Those of us who live and work in cities often forget there is a whole other way of living alongside our own metropolitan or suburban way of life: A large part of the US is still rural. According to US census bureau director John H Thompson, rural areas cover 97% of our land area and contain 20 percent of our people (60 million people).

Rural America is facing a health crisis.  Although the prevalence of mental illness is similar between rural and urban residents, rates of suicide are not.  Suicide rates (Reference – See chart attached) have been growing in the US as a whole since 2000; increasing by nearly 30 percent for both adults and children. That alone is cause for concern.  But the suicide rate in rural areas has increased by more than 40 percent in the same period.  Data from:  Trends in Suicide by level of Urbanization – United States, 1999 – 2015

Growing up in the country and on a farm in the 50’s and 60’s gave me some firsthand appreciation of rural health concerns, including mental health. My father became ill with was what then called a “nervous breakdown”. It was something shameful and no one talked it. It was all a personal failing.  Besides, the work never stops, how could one take “time off” to recover lost mental health?

I think about this issue every time I drive on our nearest rural county highway. I wonder about the health of my rural neighbors. Most of the farms are family farms and their appearance suggests times are tough.

A report entitled The Stigma of Mental Illness in Small Towns notes another of the barriers contributing to the rise in rural mental health problems is that many residents believe that that “I should not need help.”  Or simply don’t know where to go for assistance. Many times there is no mental health professional near and it is a significant burden of time and distance to travel for help.   

A study published in the journal JAMA Pediatrics in 2015 analyzed data on US youth suicide rates from 1996 to 2010. It found that the rates of suicides for rural Americans aged 10 to 24 was almost double the rate compared to their urban counterparts. This was attributed to social isolation, greater availability of guns and difficulty accessing healthcare

It seems that the stigma – that mental illness is shameful – may be felt more acutely in small rural communities. And there is a lack of anonymity there.

Again from The Stigma of Mental Illness in Small Towns:
“We as a society have a hard time asking for help, so it’s hard enough to ask for help without feeling that everybody’s going to know it,”……”Your neighbors don’t have a clue in a city if you’re to get some help. But everybody in a small town will know if your pick-up is parked outside the mental health provider’s office.”(same reference; quote by Dennis Mohatt, VP of the behavioral health at Western Interstate Commission for Higher Education (WICHE) and director of the WICHE Center for Rural Mental Health Research.

The upshot is that rural citizens with mental health needs enter care later in the course of their disease than do their urban peers; enter care with more serious, persistent and disabling symptoms and require more expensive and intensive treatment response.

A policy brief by the National Rural Health Association, The Future of Rural Behavioral Health, February, 2015, makes the case that rural needs can be met by behavioral health reforms addressing the availability, accessibility, affordability and acceptability of services. (new reference). “ Three-fourths of counties with populations of 2,500 to 20,000 lack a psychiatrist and  95 percent lack a child psychiatrist.” Primarily due to this shortage of mental health professionals, primary care caregivers provide a large proportion of mental health care in rural America and may lack the training and experience to handle serious mental health issues.

What would help the situation?

• Increased emphasis on rural practice during professional training
• Rural community residents, such as school counselors and members of the clergy, should receive educational material and information from Medicare, Medicaid, and private insurance companies concerning available resources for mental health issues.
• Programs like Mental Health First Aid (MHA) may be useful in providing basic training to providers and other community resource people and reducing the stigma in the community.

• Paraprofessionals and emerging professions can also augment the mental health workforce. One example is the emerging field of Peer Support Specialists. Peer Support Specialists themselves have personal experiences with mental illness and can offer invaluable perspective to patients in acute care settings.

And we all need to be more supportive of our rural neighbors.

What might we experience as a Suicide Survivor? _________________________________

(This, the first in a series of postings on suicide issues, is based on a very real need for me and my family to know how to support people experiencing the death of a loved one by suicide.

The people left behind when suicide has occurred face not only grief, but a complicated grief, full of many questions and challenges.  We who are left behind are often referred to as suicide survivors…..)

Most of us have experienced the death of a loved one. And we can appreciate that the grief that follows is always difficult, even though it is an instinctual and helpful reaction. Suicide survivors too, are left with grief and feelings of loss, sadness, and loneliness after the death of a loved one. Yet these are often magnified by feelings of guilt, confusion, rejection, shame, anger, and the effects of social stigma and personal trauma.

As suicide survivors we are plagued by the need to make sense of the death and to understand why suicide appeared to our loved one as their only option. We may overestimate our responsibility, as well as guilt for not being able to prevent the tragic outcome. Survivors may replay events up to the last moments of their loved ones’ lives, looking for clues and warnings that they blame themselves for not noticing or taking seriously.

We might recall past disagreements or arguments, plans not fulfilled, calls not returned, words not said, and ruminate how if only we had done or said something differently, perhaps the outcome would have been different. If it is easy for we who are suicide survivors to get caught up in self-blame, it may help to understand that many (most) people who complete suicide were struggling against mental illness when they died.

Suicide survivors sometimes feel rejected or abandoned by the death. Survivors may see the deceased as choosing to give up and leaving their loved ones behind.   Also survivors can feel bewildered, wondering why the relationship they had with the person was not enough to keep them alive.

Anger is a common response: Directed at the person who died, or at themselves, or perhaps at other family members, at professionals, at God or the world in general. “Why did my loved one not seek help or feel our love and concern?”

