Suicidal situations present challenges in rural communities

Suicidal situations present challenges in rural communities

By Heidi Marttila-Losure, Dakotafire Media

Reporting by Patty Wood Bartle, Edgeley Mail; Doug Card, Britton Journal; Becky Froehlich, Dakotafire Media; Bill Krikac, Clark County Courier; Garrick Moritz, Faulk County Record; Melody Owen, Tri-County News; and Laura Ptacek, Ipswich Tribune

 

Who would answer a call for help if your neighbor, or maybe a loved one, was contemplating suicide?
At some point in our lives, we are likely to encounter someone with suicidal intentions; it’s the ninth most common cause of death in the Dakotas, and the second most common cause of death in the Dakotas among young people, according to state agencies. In 2010, 103 lives were lost to suicide in North Dakota and 139 in South Dakota.

Those statistics have proven terribly real recently for several Dakota communities, which are still in the painful aftermath of suicides.

The need for good mental health care is clear, but rural communities often have few resources to provide it. Mental health facilities are often many miles away, so jail cells serve as temporary safe places for suicidal individuals. Many who respond to suicidal intentions and other mental health crises say they feel inadequately trained to deal with them.

“A threat of suicide is like domestic violence—you don’t know what’s going to happen,” explained Marshall County (S.D.) Sheriff Dale Elsen. “You go in thinking the worst and deal with the problem, but we’re acting like a counselor or psychiatrist and don’t have a degree to do it.”

Melody Owen, editor of the Tri-County News in Gackle, N.D., and also an emergency medical technician, said she has responded to patients who had attempted suicide, and also to calls when a loved one was worried that a person would do him- or herself harm.

“These calls are very difficult,” Owen said, “due to the emotional/mental situation that we are minimally trained to treat, versus extensive medical life threats we are trained to treat.”

Some communities in the Dakotas are working to address mental health needs with training specifically to equip people with the skills they need to deal with a threat of suicide. First responders are improving their skills—and so are many kinds of caregivers, who want to make sure they can respond effectively if they see signs of suicidal thoughts.

 

When the call comes in

If someone is contemplating suicide in a rural Dakota community, who gets the call? Who is sent to help?

Several hotlines are available for those who want to talk to someone. The one that works anywhere is 1-800-273-TALK, which is the National Suicide Prevention talk line. The number 211, intended to connect people with information about health and human services in their area, is easier to remember. In North Dakota the 211 service is available statewide, but in South Dakota, 211 only works in metro areas and the Black Hills; the alternate number is (605) 339-4357.

Those numbers are for prevention before a crisis. If the situation gets to the point that a person says, “I want to die, and I have a plan,” 911 is the number to call.

Owen explained that often both law enforcement and an ambulance are dispatched to respond to a threat of suicide. The ambulance is for the most part there as support to the efforts to help the person and as backup in case the person does do harm to him- or herself, but if there is no medical need yet, their authority in the situation is limited.

“EMS cannot transport someone against their will if they are competent to make their own decisions,” Owen said.

But law enforcement can—they can put the person into protective custody and transport him or her to an appropriate facility if that is deemed necessary.

Jeremy Wellnitz, chief of police in Clark, S.D., said they will go to the place where the person is and see if he or she will talk to them.

“We will try and find out what’s going on and why they are feeling the way they are,” Wellnitz said. “We will do what we can to get the person the help they need.”

“Generally what happens in a case like this is that we get a phone call from a friend, a neighbor or a family member, and they tell us, hey, this person is having some real problems,” said Faulk County (S.D.) Sheriff Kurt Hall. “So we go out to see them (and) try to figure out what has brought the friend or the neighbor to this point where they’ve thought that they should call us to the scene, and talk to that person. And we have to have really good firsthand information before we proceed.”

 

First stop is often jail

If they suspect the person should be committed to a mental health facility for his or her own safety, law enforcement takes that information to the local mental health board, and then to a judge who has final say.

