The first few months after her husband died, Heather Boulware was fine. She didn't feel fine, of course, but she managed to keep taking the medications she'd been prescribed five years before to treat her bipolar disorder and continued to care for the couple's three children. "I was doing what I'd always done," she says. "But I was completely numb."
Suddenly, about six months later, "everything just fell apart."
Her husband's death had been equally sudden: Pneumonia had landed him in the hospital, but he'd made a strong recovery and come back home. Then he caught a cold. She came home one afternoon from a quick trip to the grocery store to find him dead.
After a few months without him, she sent the children to her mother's house in Oklahoma. She intended for them to stay there only a few months while she pulled herself together, but after awhile, she stopped taking her medication and started making a new plan. She cleaned out the apartment, set cut-off dates for all the utilities and wrote a series of letters to friends and family, which she left to be found later.
Finally, a day came when she knew the maintenance man would have to stop by the apartment. She didn't want her body to go undiscovered for weeks or months, so it was time. "I wrapped a cell-phone charger cord around my neck," she says. "Then I put a 13-gallon garbage bag over my head. Then I put another cell-phone cord around my neck."
But she didn't die. Boulware awoke in Green Oaks, a psychiatric hospital. From there, she was transferred to Terrell State, another hospital some 40 miles east of Dallas. "I was so mad I was still alive," she says. "I was like, 'How dare you save me?'" It wasn't until hospital staff forced her to take her medication that she realized how grateful she was to have been saved. "I don't even really know how to explain it, except your thinking is totally backwards."
Her stay at Terrell lasted 16 days, a bit shorter than the month or so the average patient remains there. She wasn't completely well, not by a long shot, but the immediate storm had passed. Where would she go from here? The only person she felt she could stay with was her father, a salesman, but he was often away for work. After talking with a psychiatrist at Terrell, she realized that with so much time alone, she likely would try again to kill herself.
On a recent afternoon, Boulware was sitting cross-legged on her small twin bed in a house in Pleasant Grove. One of her roommates, a petite schizophrenic woman who at times thinks she's a very large man, hovered in the doorway, bouncing a little and smiling anxiously.
Boulware was lucky to live through her suicide attempt, and lucky too that she was able to find a decent boarding home to move into. She says that the Pleasant Grove house has helped her start to get better. But the fact is that some boarding homes may make their clients worse, by being dirty, chaotic, overcrowded or downright dangerous. For many residents, finding a good home is just a matter of chance. The city of Dallas, cash-strapped though it is, has the power to regulate these homes and eliminate some of the gamble people like Boulware face. Right now, though, the city isn't using that power, and it's unclear if or when it will.
Boulware is a pale woman in her 40s with brown hair and glasses. She's told her story so many times to so many doctors, therapists and caseworkers that all the emotion has drained out of it; she could be talking about the weather. But when she talks about resuming her life away from the boarding home, her smile falters. She looks a little queasy.
"I don't really know," she says. "I'm trying to take it one day at a time. I get bad anxiety. To think much beyond next week for me, even, everything gets bigger and bigger and I get totally freaked out."
Boulware looks around the tiny room, the neatly made beds, her few books in a tidy stack on the floor. She goes quiet for a moment, glancing over at a picture of one of her sons beaming from the dresser. "I'm grateful I'm alive," she says finally. "I'm grateful I have somewhere to go where I feel safe."
If you're mentally ill in this country, chances are better than average that at some point you'll find yourself in an emergency room, a jail cell or a homeless shelter. If you're poor, too, you might not know where you'll go next, after your immediate crisis is over. For many, that next stop is a boarding home.
Places like the house where Boulware ended up, which is run by a woman named Demetra Donaldson, are generally considered the best-case scenario: clean, orderly and calm. In other boarding homes, residents have complained to police and social workers about overcrowding, dirt, bad food, theft and drug use by other residents.
