Without access to care, anxiety, depression, addiction stalk rural Coloradans | SPECIAL REPORT
by: Joey Bunch
September 1, 2019
Originally appeared in The Gazette.
This story is part of a yearlong series about Colorado’s broken mental health care system. Read more of the series here.
There’s desperate isolation in a place where everybody knows everybody else’s business, says Laura Negley, a mother of two who has lived on the eastern plains for all of her 58 years. She has two grown children and says grace with her husband and son over about 13,000 acres in Kiowa County, between Kit Carson and Lamar, a flat, dry place that’s more a mix of Kansas and Oklahoma than the Rocky Mountains.
It was late 2012 when the “wheels fell off,” she explained in a barn half the size of an airplane hangar, surrounded by hulking farm machinery on the edge of a field.
The drought was kicking the daylights out of their property, market prices for cattle were depressed and then God threw in a cruel insult — a wildfire burned 700 acres of grass that was supposed to sustain their cows.
“We didn’t have cattle. We didn’t have crops. We didn’t have any income coming in, other than what little we were getting in crop insurance from the drought,” she recalled.
After the cows finished grazing her fields in October, Negley was alone with her worries. Her outgoing personality turned inward. She rarely left her house in Eads, and when she did go outside it was a constant struggle with anxiety. Her daughter and her friends were concerned, and her family staged an intervention when she said she wasn’t coming home to Greeley to celebrate Christmas that year, a tradition she’d previously held sacred.
“There’s many times I thought, ‘Lord, if I don’t wake up in the morning that might be the best thing,” Negley said, resignation in her voice.
The first solution was to get her away from Eads, where there was virtually no professional help. She stayed with her parents in Greeley — a big city by plains standards — while she got intensive counseling and found a path forward that’s been less about medication and more about faith and opening up to others.
“I thought it was time to speak up,” said Negley, about talking publicly in speeches and interviews. “It’s not easy to discuss it. It’s kind of a personal thing, but it helped me to hear other people’s stories about how they’ve gotten through tough times.”
Poverty, distance, stigma
In the small, far-flung communities of rural Colorado, getting help for mental health concerns is a tall task with high costs and uncertain outcomes.
Statistics and studies show that rates of depression, suicide, and substance abuse are as prevalent as in urban areas of the state, and in some instances much higher:
• In southwest Colorado, the suicide rate is 31.8 per 100,000 residents, compared with a 20.2 per 100,000 statewide — which is 10th highest among the states. On the eastern plains, in a statistical region that includes Elbert, Lincoln, Kit Carson and Cheyenne counties, the rate is 28.7.
• Nine of the 10 Colorado counties with the highest rates of overdose deaths have populations of less than 50,000.
• Twenty-two rural counties don’t have a licensed psychologist, and 24 counties do not have a licensed addiction counselor.
Mental health providers scramble to overcome what’s called “windshield time” to reach those who need help. Services lag despite the best intentions of state and local governments, partners across a variety of rural agencies and slowly changing views on getting help with mental concerns. They lag because people out here, in general, are too poor to pay the taxes to generate much more in the way of services than what they already have.
State and local agencies grapple with solutions to overcome poverty, distance and stigma.
Crisis dollars tilt toward the country, averaging nearly $10 per capita in rural counties compared with about $4 in urban counties, said Robert Werthwein, the director of the Colorado Office of Behavioral Health in the state Department of Human Services. But when you don’t have many people, the economies of scale crush a lot of solutions that take public dollars.
In other places, local mental health programs often are heavily subsidized by the local tax base or a sales tax. Amid the poverty of the San Luis Valley and eastern plains, such investments quickly fall out of reach. Layered on top is the dilemma of finding psychologists and counselors willing to work in towns of a few thousand or even a few hundred.
“If you don’t have at least a mix of wealthy in with poverty, you’re not going to be able to raise enough tax revenue to do local efforts,” Werthwein said. “But even if you have the money, you’ve still got to recruit the workforce.”
If state and local communities could find the money and staff, it doesn’t guarantee people will show up to receive help.
“They don’t want to travel to a place where their car will be seen,” said Moe Keller, a former state legislator from Jefferson County who is the advocacy director for Mental Health Colorado.
“They might not have any problem going to a hospital or a health clinic, because their car could be there for anything, but people are hesitant to go to a mental health center that’s a stand-alone facility, they’re really reluctant to do that.”
Liquidating the ranch
Tony Hass is like a throwback Colorado cowboy sent over from central casting for a John Ford Western. He’s tall and lanky and looks you in the eye when he talks, slowly. His dusty boots and weathered Mexican cowboy hat are the working kind, not the line-dancing kind.
Hass isn’t big on machinations of state politics, though he’s a Republican commissioner in Las Animas County. He doesn’t think of himself “as an R or a D,” for either party, but a “c” for commissioner for everybody, he said in a way that didn’t sound like a politician.
That c also could stand for caring, because Hass does a lot more of that these days.
A state survey indicated in Las Animas County, which does not have a practicing psychologist, more than 1 in 6 people say they suffer from poor mental health, according to the Colorado Rural Health Center.
