There is a story Judge Oscar Kazen has been telling for years — from the bench in Bexar County, San Antonio. A man gets a flat tire outside a psychiatric hospital. A patient at the fence watches, then calls out: take one lug nut from each of the other three tires. You'll have three on each wheel. You can make it home.
The driver is stunned. He asks how a smart guy like him wound up in a place like that.
The patient smiles.
"They may think I'm crazy. But I'm not stupid."
Judge Oscar Kazen tells the story because it does in ten seconds what policy papers cannot: it forces you to reconsider who ends up in the system, and why.
Taking Stock
Judge Brent Carr spent 32 years on the bench in Tarrant County, including more than two decades running specialty courts for people with mental illness, veterans, and trafficking survivors. The numbers he carries are not abstract.
"In the confinement population, particularly in the jails, it runs as high as 65%. So it's more than 300% more than what you would find in the general population. About 4% of the general population has serious mental illness — and almost 20% of people in confinement have serious mental illness." — Judge B. Carr, Tarrant County
One in five. Behind bars.
Building the Bridge
The fix did not come from one place, or one person, or one bill. It came in layers — and it started with communication. For decades, courts, clinics, law enforcement, and hospitals had been operating on separate tracks, rarely in the same room.
Professor Brian Shannon is a legal scholar at Texas Tech who has spent more than three decades shaping mental health law in Texas.
"Texas, to my knowledge, was the first state in the country where our two high courts — the Supreme Court over civil cases and the Texas Court of Criminal Appeals over criminal cases — met together, had hearings about some of these issues and established the Texas Judicial Mental Health Commission." — Prof. Brian Shannon, Texas Tech University
Established in 2018, the Commission was built to be a bridge: training judges, drafting legislation, publishing bench books, and hosting statewide summits. Its mission was simple — get the right people in the same room, and then keep them there. But Shannon is quick to point out what a commission alone cannot do.
"We can't solve all of the challenges just with new laws. And for a lawyer to say that — I have to admit — it has to come hand in hand with sufficient and appropriate services." — Prof. Brian Shannon, Texas Tech University
Laws without resources are just paper. Judge Carr learned that lesson early — not from a textbook, but from cases that didn't go the way he hoped.
"The research is pretty standard that you do have better outcomes — as long as during the participation period, you also do exit planning. You can't surround people with resources, pull the rug out from under them, and expect them to thrive indefinitely." — Judge B. Carr, Tarrant County
The Tool in the Toolbox
Judge Oscar Kazen did not set out to become a pioneer. He lost a reelection bid by six votes and was preparing to leave the bench entirely when a colleague offered him a role overseeing civil mental health commitments in Bexar County. What he found there changed his career.
People were being hospitalized, stabilized, discharged — and then left entirely on their own. No team. No follow-up. No structure. Weeks later, sometimes days later, they were back.
"If we can take a certain class of people that are consistently going in and out of hospitals — who are taken, stabilized, and then left alone — and then a month later, they're right back, or six months later, they're right back. Or worse yet, they've been left from the hospital and weren't paid attention to again — and we find them dead." — Judge Oscar Kazen, Bexar County
Kazen looked at the drug court model — which had shown that consistent judicial involvement, paired with wraparound services, could break cycles that jail alone never could. He asked: why can't we do the same for mental illness?
"I took that statute and said — I'm not just going to discharge you. I'm gonna wrap a team around you. The court is going to be responsible to you. The staff is going to be responsible to you. You're going to be responsible to your mental health and to the court. And together, we're going to figure out a way to have you succeed." — Judge Oscar Kazen, Bexar County
What he built became known as Assisted Outpatient Treatment — AOT. At its core, it is a court-ordered treatment program for people with serious mental illness who have a documented history of cycling through crisis. A judge oversees a structured treatment plan. A team — psychiatrist, social worker, case manager, defense attorney, prosecutor — meets regularly. The goal is not punishment. It is continuity.
Professor Shannon, who helped draft the legislation that brought AOT into the Texas criminal code, describes how the docket worked in its earliest days.
"He would have all the participants in the matter — representatives from the treatment team, the person subject to the order, appointed counsel, the county attorney — all come in for a docket call, every two weeks. And at that docket call, he asked three basic questions: How are you doing today? Have you been taking your meds? Did you go to your appointments?" — Prof. Brian Shannon, Texas Tech University
Three questions. And the results for that initial population were immediate.
"Just having that team together and the black robe effect of the judge being there — they greatly reduced state hospitalization for that population. Kept people in the community longer. Recommitments are down, staying with medication is up." — Prof. Brian Shannon, Texas Tech University
The goal of AOT is not permanent supervision. It is graduation — a person who no longer needs the court because the court helped them build something that holds on its own. Kazen spent years watching people misread what it is.
"AOT is not a silver bullet. It is a tool in the chest that helps a certain category of people most of the time. The people who try to make it the silver bullet — or the people who try to make it out to be the devil itself — I think do it an injustice." — Judge Oscar Kazen, Bexar County
SB 362: A New Transfer
For years, AOT was primarily a civil tool — a way to help people before they crossed paths with a police officer. But a massive gap remained. If someone with serious mental illness was arrested on a low-level, nonviolent charge, they often became trapped in a "competency restoration" loop — waiting months or years in jail for a state hospital bed just to become fit for a trial that might last only an hour.
In 2019, the Texas Legislature passed Senate Bill 362. For the first time, judges had a way to pause low-level criminal cases and transfer them into the civil mental health system.
"We create this additional option as if the person appears competent, then you could, in effect, hold this prosecution in abeyance, and then kick it over to this probate court... to look at whether the person meets criteria for any outpatient civil commitment." — Prof. Brian Shannon, Texas Tech University
This isn't just a legal tweak. It is a fundamental shift in how the state views its responsibility — reaching people who used to be written off as the system's problem and making them the team's focus.
The Policy of Doing What Works
Court-mandated treatment programs are not the kind of policy that campaigns are built on. Kazen remembers the climate in which he started.
"Back then, if you were going to get elected, you didn't get elected talking about therapy and helping people and changing their lives. You had to be tough on crime. That was on every campaign sign." — Judge Oscar Kazen, Bexar County
And yet — it passed. Professor Shannon believes the reason is simpler than it looks.
"A lot of the issues we're talking about on mental health are not liberal issues or conservative issues. They're more administration of justice issues, good government issues — where I think there's a lot of common ground." — Prof. Brian Shannon, Texas Tech University
Judge Kazen's program became its own evidence.
"We studied, several years ago, about a random 100 people that had gone through the program. We cut their hospitalization rates and arrest rates by 80%." — Judge Oscar Kazen, Bexar County
Financially, the case is equally stark.
"The average bill of cost for an individual that we pick up and put in a hospital bed or emergency room — $2,000 a day. A day. And if we can cut that over their lifetime by 80%, this thing pays for itself in the first week." — Judge Oscar Kazen, Bexar County
The stakes are sharpest when you look at where state hospital beds are actually going.
"The state hospitals, which originated primarily to serve a civil population — to keep people out of the criminal justice system — that's flipped. And today, out of their patient beds, they're about 75% criminal, forensic cases, and only 25% civil." — Prof. Brian Shannon, Texas Tech University
Texas has not solved this. No state has. The waiting lists are still long, the rural gaps are still wide, and the debate over coercive care is far from settled. But what Texas has built — through the Commission, through AOT, through specialty courts, and through Senate Bill 362 — is a system with more doors than it had before. More entry points. More moments where a person can be seen before they fall rather than after.