Recent tragedies highlight rural mental health, addiction crisis
THE 988 SUICIDE & CRISIS LIFELINE
Recent tragedies highlight rural mental health, addiction crisis
Stigma, treatment gaps, lack of community engagement undermine care
By Michael Standaert, North Dakota News Cooperative
Signs of trouble should have been obvious long before Robert Bracken shot his son Justin, his older brother Richard, his employer Doug Dulmage, and finally, himself, with a .357 revolver on Aug. 29, 2022.
With an unthinkable scene of four dead bodies in a blue-skied North Dakota grain field, it appeared an act fueled by towering instability had taken place. A formal investigation into the incident continues, leaving the ultimate motive and circumstances unclear.
It was one of two tragedies late this summer that illuminate the critical need to address mental health and substance abuse problems across the state.
A week after the Bracken shooting, near Gackle, Ryan Storbeck ran a combine over his hired man, Johannes Steenberg, a South African visa worker. Storbeck and Steenberg had reportedly split a 30-pack of beer before even starting up the combine that cool, cloudy afternoon, according to the Stutsman County sheriff’s incident report.
Not all instances of behavioral and mental health problems end so tragically. When they do, they lay bare immense barriers to treatment and prevention including social stigmas, an alcohol tradition in many communities, and a list of counselors and other practitioners that is far too small to meet the need.
Veil of silence
Many North Dakotans are reticent to address their struggles with mental and behavioral health, or the struggles of those close to them, said Heather Gibbens a counselor at Evolution Counseling in Devils Lake.
Originally from Cando, Gibbens said that stigma can be a real barrier for people seeking counseling in communities where everyone knows everyone.
When they finally acknowledge it is time to reach out, they find most providers of mental health, psychiatric and addiction services have a two- to three-month waiting list, Gibbens said.
“That’s why I started private practice, essentially, so that we can do things a little differently, and reach out to meet people where they are at, because a lot of people maybe aren’t ready for the services they need,” she said.
“Everybody is just so busy,” Gibbens said.
At the Heartview Foundation’s 16-bed residential addiction treatment facility in nearby Cando, 26 people were on a waiting list at the time of a visit there, according to Shari Timms, director of operations.
“We’ve been full, like where we don’t have people leaving, but then the next week we’ll have four leaving, so it just really kind of depends on the flow that’s coming in and the flow that’s going out,” Timms said in October.
Both Ryan Storbeck and Robert Bracken had a history of alcohol-related arrests and court orders for substance abuse evaluations according to official records.
Whether either of them ever sought or received help is unknown. Most family and friends, traumatized by the event, were unwilling to talk on the record for this story.
Rachael Angela Bracken, Robert Bracken’s daughter-in-law, said she wasn’t close to him and didn’t know what issues he was struggling with.
“I think the entire state of North Dakota drinks more than most,” she said. “I do know there can be a wait for counselors as I work in health care. That person also needs to want to get help as well. Many don’t seek it out.”
When contacted, North Dakota’s Bureau of Criminal Investigation declined to comment on the Bracken case or whether a toxicology report would be issued, stating that the investigation is still ongoing.
Besides stigma, a lack of insurance, gaps in coverage, transportation distances and associated costs are other factors inhibiting treatment.
While available during the heady days of the pandemic, insurance currently isn’t covering telehealth addiction treatment, said Jennifer Spatola, Heartview’s director of clinical services.
She said the lack of telehealth service affects people where there is no treatment available nearby, those who don’t have transportation, or those with difficulty finding stable housing.
“We had a lot of people sign up because they could just get on their phone, and they’d be an hour away from services, but now insurance won’t cover that,” Spatola said.
Sometimes, the barrier is an alcohol tradition in their small town.
Gibbens often hears clients say, “‘There’s nothing for me to do.’ We always say that the opposite of addiction is mainly connection, right? I want people out engaging in their communities and there’s just nothing for them to do,” she said.
“Anybody could be struggling with these things,” Gibbens said.
Increasingly, it isn’t one or the other when it comes to mental and behavioral health, Spatola said.
“I’d say 98 or 99 percent that come in now have both mental health and addiction issues, and it never used to be like that,” Spatola said.
Behind the headline-making tragedies are the steady stream of mental and behavioral health incidents that occur more regularly.
In North Dakota, the second leading cause of unnatural death is suicide, with the state ranking 12th in the nation, the most recent Center for Disease Control data indicates.
Suicide is also the leading cause of violent death in the state. A total of 164 suicides occurred in 2021, followed by drug overdoses at 131.
These behavioral health deaths far outpaced the 20 homicides and five accidental firearms deaths in that same year, according to state Health and Human Services [NDHHS] data.
The rate of alcohol-induced mortality in North Dakota is also higher than average, standing at 18.4 percent compared to the 10.2 percent national rate for the most recent year  data was available, according to the NDHHS.
Deaths from alcohol-related crashes stood at 41 that year compared to the national average of 28.
In a recent survey from the NDHHS of over 5,800 respondents in August, between 11.1 to 13.5 percent of people said their mental health was “not good” for at least three to up to seven days out of the month. Another 10.4 to 12.8 percent said it was “not good” from anywhere between eight and 29 days out of the month.
Pamela Sagness, executive director of the behavioral health program at the NDHHS, said the gap in treatment is everywhere in North Dakota. Scaling up is problematic because of workforce shortages and funding.
“We need more providers, for sure,” said Gibbens. “If someone comes through my door, if they need to be somewhere else, I need to help them get there. I need to help them figure out this process that’s so disjointed and everyone’s got their own rules and regulations.”
Had some of these disjointed processes been addressed previously, recent tragedies like those last summer may have been flagged when warning signs presented themselves, practitioners say.
Despite those gaps, one area where the department has made some inroads, Sagness said, is through the successful training of peer support specialists. These peers are people who typically have prevailed against addiction, mental health issues, or both,
NDHHS has trained more than 800 of these specialists over the past three years to be on the front line of care, particularly in rural areas.
“They aren’t people that are going to help at the state hospital, they aren’t doctors, but what they are is connectors,” Sagness said. “It’s someone you can connect with in your small rural area or call on a Saturday at midnight, and it’s someone that knows how to access those services.”
Sagness said many trainees come from rural areas. “They saw that in their hometown,” she said. “They saw that gap, or that missing piece.”
In addition, federal funds have enabled NDHHS to build out a treatment and provider registry, which launched in October.
The directory lists 174 mental health providers and is expected to grow, said Sagness
“At least now we can send an e-mail to all mental health providers and say, ‘Hey, we’ve got funding, let us know how we can help fill these gaps.’ We can see where our biggest gaps are when we look at the state,” she said. “[Before] we just didn’t even know.”
This story is the first of a two-part series on mental and behavioral healthcare access in North Dakota.
Some resources for those struggling with mental health or addiction are included below [These may be used as a pullout or just as the text below]
Resources for those seeking help for mental and behavioral health challenges across the state are available at the NDHHS directory: www.hhs.nd.gov/behavioral-health/directory
The North Dakota Farmers Union also provides a resource page for farmers and ranchers dealing with farm stress and other behavioral health issues at: https://ndfu.org/farm-stress/
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Cutline for photo:s
A manual for recovery sits abandoned on a picnic table outside Midwest Mental Health Clinic in Fargo, Oct. 19. Name obscured to protect the identity of the owner. Photo by Michael Standaert, North Dakota News Cooperative
Alcohol related mortality data in here: https://www.behavioralhealth.nd.gov/sites/www/files/documents/data/EPI_2022.pdf