"Boarding homes aren't a bad thing," says Dave Hogan, a licensed social worker who's also the head of the Dallas Police Department's Crisis Intervention Unit. "But there needs to be oversight." In 2007, the city didn't even know where the boarding homes in Dallas were located, much less which ones were good or bad. Hogan was part of an interdepartmental city task force that took a few older lists of possible boarding homes and set out to find out where the homes were and to ensure they were safe. It was the second time Dallas had convened city entities to look at boarding homes. The first effort was in 2004, and it didn't seem to have much impact.
What the 2007 task force found was often alarming. "There were terrible living conditions," Hogan says. "Places that were dirty, kind of crowded, the beds pushed together," at times cramming eight or more people in a single bedroom. In some homes, a slightly more competent resident was acting as the house manager. In one place, Hogan says, he asked that resident where everyone's medications were kept. The man thought deeply for a moment, then retreated into his bedroom. Hogan followed. "He was looking around like he can't remember where it is," Hogan says. Then the man brightened and reached under his mattress, pulling out a plastic bag filled with a jumble of pill bottles.
Over 15 months, the team visited 345 properties, where caseworkers interviewed 883 residents. Of those, 276 — nearly one in three — were found to be "at risk and in need of crisis assistance," in the words of a report the team put together.
"It really worked great," Hogan says. He's a small man with neat white hair in a Mister Rogers side-part. He swims slightly in the black DPD jacket he wears for work. Over time the team pared the list down and discovered which homes were still operating and which had vanished; many homes, especially in poorer parts of southern Dallas, seem to pop up and disappear overnight. "Some had gone back to single-family homes, with a tricycle in the front yard. One of them, it had gone and turned into a little mini city park. We had a good laugh at that. A good number of 'em were boarded up like haunted houses." With the intensive inspection, he says, "We got a good handle on generic problems and specific problems to some of these houses."
As Hogan points out, not all boarding homes are dangerous or overcrowded. In Texas, they've become an increasingly large part of the thin safety net that keeps the mentally ill, just barely, from falling through the cracks.
The number of beds in state-run psychiatric facilities here shrank by 30 percent between 1993 and 2010, according to Health Management Associates, which owns hospitals in 10 states. Among states, Texas also doles out the least money in mental health funding. In 2009, economist Ray Perryman found that Texas spent $34.57 per day per patient on mental health services, when the national average was $103.53. The same year, the state's mental health system received a "D" grade from the National Alliance on Mental Illness.
Outpatient treatment is just as strapped. NorthSTAR, the behavioral health program that provides services to many North Texas residents, lost around $23.7 million in funding during the last legislative session. Since 2008, the number of people who lost health insurance as a result of the economic crisis and have needed public mental healthcare has skyrocketed.
Dr. James Baker is the president of Dallas Metrocare Services, one of the largest nonprofit mental healthcare providers here. The upshot for his clinics, he says, is that "we're serving twice as many people as we served in 2004 for the same amount of dollars."
For all these reasons — the shortage of state beds and state money, poverty, lack of family willing or able to care for them — for many people in Texas and elsewhere, a boarding home is the only option after leaving a hospital or homeless shelter.
Boarding homes aren't medical facilities, and an operator isn't required to have any special training or license. "All we're required to do is provide three meals a day, one of them hot, and a roof over their heads," Donaldson says.
It's better than homelessness. But for years, mental health advocates throughout the state have been telling their cities that no one is really watching these places the way that they should be. The homes aren't overseen by the Department of Aging and Disability Services (DADS), the state agency that regulates places like nursing homes. And although a state law passed in 2009 gave Texas cities the authority to regulate these homes, only El Paso has chosen to do so.
A 2009 report to the Legislature estimated that about 845 boarding houses operate throughout Texas, many of them clustered in Houston, El Paso, Dallas, San Antonio and Austin. People who live in them are often mentally ill, elderly, disabled, recovering from addiction, or some combination of all those conditions. Most of those clients have an income of less than $650 a month, which they tend to get from federal Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) checks. An average of $21 a day is expected to pay for a person's room, board and personal needs; Texas is one of a handful of states that doesn't subsidize SSI. "Boarding houses are very much a stopgap between some basic level of shelter and food and outright homelessness," the report says. It found that most people receiving SSI would have to spend 109 percent of their monthly income to rent an apartment at regular market rate in most Texas cities.