Unfortunately, a person contemplating suicide may need to be held in a secure facility in the community while this process is completed—and in some rural communities, the only secure facility is the local jail.

“We usually end up having to put that person in a protective cell until all that paperwork can be done, and that can be tricky when you’ve got to call a judge at 3 in the morning,” Hall said. “It can take just a few hours, or it can take days.”

Spending time in jail is not ideal for a person in a suicidal state of mind, but it can be a good temporary option, said Kristin Wheeler, a prevention specialist with Community Counseling Services in Huron, S.D.

“We can help them and support them in a safe way (while in protective custody),” Wheeler said. “If someone’s desperate, taking them out of that environment even temporarily can help to calm them.”

But Sara McGregor Okroi, executive director of Aliive Roberts County, was frustrated with the process in her area, where a temporary stop in jail didn’t feel all that temporary.

“There was a severe lack of services in the community,” McGregor Okroi said. “(Authorities) couldn’t guarantee that they would have an assessment in 24 hours … For somebody that is suicidal, (spending time in jail) was just taking that and making it so many times worse.”

A suicide prevention task force in Sisseton, which had been organized by the Sisseton Ministerial Association in 2004, took up the issue and worked with the agencies involved to improve the response.

“Coteau Hospital in Sisseton has come leaps and bounds in the last year,” she said, and now a person can be transported to the emergency room in Sisseton instead of to jail until a decision is made on what the next step should be. “Medical staff has really stepped up, and now everyone is seen.”

Jail is still the only safe place in many communities, however. Law enforcement officers do what they can to make the situation as supportive as possible.

“We try to deal with the person with kid gloves, and we’re honestly trying to help and protect them, not aggravate them,” Hall said.

 

Room for improvement

Hall said his department is very pleased with their local medical personnel and their response to suicide situations—but they are frustrated with rules that prevent them from doing all they can to help people in need if they transport them out of the area for treatment.

In a several-county radius around Aberdeen, S.D., most cases of suicidal people are taken to what’s called 2-North—the Avera Mental Health Ward in Aberdeen. Sometimes people are taken directly to the Human Services Center in Yankton, S.D. The North Dakota State Hospital in Jamestown has the closest mental health facility for several Dakotafire communities in North Dakota.

Sheriff Hall said that’s not always the most effective solution.

“We just went through one of these cases recently where we took a person (to Avera) and they held that person for 18 hours and then released them—and then within six hours we had to repeat the process,” Hall said. “That tells me that first evaluation didn’t help that person very much, and it makes it quite frustrating on our end because then we can’t do our job to protect that person and the community as a whole effectively.”

Hall said the county pays for the process, but asking the folks in 2-North what happened there to help the patient is a question that goes unanswered.

“How can we be part of the solution in helping that person when we don’t know what the main portion of that help is?” Hall said. “Mental health is a tricky deal, and I’m not a counselor, but I feel there are a lot of people out there who need help, and I don’t know if they get it.”

The issue is the privacy rule of the Health Insurance Portability and Accountability Act, passed by Congress in 1996 and put in place in 2000. The intent is to keep people’s medical information private—but Hall said that in regard to mental health, it keeps things too confidential.

“If we understood the nature of their problem, maybe we could help … or prevent incidents from happening with that person in the future,” Hall said. “But that’s none of our business, apparently. Once we take them (to a mental health facility), we have no idea what happens to that person, and we’re not supposed to ask. I’m not saying it should be public knowledge, but better cooperation between mental health evaluators and law enforcement needs to happen … We all want to see this person well, and that’s not going to happen if there is no cooperation.”

Dale Elsen, sheriff in Marshall County, said they average one or two calls dealing with suicide a month, and there is no local agency to help suicidal people, so they are transported to Aberdeen. Dealing with mental health issues is a statewide problem, Elsen said—especially in rural areas. Lack of preventative services is one aspect of that.

“We do have a mental illness counselor that comes a day every other week,” Elsen said, “but we have a lack of resources in Marshall County, and it’s a big problem. The whole state is failing in mental health situations, and we need to do something about it.”