Suicide is stigmatized. The bereaved may find it difficult to talk to others about their loss because others often feel uncomfortable discussing a death by suicide. This can leave the family/friends feeling isolated. For all of us, talking about a loved one’s death is vital for our recovery. Stigma concerning suicide poses an unwelcome barrier to the healing process.

Finally, survivors of suicide find themselves at a higher risk for suicidal thoughts and behavior than are other bereaved individuals (Dialogues in Clinical Neuroscience, Vol 14, No. 2, 2012).

What can we do to help support suicide survivors? ___________________________________

Individual counseling and suicide support groups can be particularly helpful. While there are many grief support groups, grief support focused specifically on suicide appears to be much more valuable for suicide survivors.

As Dialogues in Clinical Neuroscience, Vol 14, No. 2, 2012 reports, “For many friends and family of a suicide victim, participation in support groups is felt to be their only access to people whom they feel can understand them, or the only place where their feelings are acceptable.”

As the support group talks together, we who are suicide survivors may obtain assurance that we are not alone in our feelings. Others, we find, have faced similar experiences and have survived not only intact but often able to better bear their grief. The bonds that form among participants can be very strong as they offer each other mutual support. Also there is practical advice for such real-life obligations as dealing with legal issues, talking to others (including one’s children), developing fitting memorials for the deceased, coping with holidays and special events, and setting realistic goals including care for one’s self.

Successful suicide support groups share the characteristics of other successful groups:  They provide accurate information, give permission to grieve, help normalize emotional and behavioral episodes that are out of keeping from one’s usual personality and deportment.  Most importantly, successful groups convey to survivors that they are not alone.

Please note, a support group may be especially effective for children who have lost a parent or family member by suicide.

Support groups can be found on Web sites of such groups as the American Foundation for Suicide Prevention (AFSP) and the American Association of Suicidology (AAS) which host directories for hundreds of suicide support groups in the United States.

Here are some tips for supporting a grieving suicide Survivor

LISTEN WITH COMPASSION

*Accept and acknowledge all feelings

(Let the grieving person know that it is ok to get angry; to break down. It is ok to cry.  Grief is emotion, so we suicide survivors need to feel free to express our feelings without fear of judgment, criticism or argument.)

*Be willing to sit in silence.

(It is a true comfort to a survivor to simply be in your company. Offer eye contact, a squeeze of the hand or a reassuring hug.)

*Let the bereaved talk about how their loved one died.

(Those grieving may need to tell their story over and over, sometimes in painful detail. Repeating the story is a way of processing and acceptance. Pain lessens with each retelling.)

*Offer comfort without minimizing the loss.

(Again, the emphasis is on listening and asking the other to tell you how they’re feeling. Avoid hollow reassurance.)

OFFER PRACTICAL ASSISTANCE TO A SUICIDE SURVIVOR

Just as we might in the aftermath of any death, we may offer to –

• Shop for groceries or run errands
• Drop off a casserole or other food
• Stay to take phone calls or receive guests
• Help with insurance forms or bills
• Help with housework like cleaning or laundry
• Watch their children or pick them up from school
• Drive them wherever he or she needs to go
• Go with them to a support group meeting
• Accompany them on a walk, lunch, or movie

PROVIDE ONGOING SUPPORT

* Our ongoing support may be more important at this time than ever.

(Stay in touch with the grieving person, periodically checking in, dropping by, or sending letters or cards.)

(Don’t make assumptions based on outward appearance; some may be struggling on the inside.)

*Avoid saying things like “You are so strong” or “You look so well”.  Also avoid comments like “He/She is in a better place now.” Or “This is behind you now; it’s time to get on with your life.”

(These comments are well intended, but put pressure on the survivor to keep up appearances and to hide true feelings.)

*The pain of this loss may never fully heal.

(Life may never be or feel the same. You don’t get over the death of a loved one. The suicide survivor may learn to accept the loss. Pain may lessen but sadness may never completely go away.)

*Offer extra support on special days.

(Holidays, family milestones, birthdays and anniversaries often reawaken grief. Be sensitive on these occasions. Let the person know you are there for whatever they need.)

WATCH FOR WARNING SIGNS OF DEPRESSION

*It is common for a suicide survivor to feel depressed.  Or to feel confused and disconnected from others, or that they are going crazy.

(If the bereaved symptoms don’t gradually fade —or they get worse with time- this may be a sign that the grief has become a more serious problem, such as clinical depression.)

*Encourage suicide survivor’s to seek professional help if any of the following warning signs are observed after the initial grieving period:

• Difficultly functioning in daily life
• Extreme focus on the death
• Excessive bitterness, anger or guilt
• Neglecting personal hygiene
• Alcohol or drug abuse
• Inability to enjoy life
• Hallucinations
• Withdrawing from others
• Constant feelings of hopelessness
• Talking about dying or suicide

FINALLY, STAY CLOSE

*Families often feel stigmatized and cut off after a suicide.

*From the Harvard Women’s Health Watch, July 2009, Left Behind After Suicide:

“If you avoid contact because you don’t know what to say or do, family members may feel blamed and isolated. Ignore your doubts and make contact. Survivors learn to forgive awkward behaviors or clumsy statements, as long as your support and compassion are evident.”

Grief works at its own pace.