Hass looks out from the big picture windows of his two-story ranch house a few miles out east of Trinidad, past his cattle, his wander-prone horse and the plains and hills of the Walking Y Ranch. He sees God’s grace and mercy on the people of his community.
Hass never thought all that much about the unique mental health needs of farmers and ranchers before he went to work for the Colorado Farm Bureau as a regional manager in 2007. He took on its safety and health program.
Hass took a trailer of exhibits and training equipment around to Farm Bureau gatherings, schools and other community meetings to talk about things like grain bin and chemical safety, plus hopefully keeping people from winding up tangled and mangled in their machinery.
He soon learned rural residents were struggling with other common dangers, from anxiety and depression to substance abuse and suicide. He expanded the bureau’s safety and health program.
The struggle turned to desperation around here when a lingering drought intensified from about 2010 to 2014. The weather took a toll on more than the crops and livestock. Hass had to liquidate his ranch near Piñon Canyon.
It wasn’t easy, but he got by with the support of his faith and his wife, Connie, he said.
“When you’ve got a ranch, if you can’t feed your cows, you can’t feed your family,” he recalled, sitting at his dining room table. “When you get to that point you start thinking about drastic measures.”
Two of his close friends committed suicide under the weight of failing fortunes.
“You see the stress on people’s faces, and you know they’re experiencing some tough times,” Hass said.
The code of going it alone
There’s been a code out here for as long as anybody can remember: Your problems are yours alone, Hass explained. And that way of thinking can feed the invisible beast that gnaws away at people’s emotional well-being.
The economic and emotional cycle, like the cycles of blizzards and droughts, is especially tough on young adults.
They tend to learn from experience and old-timers about how to weather the tough times in farming and ranching, setting back emergency sources of feed and money, Hass said.
New farmers and ranchers are often living from year to year; one storm or a bad market wipes them out, and sometimes takes with it a family legacy.
Hass recalled one safety presentation that had a big turnout. People were sharing their thoughts about the causes and effects of anxiety and depression more openly than usual. Then an old-timer said in his day people just picked themselves up by their bootstraps and dealt with things.
“Nobody wanted to divulge anything after that comment,” Hass said. “That old way of thinking really hinders anybody really talking about it.”
He couldn’t recall the best advice he offered a proud but struggling farmer or rancher.
“You don’t say much,” Hass said. “You listen. And then if they want your advice you give them what you can. The main thing, I think, is they want to know somebody cares.”
He thinks there’s merit in community support groups, no matter what they’re called. The only time people get together anymore is funerals, he said.
“Everybody says we need to do more of this, get out and visit with the neighbors and have a barn raising or a barn dance or whatever,” Hass said. “I think that would be a lot of help for people and maybe, in the corner, they might talk to somebody when they need help.”
Colorado has been proactive about mental health since about 2006, “but up until then I don’t think they addressed it much,” Hass said.
School programs, health clinics and crisis hotlines exist now that didn’t exist much before then.
“They’re starting to realize we’ve got a serious issue here,” Hass said.
In 2017, then-state Agriculture Commissioner Don Brown took the Farm Bureau program statewide in a collaboration called Let’s Talk in partnership with the Rocky Mountain Farmers Union and the Colorado State University Extension Service.
Let’s Talk emphasizes that “economic stress is real, your stress is real,” Moe Keller of Mental Health Colorado said.
Former Gov. John Hickenlooper took strides on providing more rural services as his administration revamped the mental health care system, including a statewide 24-hour crisis line and four mental health crisis centers to cover the state, operated by private, nonprofit contractors.
The San Luis Valley Behavioral Health Group operates a network from a center based in Alamosa with outlying offices in Antonito, Center, Del Norte, La Jara, Monte Vista and San Luis.
The program’s website directs visitors to Man Therapy, which allows men who might never go to therapy to consider videos about serious mental health issues, including rage, anxiety and opening up.
The San Luis Valley Behavioral Health Group operates a network from a center based in Alamosa with outlying offices in Antonito, Center, Del Norte, La Jara, Monte Vista and San Luis.
And, since 2009, it has partnered with Valley-Wide Health Systems to integrate physical and mental health care. In 2017, Valley-Wide opened a clinic on the San Luis Valley Behavioral Health Group campus in Alamosa. The valley group also provides a 24-hour crisis hotline and a mobile emergency response team.
On Sept. 26 at Adams State in Alamosa, the group is sponsoring a speech by suicide prevention advocate Kevin Hines, who survived his attempted suicide when he jumped off the Golden Gate Bridge in San Francisco.
Group CEO Fernando Martinez said he keeps a fleet of 24 cars on the road to provide services to a region of 8,000 square miles, larger than New Jersey.
“Those who want to come for services don’t have a waiting list,” he said. “They can have access to us right away.”
Martinez said he expects to somehow continue to expand services “because the need is so great.”
Victoria Romero, the mental health service’s chief operating officer, thinks solutions lie in networking with existing resources, including those providing physical health care — a “medical neighborhood,” she called it.
