Brown: For rural patients, the mental health system can’t keep up with the crisis

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This column is part of a series of occasional columns regarding mental health in Minnesota, chronicling ongoing struggles, emerging progress and voices of hope.

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Alyssa Broking made a somber realization looking at her high school yearbook. Just eight years after graduation, Broking counted five members of her Grand Rapids, Minn., graduating class who had died by suicide, including a friend with whom she had lost touch.

She was saddened but not surprised. After all, she faced her own challenges. After high school, Broking wanted to be a nurse. But after starting college, she experienced a mental health crisis spurred by anxiety, depression and a traumatic experience. Then COVID-19 happened.

“Everything was so weird,” said Broking. “That time between 2018 and 2022 was the worst.”

She left school to focus on her mental health.

“I was going to therapy and realized I really liked this,” said Broking. “I also worked at a hospital in the ER and would sit with people going through similar situations. People are really vulnerable in that stage, and I like to advocate for people when they’re at their lowest.”

Seeing the impact of mental illness on her peers changed her path. She’s now finishing a degree in psychology and human services at Minnesota North College in Grand Rapids with a goal of becoming a licensed therapist.

The demand for mental health care remains high across Minnesota, but the needs are particularly acute in rural Minnesota. Aspiring practitioners like Broking will make a difference, but deeper issues remain. Limited capacity, greater distance to services, and a higher proportion of lower-paying Medicare and Medicaid patients make it harder to provide needed care.

“Treatments are effective, but we can’t meet the needs,” said Sue Abderholden, executive director at the Minnesota chapter of the National Alliance on Mental Illness.

Stigma over mental illness remains a problem, and those who live in rural areas are often the most reluctant to seek help.

One startling statistic cited by experts is that it typically takes 10 years of symptoms for people to seek treatment for mental illness, usually when things have gotten bad.

“When there is an emergency, you have to go to the ER,” said Marnie Werner, a researcher for the Center for Rural Policy and Development. “There’s an emergency because [patients] weren’t getting help before that. They couldn’t get in, or they didn’t know, or the family didn’t know what to do.”

The ER is where the system bottlenecks.

To save lives, we must break the silence and stigma facing mental illness long before a crisis hits. It’s hard to find peace lying in a hospital bed as people chatter in the hallway. The longer the wait, the greater the danger.

Rebekkah Anderson of Hibbing spent a lot of time in the ER. As a former foster mom, she’s cared for kids with severe mental illness. She described how the system breaks down.

“If you go into the ER because your child has suicidal ideation, or homicidal ideation, they do that first triage,” she explained. “But you’re not having a heart attack, so you’ll be there three hours waiting.”

She said that in-patient treatment likely won’t be available on the first visit. So you’re sent home to wait for the next crisis. This process traumatizes not only the patient but also their families as outbursts persist. Fetal alcohol syndrome disorders, more common among foster kids, come with widespread mental illness comorbidities.

“There’s no proactive attention to treatment,” said Anderson. “The ER becomes a revolving door.”

Even when care is approved, mental health treatment centers are often at capacity, either because they don’t have enough beds or enough workers. If you live in Greater Minnesota, the chances of finding a bed near your family are low. That means travel expenses. For Anderson, an international business consultant and podcaster, it meant taking her kids along and time away from work.

Thad Shunkwiler, an associate professor of health sciences at Minnesota State University-Mankato, founded the Center for Rural Behavioral Health in 2021 to address rural provider shortages.

“One of the things we found early on was that we didn’t have a recruitment problem. We have a capacity issue,” said Shunkwiler.

People want to work in mental health care, but it’s hard to log the training hours necessary when there aren’t enough people to offer supervision. As a result, too many people get the education but can’t complete the licensing.

Shunkwiler said he surveyed current providers about their age, how long they planned to practice and their job satisfaction. The results show an impending collapse in rural mental health services.

“Looking at the data, we have a substantial problem currently, but the problems get a whole lot worse if we don’t do anything,” said Shunkwiler.

Insurance is also an issue. Not all plans treat mental health care the same way as physical health care. Medicare and Medicaid reimbursement rates are typically much lower. That means many available providers can’t take patients because they lose money. Private payers can get care. Everyone else either can’t or must wait months.

Funding would help, but some concede that more money won’t be forthcoming in the current political climate. Shunkwiler argues that what’s needed goes beyond funding.

“It is less about what we can get the government to do to solve this and more about how the industry can change to meet the needs,” said Shunkwiler.

Shunkwiler sees two main ways to improve the system. One would be to improve diagnosis and triage for mental health patients. Those experiencing worsening symptoms should be seen sooner.

“Providers need to do a better job to set up a system where those most at risk of serious emotional distress can get in to be seen before the ER and crisis,” said Shunkwiler.

In addition, he said, not all mental health issues are best handled medically.

“Normal psychological distress doesn’t have as many outlets,” said Shunkwiler. “The breakdown of community is a big part of that.”

Institutions like church, civic clubs and community organizations once helped ease feelings of loneliness. Today, people turn to these groups less often, while spending fewer hours each week with friends than a generation ago.

Werner thinks the move toward banning cell phones in school will help kids make more human connections at an earlier age. Spending time with people away from work or school is good medicine for adults, too.

Addressing mental illness in its earliest stages heads off the most dangerous symptoms and avoids complicated care plans. Oftentimes, human connection provides an important catalyst for healing.

That’s what Broking experienced in therapy.

“I said, thank God somebody understands me,” said Broking. “I wanted to do that kind of work. I’ve been doing it ever since. I think there was a reason nursing didn’t work out for me.”

NOTE: If you are experiencing thoughts of suicide or self-harm, the 988 Helpline connects you with local resources wherever you are. This story describes challenges in finding long-term care, but immediate aid in a crisis is always available. Call 9-8-8.