In Dallas, "boarding home" is really a catch-all term for several different types of group facilities run by private operators: disabled group dwelling units, residential hotels, group residential facilities and halfway houses. These are the designations provided by the city's Code Compliance Department, and each is a little different in how many people it's allowed to house and where it can be located; group residential facilities, for example, have to be at least 1,000 feet from one another. But most of them are small homes in residential neighborhoods, filled with people who aren't quite sick enough to be in the hospital. There are other technicalities: Boarding homes can't give out medication, but they can help residents take it, and the homes can't house anyone unable to bathe, clothe or feed themselves. Boarding home residents stay in the same place for anywhere from a few months to several decades; some cycle through homes and hospitals in a years-long loop.
Mental health advocates guess there are around 300 homes all over the city, many of them clustered in North Oak Cliff and Pleasant Grove. The real number could be higher; it's not hard for some of them to stay hidden. Code Compliance keeps a list of 338 homes it believes are open now, but some of those are licensed assisted living facilities, which receive Medicare funding and are overseen by the state.
Boarding homes are supposed to register with the city, get a certificate of occupancy and receive yearly code and fire inspections. Donaldson, a former NorthSTAR caseworker who runs two houses in Pleasant Grove and one in North Dallas, says many operators are following the rules. "Sometimes this industry gets a lot of bad rap," she says. "But don't get me wrong, there are also people who just open up homes and don't let the city of Dallas know."
Donaldson's clients are either mentally ill or in court-ordered rehab for drugs and alcohol. Boulware's boarding home is a roomy, spotless place in Pleasant Grove with a big deck out back, a barbecue grill and a daily schedule posted on a whiteboard in the living room. On a recent afternoon, Donaldson points out a metal kitchen chair that was dragged out to the far corner of the yard by a resident.
"He likes to sing out in the backyard," she explains, smiling a little. "Because if he sings loud up close, it's an issue."
Not all boarding homes look like Donaldson's, as Hogan and his team found. One persistent problem mental health advocates hear about is the behavior of some operators who become the "representative payee" for their boarders. Representative payees have the residents' SSI checks signed over to them. It's legal and sometimes necessary when a resident can't be trusted with his own money and has no family to take charge of it.
"For some of them, no one else is showing concern," says Saprina Winbush, who runs four homes in Dallas and Lancaster. "Some people can manage their money better, but others really need an allowance." But bad operators, mental health advocates say, take advantage of that system by giving the residents only a fraction of their money and pocketing the rest.
You don't have to look far to find examples of the bad homes and operators. In 2009, the Austin American-Statesman wrote about a woman named Tommie Yvette McKinney, who allegedly opened credit accounts in her clients' names and racked up thousands in debts. Neglect can be just as serious a problem as outright maliciousness; Lee Hancock and Kim Horner at The Dallas Morning News wrote multi-part reports about homes that were dirty and poorly maintained.
Inspection reports obtained by the Observer from the city's Code Compliance Department spanning the last five years show the city sometimes struggles to make boarding homes comply with basic health and safety rules. Though most homes pass inspection, the City Attorney's Office frequently must take action against operators who repeatedly fail to fix violations.
Despite a sustained media spotlight on the problem, the city of Dallas has vacillated between discussing the boarding home issue and virtually ignoring it, at least publicly. In many ways, Dallas seems further behind the problem in 2012 than it was five years ago, when Hogan and his team went to work. After they worked for 15 months, the city's next budget was tight, and task-force funding evaporated.
"Now, what happens is I can call the team members together informally and we can go out on a site, if we think there's real problems there," Hogan says. "But it's not an official entity anymore."
With the loss of the interdepartmental team, Hogan says, "We lost a lot of that information. Now we have a vague idea of what's out there." Each department, he says, has its own list of homes, but they become more "fragmented" as time passes.
"We're not back to dead zero," he says, "but we really lost some ground."
Janie Metzinger, the public policy director at the Dallas branch of Mental Health America, is a restrained woman with shoulder-length gray hair. She works out of an airy office in a former church, and bad boarding homes seem to make her very, very angry — in her polite, ladylike way. "What would motivate you to exploit people?" she asks, shaking her head. She's fiercely protective of boarding home residents. "Everybody needs someplace to live," she says. "The problem we see with some boarding homes is that they mitigate against recovery."