“They’re going to want to get services where they feel most comfortable, and in a rural area that means going to where they are instead of them coming to where you are,” Romero said.
Local, legislative solutions
Carey Deacon grew up in the San Luis Valley. Her dad was a cop here and now he’s a probation officer. Her boyfriend also works in law enforcement.
Deacon is the program manager for the Law Enforcement Assisted Diversion, or LEAD, program in Alamosa, which offers extensive services to help previous offenders stay out of trouble, a net saving to clients, law enforcement, courts and society.
The problems involving behavioral health are often complex, but in the valley a lot of agencies find a way to work together around common goals. They have to, Deacon said, because of distance, limited resources and because opportunities for success are precious.
“The valley has a very strong collaborative spirit,” she said. “I think all of our partners have learned that we have to learn to work together to serve our community in the best way that we can. We can’t work in silos, and we cannot be competitive.”
State policymakers are tuned in, as they have sought to make mental health a higher priority for programs and funding in recent sessions.
Amid a recent flurry of bills to address aspects of the mental health picture in Colorado, lawmakers two years ago outlawed holding people with mental health needs in jail cells and provided resources to get them to hospitals or other more suitable care.
In 2018, the Legislature put $2.5 million into expanding behavioral health services in rural Colorado. That same year, lawmakers passed a Senate bill to expand rural broadband internet service.
That’s key, several experts said, because the future for people in remote areas will allow them to access telehealth services, including counseling and psychiatry, without having to leave home.
“If they can be at home, and it’s their own business, they don’t have to go anywhere and no one has to know, they are much more likely to respond to mental health services,” Keller said.
Gov. Jared Polis was elected last year with a promise to make health care more available and more affordable.
Polis has since made clear he sees no difference between physical health and mental health, and no difference between Front Range and rural Coloradans.
“You can’t separate behavioral health from physical health,” said Polis, who released his “roadmap” to improving health care in Colorado in April.
Lt. Gov. Dianne Primavera, who is Polis’ point woman on health care issues, said the state still needs “to make some big changes,” citing that more than half the state’s 64 counties have no addiction treatment services.
“Every person who needs mental or behavioral health care should be able to get it when they need and where they need it,” she said.
Werthwein, the Office of Behavioral Health director, who worked for Hickenlooper before Polis, said the new governor charged a new 25-member Behavioral Health Task Force with looking for more options for rural Colorado. He appointed a third of the task force members from rural counties and small towns.
The group will issue a report with recommendations before June.
Starting in the fall, to address opioid treatment, the state will deploy six RV-sized medical assistance treatment vehicles paid for with federal grant money to rural communities around the state.
The idea will be to set up discreetly in local communities while inviting residents to come in for education and assistance. In some cases, the vans will offer a physician via a live internet connection to assist with medication-assisted treatment or counseling.
The traveling vans are one way to mitigate the difficulties in finding medical professionals to reside in far-flung farm communities, a tall order in itself, Werthwein said.
There are programs that offer student debt relief in exchange for doctors and counselors agreeing to work in rural settings, he said, but professionals often move on for better locations when the debt is paid, he said,
“Getting someone who grew up in an urban area to go rural, is difficult, especially if it’s not Telluride or mountain country,” he said. And even then, he said, “it’s about the cost of living in those places, so workforce is a big part of it.”
While rural Colorado needs services, the economy of scale — the number of patients — make it difficult to support brick-and-mortar facilities with professional staff.
Werthwein hopes to enlist physicians in rural communities to help with medication-assisted treatment for substance abuse.
The struggles of place
For a lot of people in Colorado’s agricultural belt, the tightening vise of economic and social challenges continue to drain the sense of place from the historic and sometimes fertile frontier.
“You see the Front Range economy booming and you see the recovery they have, but yet rural economies, we’re not getting that,” said Negley, the Kiowa County farmer and rancher.
She and her family live in Eads and drive about 13 miles out to the farm each day to tend their wheat, millet and cattle. The water’s too hard on the farm, so it’s better to live in town, said her 25-year-old son, Jayce, while he was pointing out places on a map where his father and grandfather have ranched since 1948.
His mother said she’s proud of his degrees in engineering, precision agriculture and business. She is also proud he worked for a John Deere contractor and worked on experimental equipment before he came back to the homestead.
He and his father handle the crops, and Laura manages herds that graze their property from May to November.
“I said, ‘I want you out of here, to the world, to see other perspectives,’” Negley said. “And I want you working for other people, not just mom and dad.’ My husband said, ‘You’re chasing him away. He’s never going to come back.’
“I said, ‘Well, if that happens, maybe that wouldn’t be the wrong thing. Maybe it’d be the right thing.’”
She describes rural outreach on mental health much the way she might describe herding cows or raising kids.
“You’ve been there so you can give a little bit of perspective and say, ‘Yes, there’s light on the other end of that tunnel,’” she said.
Contact Joey Bunch at firstname.lastname@example.org or follow him on Twitter @joeybunch.