It’s a topic that tends to make everyone a little uncomfortable but one that keeps popping up in public meetings and presentations around town: suicide.
The issue has shot to the top of the priority list for mental health care professionals and even public officials because the community has seen an “increase in adolescents in crisis,” said Deidre Ashley, executive director of the Jackson Hole Community Counseling Center.
“We normally see a spike this time of year, after school has been in session a month or two,” Ashley told members of the Teton County Board of Health in a recent meeting. “This is more intense.”
Since the summer St. John’s Medical Center has evaluated more than a dozen adolescents for “suicidal ideations,” hospital CEO Lou Hochheiser said. The Jackson Hole Community Counseling Center, the area’s most prominent source of mental health assistance, reports that counselors have been seeing one to two cases a week of kids and teens in severe mental crisis, up from one to two cases a month, Ashley said.
Professionals say it’s a trend without a clear explanation, though several factors are known to be heavy contributors to suicidal thoughts.
Underlying mental illness often plays a significant role, according to Joanne Harpel, president of Coping After Suicide, a newly formed organization that provides education on suicide prevention and guidance for people who have lost someone to suicide. Harpel recently visited Jackson Hole for three days of community outreach events.
Experts also point to a phenomenon that can be seen in the wake of one death by suicide: contagion and clustering. Unfortunately, it’s not uncommon for a community to experience suicides in clusters, and while contagion is not restricted to youth it is “heightened,” Ashley said.
Other potential influences that have been suggested include increased academic stress, lack of coping skills, bullying, family disruptions and even the housing crisis.
It’s a complicated issue to explain and address, especially in a rural state full of isolated communities.
Limitations of St. John’s
Hochheiser has long said the hospital is ill-equipped to handle people in severe mental crises, be they children or adults.
“We’re not a psychiatric facility,” Hochheiser said. “Our psychiatrists aren’t available 24/7, and I think that’s one of the things the hospital needs to address in the near future.”
But because St. John’s is the only hospital serving Teton and Sublette counties, people struggling with mental crisis often find their way through its doors. The staff has been handling an increased caseload in recent months, which Hochheiser attributes to the closure of the Van Vleck House group home.
The suicide of a 16-year-old at Van Vleck sparked an investigation that closed the home this summer. It recently reopened in September.
At St. John’s treatment often equates to little more than holding a patient until a more appropriate facility can be identified, Hochheiser said. Patients receive an evaluation, typically conducted in partnership with the Community Counseling Center, followed by a referral to a treatment facility.
That is often where the process bottlenecks, because treatment centers are scarce and open beds even more so.
The wait for a bed in a more intensive facility can stretch to weeks, as noted in a study done by the Treatment Advocacy Center, a nonprofit mental health advocacy group. The study gave Wyoming a failing grade on its process for getting people into residential treatment, noting that waits are often two weeks or longer.
Earlier this year two court cases were delayed more than three months while the Wyoming State Hospital waited for beds to become free to perform competency evaluations. One of the defendants needing a professional evaluation was a 15-year-old boy.
Not every patient who ends up at St. John’s requires detention in one of the hospital’s three “lock rooms,” which consist of a bedroom and bathroom fixed with smooth surfaces to prevent the occupant from harm.
“Not every person or child that has had those thoughts necessarily needs to be hospitalized,” Ashley said.
In such cases hospital staff and counselors work to sift out the most appropriate spot that can address the patient’s needs, she said. But it’s a complicated and difficult process, especially when the community loses a resource and state funding continues to flatline.
‘Titling’ kids and adults
For teens and adults who need a higher level of care, the lock rooms merely provide some certainty of physical safety, Hochheiser said. But he questions the effects of “locking up” people who are struggling through a mental health crisis, especially for extended periods of time. Hochheiser said one adult patient was detained at St. John’s upwards of 20 days, waiting for a bed to open in a psychiatric care facility.
Though patients in such situations are evaluated every two to four hours, depending on their age, Hochheiser worries the effects of such isolation cause more trauma.
“Do we want to lock up an adolescent in a lock room for five days?” Hochheiser asked. “It doesn’t help them. And it’s often that beds aren’t available to take them.”