Metzinger lobbied hard for the passage of House Bill 216, written by state Representative José Menéndez. Originally, the San Antonio Democrat tried to require DADS, the state agency that oversees nursing homes, to take on boarding houses; DADS testified that would cost the state $50 million, and the idea was dropped. Instead, HB 216, which passed into law in 2009, authorizes cities to register the homes and permits municipalities to set some standards for care of residents.
Metzinger, Donaldson and Dave Hogan were part of a group that also helped create model standards adopted by the state Health and Human Services Commission. They recommend that cities require the houses to have working heat and electricity, for example, doors that lock, at least one window in every room and at least three feet of space between each bed. For the first time, cities could require boarding homes to report clients' complaints of abuse, neglect and exploitation, as well as deaths, fires, missing people, criminal acts and fights between residents.
Right now, Metzinger says, "Boarding homes need to meet fire and safety codes, and not much more. So that's why we want standards, first of all. And we want inspections to be done [annually]" and more frequently if the home needs it. Also, she says, the city should levy fines against boarding homes operators who don't comply, "fines of significant seriousness that they will get your attention, so it won't be worth an individual's while to run an unlicensed boarding home."
Metzinger says the city could charge boarding homes registration fees. Those, along with fines for noncompliance, would help offset the cost. All of the requirements in the state model standards are still up to Dallas to include, or not, in its own city ordinance.
"I thought I'd crafted a very flexible bill," Representative Menéndez says. "It gives cities the authority to go out and fix the situation."
Instead, Dallas appears to have had a curious reaction to the passage of the new law. In April 2011, during the Legislature's last regular session, City Manager Mary Suhm informed the City Council that assistant city attorney Larry Casto would brief them on new laws, with a special focus on "state decisions that could potentially negatively impact local government budgets." One of those was the boarding home law passed two years earlier.
"The City of Dallas hoped to amend this legislation in 2011 to address concerns regarding municipal enforcement of the registration standards," Suhm wrote in her memo. "However, the author was not amenable to such amendments."
The City Attorney's Office didn't respond to repeated interview requests from the Observer, but Menéndez and his chief of staff, Don Jones, say Casto visited the representative's office to ask him to retroactively amend the bill so that cities also would have the power to regulate nursing homes and assisted living facilities. The problem is that those types of institutions are already overseen by the state, and the addition would have made the entire law unenforceable.
Neither Menéndez nor Jones will say outright whether they think that was what the city intended. "I think the gentleman we sat with was just ill-informed," Menéndez says, but he's found that many cities are leery of the costs and potential legal liability of formally acknowledging boarding homes. "A lot of city managers and people who are responsible for the fiscal well-being of cities seem to think, 'Once I start doing this, I can't stop,'" he says. "Ignorance can be their defense. I hope that's not the case, though."
Council member Scott Griggs, a member of the council's Housing Committee, says he has begun putting together a possible ordinance for Dallas, though he acknowledges that it's still "very early."
"I think the time for action is here," he says. "The state passed this enabling legislation creating these powers for the cities, and since then we've seen a model ordinance. It has been put out there, and the city of El Paso stepped up."
Griggs says many city officials have "a sense of where the bad operators are," and an ordinance would allow the city "to have something actionable." El Paso's law should serve as an example, he said, and he's already shown it to council member Carolyn Davis, who leads the housing committee, and to representatives at the city attorney and city manager's offices. El Paso's ordinance "shows that we don't have to reinvent the wheel," he says. "It dispels this mythology that there's nothing we can do."
While the city moves at its own pace, mental health caseworkers keep referring clients to boarding homes. Or rather, patients choose their own homes and their caseworkers try their best to help them, using incomplete and constantly changing information.
"Patients choose," says Dr. James Baker of Dallas Metrocare Services. "And sometimes they make bad choices." Five years ago, he says, DMS developed a process to assess a home at the time a client was placed there. "If we see there are poor living conditions, we try to present alternatives to the patients and hopefully get them to make a better decision.
