In January 1942, not long into his tenure as director of the Hogg Foundation, Robert Sutherland received a letter from Weaver H. Baker, chairman of the Texas State Board of Control (TSBC). The board, which was responsible for overseeing the state’s seven mental hospitals, wanted to welcome Sutherland to the mental health community. It also — though Baker didn’t quite come out and say it explicitly — wanted him to know that they needed help.

The facilities that the TSBC managed were under-staffed and over-crowded, and in general were rather horrifying places to be. A survey of the state’s facilities, conducted by the U.S. Public Health Service, had identified deficiencies in physical plant, sanitation, staff-patient ratio, salary, safety, and staff qualifications. Because of the many shortcomings, asserted the study, a “repressive atmosphere” that was more custodial than therapeutic had set in. 

The Opening Door, written by foundation officer Bert Kruger Smith, was one of two reports written toward the end of the 1950s intended to assess both the gains achieved and the work remaining to do.  

The Opening Door, written by foundation officer Bert Kruger Smith, was one of two reports written toward the end of the 1950s intended to assess both the gains achieved and the work remaining to do.  

Sutherland became an ally of the board and soon recognized that one of his major tasks as leader of the Hogg Foundation would be to help in the effort not just to improve the state hospital system, but to fundamentally modernize the mental health infrastructure in Texas.

The campaign to do so, which the foundation helped lead, would ultimately last for more than two decades. In the 1940s the work consisted primarily of incremental, mostly behind-the-scenes reforms. The foundation sponsored seminars and studies, for instance, and disseminated its findings on modern mental health concepts. It worked with state officials and agencies to improve training for staffers. And it formed an essential partnership with the Texas Society for Mental Hygiene, for which Sutherland served as an officer in numerous capacities during the 1940s and 1950s.

The challenge for reformers in the 1940s was not that the state opposed reform. In fact, as Sutherland’s welcome from Baker and the TSBC indicated, Texas officials and agencies responsible for mental health services knew that things needed to be better. The challenge was money. It was one thing to get conceptual support from the mental health officials to modernize the infrastructure. It was quite another thing to get the Legislature to pay for it.

By 1949, despite incremental improvements, Sutherland and fellow reformers felt that they needed to take their case to the public. During the next decade the foundation would commit considerable resources to this more public campaign for reform. It included funding journalistic exposés on the conditions in the state hospitals, the production of a 30 minute documentary on the state hospital system, extensive testimony from Sutherland and other foundation staff members before legislative committees, behind-the-scenes lobbying, funding public lectures from national experts, funding and facilitating legislators’ visits to mental health facilities, and persistent public education efforts. The campaign proved dramatically successful.

The first major victory in this campaign came with the creation in June 1949 of the nine-member Board of Texas State Hospitals and Special Schools (BTSHSS) to replace the three-member TSBC. The enabling legislation declared “the responsibility of modern society to afford adequate treatment for its less fortunate citizens who suffer from the impediment of mental and physical ailments” and acknowledged the “growing sentiment in Texas that its system of State Hospitals and Special Schools has not kept pace with modern thinking, training methods and procedures.”

It further stated that the TSBC was too broadly construed to provide the specialized expertise and supervision needed. In an unusual move, the routine bill-reading procedure was suspended to allow the law to go into effect immediately, reflecting the perceived urgency of the situation.

In this video, historian William S. Bush discusses the broad reform campaign led by the foundation, as well as a series of investigative pieces funded by the foundation.

During the next eight years, due in no small part to the work done by the foundation and its allies, funding for mental health services would increase dramatically, conditions in the state hospitals would improve, and the mental health workforce would expand and become better trained. In 1957 the reforms culminated in the enactment of the the landmark Texas Mental Health Code (House Bill 6) and the Commitment of the Criminally Insane (House Bill 906) in May 1957.

The code began with a statement of purpose that expressed well the goals for which the Hogg Foundation and its cohort of mental health reformers had been working for more than a decade:

It is the purpose of this Code to provide humane care and treatment for the mentally ill and to facilitate their hospitalization, enabling them to obtain needed care, treatment, and rehabilitation with the least possible trouble, expense, and embarrassment to themselves and their families and to eliminate so far as possible the traumatic effect on the patient’s mental health of public trial and criminal-like procedures, and at the same time to protect the rights and liberty of every one. In providing care and treatment for the mentally ill, the State acts to … restore [the person with mental illness] to a useful life and place in society. It is also the legislative purpose that Texas contribute its share to the nationwide effort through care, treatment, and research to reduce the prevalence of mental illness.

The code not only set forth the state’s first procedures for voluntary, temporary, protective, and indefinite admission to a state mental hospital, it addressed nearly every facet of the patient’s experience with the state’s system of mental hospitals.

Without exception, all patients were to receive “adequate medical and psychiatric care and treatment in accordance with the highest standards accepted in medical practice.” The use of physical restraint was prohibited unless prescribed by a doctor, and then “should be removed as soon as possible,” with a record made of its use and the reasons for it. Transfer, furlough, and discharge procedures were set forth for various categories of patients, notably with patient and family input required for most of them. The bill set forth patients’ rights to visitation, religious freedom, communication, confidentiality of their clinical records, and a right to release. These provisions also applied to privately run mental hospitals, which for the first time were required to apply for a license to operate. Both private and public hospitals were to be run by psychiatrists certified by the American Psychiatric Association.

Hailed as “a jewel of a law” in the Texas press, the mental health code represented a watershed moment, borne of years of efforts to mandate fair and humane treatment of people with mental illness. A key component of this campaign called for individuals with mental illness to be viewed as individuals, and for the disaggregation of distinctive conditions that previously had been lumped together. No more would people who had developmental disabilities be housed with people who had mental illness. Children would not share spaces with elderly people. Mild, moderate, and severe conditions would be better differentiated and then treated in different contexts with differing levels of supervision and intervention.  

The code did not solve all problems and brought with it unintended consequences necessitating further reforms in the 1960s. But in fundamental ways it represented the modernization of the mental health system in Texas, which had been one of animating goals of the foundation. Its success and the network building that had led to it also established the foundation as the single most important organization in the field of mental health in Texas and its surrounding region.

The foundation was so successful in its efforts that it would prompt then-Texas oil attorney and Democratic Party operative (and future Texas Governor) John Connally to marvel at the Hogg Foundation’s role in leading “a real revolution in mental health concepts.”