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Nick Wagner, Deseret News
Gunnison Valley High Resource Officer Carl Wimmer chats with students during a period break in Gunnison on Tuesday, Nov. 22, 2016. Significant adults and peers are the first line of defense for teens with suicide ideation.

Editor's note: This is part of an ongoing series about how communities are addressing rising teen suicide rates. This article tells the story of a tight-knit rural community. Read more about an affluent urban response here.

GUNNISON — A young man walks out of the bank in the rural city of Gunnison, dressed in a shirt and tie despite the blazing sun. When he spots Officer Carl Wimmer in his police car, his face lights up. He tells Wimmer he just got a loan to buy a rental property. He owns a small business now.

It’s a beautiful day and life looks pretty darn good.

He made it. Past the desperate text he sent a few years ago: “It’s over, Wimmer. I’m gone. I’ve overdosed.” Through the trip to the hospital, where doctors pumped his stomach and Wimmer waited anxiously to hear if he’d be OK. Through a grueling mental and physical recovery. He even made it through high school, where he’d had a hard time — in short, through a very rough patch in his life.

Wimmer, a stocky, brown-haired cop on a small-town force, spends much of his time among the community’s youths as a school resource officer, anxious to hear their stories and willing to offer advice. Sometimes, that relationship means he receives a desperate farewell note that he does his best to keep from becoming real.

Now this young man is beaming, and as Wimmer shakes his hand, he thinks he’d offer him a hug if he weren’t on duty. He knows the sobering odds this guy bucked.

Suicide is relatively rare among Utah teens, but not nearly rare enough. It is the leading cause of death for youths ages 10 to 17, according to a July 2016 report from the Utah Department of Health. The state had the eighth-highest youth suicide rate in the country in 2012-2014, according to the most recent data available. The raw number nearly tripled from 3 to 8.5 suicides per 100,000 young people between 2007 and 2014, says another department report. Fourteen percent of teens say they’ve thought about suicide, while nearly a thousand a year survive self-harm or suicide attempts (not necessarily the same thing), some living with varying degrees of damage.

Risk factors for teen suicide include genetic predisposition, mental illness, even the possibility that high elevation plays a role, as a University of Utah study found.

Living in the countryside can also have an impact. A 2015 study comparing teen and young adult suicides in all U.S. counties from 1996-2010 showed suicide rates in rural communities were nearly double those of urban areas — and the gap is increasing.

One of the biggest challenges facing nonurban areas is access to mental health care, along with confronting the stigma associated with it. Experts also theorize that the same features that make rural life special can be both protective and risky: Wide-open space is great if you’re riding horses, but awful if you’re trying to reach a mental health specialist. A tightknit church community is life-affirming, unless you feel you aren’t included. And it’s nice to know everyone until you’d like some privacy.

Still, city kid or country kid, fewer than 5 percent of people who kill themselves actually want to die. “They just want to not be hurting any more,” says Chet Ludlow, suicide prevention specialist at the Central Utah Counseling Center (CUCC), which provides mental health services in six rural Utah counties.

That means suicide can be prevented by helping individuals find other ways to cope with pain and manage suffering, says Craig Bryan, a suicide specialist at the University of Utah. He tells patients, “We’re not going to get rid of all of your problems. You’re still going to be sad, you’re still going to be angry, you’re still going to be anxious. That’s just part of the human experience.” But changing how suicidal teens understand these emotions and expanding their capacity to experience them will help them choose life.

“It’s possible to suffer and have a life that’s worth living,” Bryan says.

Rural vs. urban

Sanpete County covers 1,600 square miles in central Utah, where summers are blazing hot and winters severe. Its 18 communities are spread out across a desert surrounded by high mountains, from tiny Jerusalem with maybe three houses to its “big” neighbor, Ephraim, population 6,400. In a half-hour, you can be in another community, though it may not offer significantly different amenities. Some don’t have internet access or their own gas stations or groceries, though the vast majority have their own small cemetery.