"We and other providers have a list," Baker says. "It's basically a list of anybody who's willing to have you live with them. The issue our caseworkers have is usually trying to find a place for somebody, particularly folks who sometimes burn their bridges at other places." Clients tend to choose homes based on word-of-mouth, or go back to places they've been before. DMS caseworkers are seeing a new trend too: boarding home operators who show up at state hospitals and recruit new tenants directly.
Baker says it's rare for DMS or other providers, as far as he knows, to blacklist boarding homes. "We don't typically take places off the list, because the homes are so variable in our experience," he says. "It's not a good list. It's not a bad list. It's just a list."
The real issue is the dire shortage of housing for the mentally ill, the disabled and ex-cons, he says, particularly sex offenders, which leaves his caseworkers with few options. "Sometimes you're just desperate because no one will take some of these people."
Brandy Ruckdeschel is the clinical director of North Texas Behavioral Health Authority (NTBHA), the local entity that oversees NorthSTAR services in seven counties, including Dallas. She says NTBHA would like to create "recommended" and "not-recommended" lists of boarding homes, but it can't until the city creates some standards. "We just don't feel like we have enough information where we can comfortably tell people, 'This is a recommended boarding home,' without the city moving forward," she says.
In the meantime, boarding home operators keep talking about what they themselves need, although no one appears to be listening.
"I'd be excited to be getting some type of standards," Demetra Donaldson says. She thinks most boarding home owners "are trying to operate appropriately, with what they know. Only a few are not, who are just inhumane." She teaches workshops once a month for new operators, where she shows them examples of forms they should require their tenants to sign. A lease, for example, doesn't work well for mentally ill people, because they often don't quite know what they're agreeing to, but a code of conduct can make the expectations of the house clear.
"People don't initially know how hard this is," she says of new operators. "They look at the bottom line. They hear about the business side, the financial side, but they don't even know what mental illness is." Nor do they know how expensive taking care of sick people can be. "I tell people all the time, if you're making money in this business, then you're probably not doing it right."
But operators need much more help from the community than they're getting, she says. "Boarding homes could operate properly if we had more support. There's so much turnover with social workers, caseworkers and case managers." And mentally ill people need places to go during the day, away from the home, and ways to get there. "We need day centers and transportation programs," Donaldson says. "We can't even get [discounted rates for] bus passes, and some of them are too paranoid to get on a bus anyway." She dreams of buying a van to transport her residents — the staff car is long gone, stolen by a resident who wrecked it. Many food banks won't give boarding home operators food, she says, "because they think we're making a profit off it." So her husband, a children's pastor, volunteers at one food bank to get groceries from them. "Food is our greatest expense," she says, especially because anti-psychotic medications tend to make people hungry.
"We're supposed to do all of this, run all of this, on $17 or $18 a day per person," Saprina Winbush says.
And the operators keep warning of more disturbing things they see. Chiquita Spears, who runs several homes in Pleasant Grove, says a fellow operator came into one of her houses and lured several tenants away by offering them "drugs and no rules." Several people said they had heard of operators who take clients referred to them by hospitals and social work agencies, then sell them to other boarding homes.
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"We've gotten complaints in the past," about selling clients, Dr. Baker at DMS says. "That turned out to be unfounded. ... We could never show that that was the case." He allows that "it could very well be real," but that the boarding home business is "so competitive, it lends itself to rumor-mongering."
For Janie Metzinger, the confusion over something as sensational as whether boarding home operators are selling their clients is precisely why the industry should be better regulated.
"I am appalled that anyone would sell another human being," she says. "We have done everything we can to make sure that when we hear of an individual doing that, we make sure the hospitals know what exactly is going on, and the service providers too. ... It is an absolutely immoral practice. I have no idea how anyone could think that that was in any way whatsoever conscionable."
But even with the city frozen, rumors flying, and more money bleeding away with every passing year, Metzinger still finds a way to look on the bright side. "I think they are working on drafting something," she says. "We're optimistic we'll be getting a good law here in Dallas." Someday.