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Suicide Has Become an Epidemic in Rural Minnesota — How Can We Prevent Further Loss?

Our mental health coverage in 2024 is made possible by the Minnesota Association for Children's Mental Health.

In February, the Center for Rural Policy and Development released a report titled “The Suicide Epidemic in Rural Minnesota: How we got here and how we move forward.” Researchers interviewed rural mental health care providers and state agency officials, and analyzed data to determine why suicide rates are rising faster in the rural parts of the state, and how rural residents struggle with lack of mental health services and information.

Minnesota Women’s Press spoke with the report’s two authors, Marnie Werner, vice president of research at the Center, and Dr. Tracie Rutherford Self, a mental health provider and professor of counseling at Minnesota State University, Mankato.


Suicides per 100,000 population by Minnesota region, 2018–2021. Data: Centers for Disease Control and Prevention, National Center for Health Statistics. Graphic courtesy Center for Rural Policy and Development


In the report’s concluding paragraph you write, “The suicide epidemic caught many of us by surprise, so much so that there is no ‘getting ahead of the situation’ any longer.” Can you give readers an overview of what motivated this report?

Marnie Werner: We knew we had a problem with mental health — you just hear about it on the radio, on TV. But in this case, it was people that I knew [dying by suicide]. Hearing “My sister’s son died,” or about a neighbor’s kid dying. I’ve heard more people telling me somebody they knew died from suicide in the last six months than I ever have in my whole life put together. When it gets to that point, you know there’s something going on.

Tracie Rutherford Self: A lot of my research is informed by growing up in a rural community and seeing a lack of access to mental health care in general, as well as being a clinician working in rural communities for almost two decades — in my case communities of fewer than 5,000 people. Often there isn’t a clinic or hospital nearby.

I was working with clients with high levels of suicidality. There are a lot of reasons for that, and it sparked my interest. In rural communities, that just looks different. Finding a hospital bed, particularly for an adolescent, is very painful. They can sit in an ER for, in some cases, up to two weeks. My youngest patient who attempted suicide was seven years old. Trying to find access to care for a seven-year-old rural male was almost impossible. Unfortunately, this is happening, and it’s happening with more frequency.

The report outlines some positive rural values — including pride in place, sense of occupational duty, and close-knit relationships with neighbors and friends. Can you explain how these values and customs might also be creating barriers to getting mental health care?

TRS: I really appreciate you bringing up the point that these can be positives. In fact, I would say this reliance on family and friends is a real strength. The potential negative is our family and friends might not understand the particular concerns that we’re experiencing [in the way a mental health professional could].

I also talk a lot about the myth of meritocracy, which essentially postulates that if you try hard enough, you can work yourself out of anything. Unfortunately, in rural communities, that often applies to mental health and behavioral health issues. People think, “There must be something inherently wrong with me, because I wasn’t able to think my way out of it.”

When we look at that rural values piece, we see the strength of independence, but we also see how that can be harmful.

People in rural communities have a very strong work ethic. Farmers are a perfect example; they’re up at crazy hours, they’re working long days. We reviewed how farmers might be afraid to tell people they are struggling with their mental health because “if I’m struggling with thoughts of suicide, does that mean I’m not a hard worker? What does that mean for my business operation moving forward?” Of course, nothing is further from the truth, but if you have this belief that “I’m less than,” or “there’s something wrong with me,” you tend not to share those things.

MW: Governments are key to getting people resources and treatments. When you have this ethic of “don’t complain, don’t explain,” policymakers don’t know that there’s an issue. One of the things that’s happened now is that [the suicide epidemic] has gotten to a level of seriousness that local governments really do see it and understand why they should put money into resources for solving it.

The report highlights farming and mining as two sectors that have higher than average rates of suicide. Could you describe what unique mental health challenges women on farms are facing?

TRS: As a profession, we talk a lot about people engaging in self-care. That’s a great concept, but in my experience, it is two four-letter words. Some of the providers we interviewed explained that a woman in farming could be taking care of three kids, doing the books, and working off the farm because the family needs to have insurance. She comes home, her husband’s gone from 6am until 2am in the fields, when does she have time to care for herself? I think we have to look at the challenge that you experience from a societal perspective and the trickle-down effect of how gender roles function in farming communities. Rural communities still establish a pretty high level of patriarchy. I wouldn’t say that’s either good or bad — it just simply is — but it can have a negative consequence for a lot of the women in those communities.

In the most rural areas, the ratio of mental health providers is 1 to every 700 residents, compared to 1 to every 190 in metro areas. However, this report emphasizes getting the “right” providers into rural areas, rather than simply increasing providers in general. Could you explain what rural cultural competence is?

TRS: We absolutely need more practitioners in rural communities, but it’s not sufficient to say that if we put in more people, they’re going to be effective. Going back to the example of the farm women, if you don’t understand that it’s not going to be appropriate to say, “You should engage in some self-care, take a trip to Florida,” then you’re not going to effectively engage that individual because you didn’t understand the culture from which they are coming from. You also stand to do some real harm because [that patient] is going to think things like, “Is anything in mental health going to make sense for me? Do they understand me? Do they see me?”

