up with a “magic” word that they can use whenever they are feeling sad and want a hug from their parents, with no explanations or questions asked. One girl chose the word “pigeon.”
After a recent session that left her emotionally depleted, Soto-Quintanilla decided to go on a coffee run to collect herself. As she was walking she saw the same girl peeking out of the car window, screaming at her: “Pigeon!”
She sprinted toward the counselor and gave her a hug, no questions asked.
“You need one, too,” the girl said.
Karin Brulliard contributed to this report.