The process, while similar in many cases, is also unique to the patient. Kids are handled differently than adults in that the hospital tries to avoid “titling” adolescents.
“Titling” refers to Title 14 or Title 25, Wyoming statues that allow the state to hospitalize a person who may be a threat to himself or others. Title 14 contains a clause related to children. Title 25 covers adults.
“They try very hard not to title kids and teenagers,” Hochheiser said. “The problem with the title process is it puts things in motion that could interfere with a family that might be in crisis.”
St. John’s did not provide exact numbers on how many adolescents or adults have gone though the titling process or how many mental health evaluations have been provided in recent years.
But Hochheiser said St. John’s has “about 100 admissions a year that are Title 25.”
In an interview in the beginning of October he said hospital staff was stressed after recently handling “three kids in three weeks.”
“It’s incredibly stressful on the staff,” he said.
But there is often nowhere else for patients to go.
“There’s not an adequate system that exists,” Hochheiser said. “Part of it is funding from the state for mental health, part of it is the facilities that we have,” he said.
In Teton, Lincoln and Sublette counties the most reliable places to send youth requiring more intensive supervision are the facilities run by Teton Youth and Family Services.
The nonprofit runs two residential facilities and one temporary crisis shelter. It accepts troubled youth at all three.
In its most recent annual report, from 2014, the agency noted the same increase in the intensity of local adolescent mental illness that Hochheiser and Ashley noted from this summer and fall.
Red Top Meadows, a residential treatment center for boys ages 12 to 18, reported seeing “more severe histories and serious mental health, emotional and relationship issues” among the young men entering its doors during 2014.
Van Vleck House Group Home, which accepts male and female students ages 10 to 18, cited a “much higher level of needs” in several of its new students during the same time period.
After the 16-year-old student’s suicide, Van Vleck House was shut by the Wyoming Department of Family Services over the summer to investigate its policies and practices.
The closure of one of the main resources for that age group only served to highlight its role in the valley, Ashley said.
Ashley also cited Van Vleck’s long history of accepting only those students who fit the facility’s ability to serve them.
The Department of Family Services, at least, believes Van Vleck deviated from that history in the months before the closure.
In the investigation report listing what needed to be addressed before Van Vleck could open again, the investigator stated that “youth in the program were not appropriate for a group home setting,” but required a residential treatment center or other such facility.
The nearest such facility on the western half of the state is in Rock Springs. That trip would fly in the face of accepted best practice among mental health professionals, which is to treat patients in their own community as much as possible. That goes double when the patient is a teenager, Ashley said.
“The more you cut into community mental health, the more you’re not going to be able to keep people in the community,” Ashley said.
It is just that kind of funding that has seen the most cuts over the past decade. Overall, Wyoming’s funding for mental health programs at nearly every level has either gone down or stayed static, regardless of reported need.
The National Alliance for Mental Illness said in a 2014 report that Wyoming was one of six states that reduced mental health funding in the 2014 and 2015 budget cycles, when the vast majority of states were increasing that funding.
Wyoming also is one of the few states that has not passed legislation expanding mental health access or programming in the past two years, according to the alliance.
In a conversation a week before Van Vleck closed, Bruce Burkland, executive director of Teton Youth and Family Services and director of Red Top Meadows, said the decreased funding was contributing to “an overtaxed system.” He also attributed some of the increase in severely ill teens coming across his desk to that system.
Suicides in Wyoming have received national attention lately, with the Center for Disease Control release of numbers that show the state’s suicide rate as one of the nation’s highest.
“Suicide rates in general are interesting because despite prevention efforts, awareness, all that stuff, it continues to rise nationwide,” Ashley said. “Which is sort of an unusual phenomenon.”
There has long been a perception among Teton County residents that the valley tops the state. That has not been true for any year between 2000 and 2013, according to the most updated data available from the Wyoming Department of Health.
But during that time, Teton County has never been among those counties to see zero suicides in a single year.
It’s not to say that prevention efforts, don’t work. Rather, there are many factors that play into suicidal ideation and many factors that contribute to how well a community — especially a rural, isolated one — can address the problem.
“Even one feels like a huge amount,” Ashley said. “It’s a small town, and it affects us all.”