Stigma and limited resources stifle rural mental health care

POWELL — For too long, Wyoming has had the dubious distinction of having the highest rate of suicide in the nation. Total numbers of deaths from suicide are among the lowest, owing to the state’s small population, but the suicide rate per 100,000 people in 2020 was 30.5. In 2005, the rate was 17.3 per 100,000.

“That is not an area we want to be leading the country in,” said Wendy Morris, outreach coordinator for Healthy Park County.

As with all aspects of rural health care, mental health services suffer from a shortage of resources and staff. There are miles between providers, creating barriers to those seeking help for their illnesses, and the “cowboy culture” of Wyoming lends itself to stoic silence in the face of pain. Untreated mental illness in Wyoming either manifests itself in the state’s high suicide rates or increased costs for law enforcement services, unemployment and homelessness.

Becky Ransom, executive director of Yellowstone Behavioral Health, has an optimistic outlook, despite the challenging environment she works in.

“The trends are not all negative,” Ransom said. “If we focused on all the challenges in the world today, we’d have a dark day.”

While the stigma attached to mental illness is nothing unique to Wyoming, it can be especially pronounced in a rural area. Where everybody knows everybody, someone needing help might not want to be seen in the waiting room of a mental health provider.

“I think stigma in Wyoming and the mountain states is still a big issue,” Ransom said.

Yet mental illness is highly common.

The National Alliance on Mental Illness estimates 20% of the U.S. population will experience a mental illness at some point in their lives, and 1 in 20 people will experience a serious mental illness.

Besides the perceived shame in seeking treatment for common illnesses, Ransom said people in the Basin communities tend to be less equipped to identify mental health issues. They might not recognize, for example, that an inability to find enjoyment in activities that once brought much joy is a symptom of a much larger issue than just having the blues.

“Once people understand, they’re more comfortable talking about it,” Ransom said.

People are often under the impression that mental health issues aren’t treatable, which Ransom said isn’t true.

Healthy Park County is one partner Yellowstone Behavioral Health works with to create more public awareness. The organization provides community training sessions that cover all kinds of mental health issues. There are separate sessions for young people and adults, and they’re free of charge.

Wendy Morris, outreach coordinator for Healthy Park County, said a range of people participate in the eight-hour training, including parents, adults who work with kids, health care professionals, and employees of the Department of Family Services.

“They want to make sure they have tools in their toolbox, as they say, to be able to recognize the signs of a mental health crisis or, more importantly, suicidal ideation. Then they know exactly how to respond,” she said.

The training with teens teaches them to recognize the warning signs of a friend in crisis and how to ask direct questions to get the friend talking about what’s going on. The instructors explain to the teens that they’re not counselors, so they help them identify that trusted adult — whether it’s a parent, a school counselor, or a coach — who can get their friend help.

“We don’t want to put that on our young people, but we also know they are more likely to recognize when one of their friends is in crisis, maybe before the adults in that person’s life recognize it,” Morris explained.

Another session was held at the Powell Senior Center, at the center’s request.

The elderly population can be vulnerable to mental health issues, and following the COVID-19 pandemic — when many of them couldn’t be with loved ones — depression and loneliness were much more common.

Ransom said the efforts of Healthy Park County, as well as others in the community, are greatly improving people’s awareness of mental health needs. There’s still some work to be done, she said, but illnesses can’t be treated if those who suffer from them aren’t seeking help.

“I’ve seen a huge jump in understanding, awareness, and acceptance. It’s getting better, but it’s still concerning that people are afraid to seek treatment,” she said.

Another tool providers use to close some of the gaps is the partnerships they form between organizations. Both Morris and Ransom commented on how well community partners work together to help each other through the challenges.

“It’s about making our community safer and healthier. It’s about all of us looking out for each other… We have to rally together,” Morris said.

For those who know they need help and seek it, there are still barriers.

“In a rural setting, there’s a real lack of resources to meet the need,” Ransom said.

There is a lack of providers and a lack of health care professionals to fill positions at what facilities there are. Salaries aren’t competitive, and so it can be very hard to recruit.

When members of the community with mental health needs reach out to find help, they often have to go a long way to get it. With a lack of public transportation options, that might mean help is out of reach.

“If you don’t have access to a vehicle, how do you get to your appointments?” Ransom said.

At a recent meeting of the Wyoming Legislature’s Joint Labor, Health and Social Services Committee, legislators heard a lot about these gaps in care, which are a common problem throughout the state.

Andi Summerville, executive director of the Wyoming Association of Mental Health and Substance Abuse Centers, presented a map of the handful of providers spread across 23 counties in Wyoming.

In the Basin, the community mental health organizations — which are non-profits that have competitive contracts with the Wyoming Department of Health — are Yellowstone Behavioral Health, Cody Regional Health, and Cloud Peak Counseling in Worland.

Three years ago, Wyoming had 17 community mental health organizations. Today, there are 11.

Decreased funding is part of the reason, but Summerville said the administrative burden in mental health care makes it extremely difficult for community mental health agencies to operate sustainably.

Cloud Peak Counseling is the only Basin resource providing crisis stabilization services. There are three others in the state.

“You’re talking about trying to move people around in the system — so if you’re talking about someone in Jackson and they’re in need of crisis stabilization services, that’s a long trek,” Summerville told the committee.

She provided a graphic to illustrate what a comprehensive system that addresses mental health care would look like, based on national best practices. It begins with crisis hotlines, which provide that initial, easily accessed point of contact for someone in a crisis.

“We can’t underscore enough how important that component is,” Summerville explained. About 80% of calls can be resolved over the phone, she said. The caller can be referred to services and “(given) a warm handoff — whatever they need.”

For others, they may need an active response from a mobile crisis team, but Wyoming has none. That means these responses come primarily from law enforcement.

Some people need to be taken to a crisis facility, and from there, a comprehensive system would include post-crisis support services at the back end of the line.

Such a network, Summerville said, will result in about 85% of those with a crisis remaining stable in the community after treatment. That means fewer resources spent on caring for people who can’t work and can’t take care of themselves — and who will likely find themselves in crisis again.

“That’s an 85% diversion rate from the state hospital waiting list,” she said.

Summerville noted that Wyoming will soon be connected to a federal 988 crisis lifeline network, which will work like the 911 emergency system.

However, she added, without the backend services to support the lifeline, its effectiveness will have limitations in the state.

It is an improvement, though, as Wyoming currently has no 24/7 hotline services.

Ransom said Yellowstone Behavioral and its community partners are being creative in finding other ways to serve clients with the resources it has.

For example, it has started to use tele-health a lot more — something that came out of the COVID era. This helps people talk to providers at a distance and also pursue help for issues with greater privacy.

It also continues collaborating with community partners and providing support wherever possible.

“In a rural setting, you have to come together. You can’t be the mental health provider sitting by yourself on one corner of town,” Ransom said.