Providers also need to look at how race, ethnicity, ability issues, gender, and LGBTQ+ identities impact their patients and how those identities intersect with the rural cultural component. In many of our rural communities, we’re seeing an expansion of diverse populations. We really need to focus on creating more formalized trainings on how to provide mental health care in a rural setting. There is a training on farm competence through the Ohio Extension Office, which is amazing. But Ohio and Minnesota are not the same place. We need to work on developing individualized trainings for different parts of the Upper Midwest.

MW: Rural areas are not homogenous.

If a well-meaning provider comes in with the completely wrong conception of what rural is and what rural people are like, that’s going to render any help that they could have given useless.

Besides increasing competent providers, what other solutions do you want to emphasize for readers?

TRS: The people who have the most credibility in a rural community are the anchor members who are already there. There’s a project I am currently embarking on that will train volunteer EMS and firefighters in some brain- based behavioral health strategies, as well as how to deal with individuals who might be in a crisis, including a suicidal crisis. Because the truth is [as a mental health professional], I’m not the first phone call. I was in a community of 2,500 people — everyone in the community knew me. If someone was having thoughts of suicide, their first phone call was to their pastor. It could be a conversation that happened over lunch, or when they were getting their tires changed, or with a banker, because bankers hold the purse strings for farmers. So we really need to equip more people in the community who are going to have positions of influence.

As we do that, we also need to start normalizing conversations about suicide. I used to go into rural schools in Iowa and do presentations on suicide, and I would get comments back from the administration saying, “We don’t want you to give those presentations here. We’re afraid if you start talking about suicide we’re going to have an epidemic on our hands.” My response is, it’s already there, and the fact that we’re not talking about it is what leads to loss.

MW: The economies of scale work against rural areas. It costs more to provide services in rural areas because of the sparser population. There is the challenge of getting providers to rural areas and making it economically feasible for them to stay. It’s a shame that something so important is based on a profit-and-loss statement. If there is a way that we can make these things more financially sustainable, that will help a lot of people, but it’s going to take some will to get that done.

TRS: Medicaid does not pay as well as many of the commercial providers — sometimes less than half. I’ve had three people who suddenly had their insurance change to something I don’t take, a different type of Medicaid provider, and I had to decide to eat that cost or stop providing services. Because I have another job, I just dealt with it. For the vast majority of people who are out there practicing, that’s not a reasonable option for them. Internship opportunities in rural areas are also important, but rural providers often can’t afford to do internships because they’re not paid for that time.

When negative headlines come out about rural places, it can make the situation seem hopeless. How would you suggest people talk about this issue without continuing to “other” impacted communities?

TRS: As an individual who grew up in what was at the time the poorest county in the country, well-meaning people would often pile into our community and try to save us. So I think we have to recognize this isn’t about saviorism. What this has to be about is equipping a community that is perfectly capable of implementing all the things they need themselves. It is about recognizing communities for the amazing strengths they already have, and finding ways that we can work together and collaborate.

LGBTQ+ Care in Rural Minnesota

Minnesota Women’s Press spoke with Ryan Fouts, executive director of Reclaim, which is the only organization in Minnesota that focuses solely on providing mental health care to LGBTQ+ youth. In August 2023, the Twin Cities-based nonprofit received a $50,000 grant from the U Care Foundation to support their efforts to train providers currently based in parts of rural Minnesota. Providers would be able to use Reclaim’s resources and best practices in order to support young people in their communities who identify as queer and trans. They are actively seeking rural therapists who are interested in forming partnerships.

“Coming out is going to have different impact in different communities,” Fouts said. “Having an awareness and understanding of what it means to come out in a rural community [is important], so our priority is finding folks who have an existing understanding of a community.”

Fouts also said that with the passage of the Trans Refuge Bill during the 2023 legislative session, Reclaim! has seen an increase in cases as more and more families move to Minnesota because of the bill. Fouts said families may move anywhere in Minnesota, so Reclaim! wants to “equip [mental health professionals everywhere] to do this work. People shouldn’t have to relocate [to the metro] for mental health care.”

Resources

If you or someone you know is in crisis, text or call 988 to be connected to a trained counselor in Minnesota. The service is free and completely confidential. The CRPD report strongly advises that the crisis line be more heavily promoted throughout Minnesota. In Northeast Minnesota, where the suicide rates are the highest, the 988 usage rates are the lowest.

Among the many factors contributing to a higher suicide rate in rural Minnesota, higher rates of gun ownership may be the largest. In about half the suicides statewide between 2018 and 2021, the person used a gun, and those percentages are higher in rural areas. Strategies like Conversations Around Lethal Methods (CALM) help friends and family talk to loved ones who may be suicidal about removing their guns in a way that shows care and respect without escalating the situation. calmamerica.org

https://www.womenspress.com/category/self/mental-health/