The problem is the same in Faulk County, explained Deputy Sheriff and County Emergency Manager Bill McKeon.

“Just the immediacy and the availability of help and service is an issue,” McKeon said.  “When you live in a big city, you can usually get on the phone and talk to somebody who will help you, find a counselor, find a group meeting almost right away. There is usually somebody there. But you live out here, you have to drive 2-3 hours in order to get that personal one on one help.”

 

Strengthening the front line

Addressing the need for more mental health resources in rural communities through political channels is likely to take time and considerable effort, but while waiting for those efforts to yield fruit, some Dakota communities have found a way to address mental health needs more directly: They are training more people to be effective “first responders” in suicidal situations.

Some area residents have taken a course called Mental Health First Aid (www.mentalhealthfirstaid.org), “an interactive 12-hour course that presents an overview of mental illness and substance use disorders in the U.S. and introduces participants to risk factors and warning signs of mental health problems, builds understanding of their impact, and overviews common treatments,” according to their website. Trainings were held around the state in 2011, and more could be arranged if a community is interested.

Another training option is called ASIST, or Applied Suicide Intervention Skills Training (www.livingworks.net), a two-day workshop “for caregivers who want to feel more comfortable, confident and competent in helping to prevent the immediate risk of suicide.” An ASIST training session is set for April 25 in Jamestown; contact Jennifer Lindsey at jlindsey@nd.gov or 701-253-6320 to register.

The courses aren’t intended only for official first responders. Teachers, coaches and ministers are among those who might find the trainings useful, according to McGregor Okroi in Sisseton.

She said a less intensive training called safeTALK is available for teens. The appropriate response for young people is to get an adult involved, she said, but they can learn the warning signs so they know when and how to get help.

The more the general public knows about how to help, the better the situation will be, according to Craig Peterson, school counselor at Madison (S.D.) High School.

“The key is keeping people informed about our steps and procedures,” Peterson said. “I think we’re well-informed now because it’s in the press and media. … Law enforcement, professional and even the public now know better. Teachers are mandated to act, and that’s accepted now. People are more comfortable knowing that they have to help, that they need to do it.”

 

What do you think about the mental health care services available in your community? Share your opinion: Go to www.dakotafirecafe.com/beyond-the-story-mental-health.

 

Know the warning signs of suicide

While there are some situations in which no warning signs are present prior to a suicide attempt or suicide death, most often an individual does exhibit some clues or warning signs that they are struggling with suicidal ideation. It is important to be aware of the warning signs of suicide so that appropriate help can be given.

Here’s an  easy-to-remember mnemonic: IS PATH WARM?

I Ideation
S Substance Abuse

P Purposelessness
A Anxiety
T Trapped
H Hopelessness

W Withdrawal
A Anger
R Recklessness
M Mood Changes

Warning signs of acute risk:

  • Threatening to hurt or kill self, or talking of wanting to hurt or kill self
  • Looking for ways to kill self by seeking access to firearms, available pills, or other means
  • Talking or writing about death, dying or suicide, when these actions are out of the ordinary

If these warning signs are noted, seek help as soon as possible by contacting a mental health professional,
calling 1-800-273-TALK (8255), or calling 911.

Additional warning signs:

  • Increased substance (alcohol or drug) use
  • No reason for living; no sense of purpose in life
  • Anxiety, agitation, unable to sleep or sleeping all the time
  • Feeling trapped—like there’s no way out
  • Hopelessness
  • Withdrawal from friends, family and society
  • Rage, uncontrolled anger, seeking revenge
  • Acting reckless or engaging in risky activities, seemingly without thinking
  • Dramatic mood changes

If these warning signs are noted, seek help as soon as possible by contacting a mental health professional or calling 1-800-273-TALK (8255)

 Information from sdsuicideprevention.org/get-help/warning-signs/. Adapted from American Association of Suicidology.

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