Most adults in Gunnison, population 3,269 and pretty typical of the area, work in a coal mine or at the prison there. In the northern part of the county, mining and construction are the main employers, while a local turkey plant hires people throughout the county. Kids attend one of three high schools: North Sanpete, Gunnison Valley or Manti. If they’re involved in after-school activities, the older ones may drive themselves, but the younger ones may have to catch a ride home, most often with a parent. This is tricky because Sanpete is one of the poorest counties in the state and most parents have to work, says Liz Brotherson.

Addelyn "Addie" Brotherson and her father, Jared, pose for a photograph outside of their home in Wales, Utah, on Nov. 22, 2016. | Nick Wagner, Deseret News

She and her husband, Jared, have both lived in Sanpete County their whole lives. Home now is Wales, population 207, a town so small it has no traffic light. Their daughter Addelyn "Addie" Brotherson, 14, was recently named the 2017 Miss Utah’s Outstanding Teen. She is on the cheer squad, dances, plays violin and piano and this year played volleyball for North Sanpete High, so her mom burns a lot of miles picking her up after school, despite her own jobs as an estimator for a construction company and a mortgage loan officer. Jared is a foreman at the gravel pit in Freedom, a handful of miles from home.

Addie’s activities provide “structured fun,” says her mom, because there’s not a lot for kids to do and consequently some teens drink and do drugs, maybe to combat boredom. The entire county boasts one bowling alley, Gunnison and Ephraim both have a movie theater and Snow College has an activity center with a basketball court and a swimming pool. Mount Pleasant has a rec center, too.

It’s a reasonable county to use as a sample for exploring rural challenges when it comes to mental health and teen suicide. While it's not too far from urban centers, residents still stretch to find professional help for their children and sometimes for themselves. It has the pockets of poverty, unemployment and transportation woes common to rural living. When someone dies, communities are rocked.

This happened in a big way in 2011, when Sanpete County experienced suicide contagion firsthand: At least 14 residents of various ages killed themselves. If you don’t live there, it’s hard to count how many of them were teens because of privacy issues and government reporting rules. But just last year, two young Gunnison males — one 13 and the other 14 — killed themselves, independent of each other. And Wimmer, the Gunnison resource officer, says he’s gone looking for youths after receiving “farewell” messages about five times in the four years he’s lived there.

Experts say too few mental health specialists practice in rural communities. “We always end up circling back on a lack of workforce ... and essentially a lack of transportation from rural areas to where they can receive care,” says Paul Mackie, president of the National Association for Rural Mental Health.

Roughly 90 percent of practicing psychiatrists and psychologists and 80 percent of clinical social workers are in urban areas, he says, and there aren’t many specialists or therapists in rural communities. Nor does everyone have insurance — or insurance for the available provider.

As for distance, many Gunnison residents travel just to buy groceries: It’s a half-hour to the Ephraim Wal-Mart. Specialized care of almost any kind is farther still, with far-bigger Provo a couple of hours away and Salt Lake City 45 minutes past that. Seeking mental health help in one of those cities would mean a parent taking a full day off work and his or her teen missing an entire school day, in addition to the cost of gas and child care for younger siblings.

It’s a nearly impossible task for a Sanpete parent earning $20,000 a year and driving a car that barely makes it to work, says Kris Lundeberg, a social worker at Sanpete Valley Hospital in Mount Pleasant. Many who do see an urban mental health specialist soon stop because of the daunting logistics and expense.

Some experts blame other uniquely rural cultural factors for discouraging people, including young people, from getting help. Attitudes that encourage individuals to “cowboy up” and “pull yourself up by the bootstraps” are not conducive to seeking therapy. Stigma and shame stymie it. Brian Whipple, CEO of the CUCC in Ephraim, says a friend once refused to pick him up at his office, meeting him down the block and out of sight lest neighbors wonder why his car was in front of the mental health center.

Rural residents also tend to be more isolated and experience more poverty than urban dwellers; both create significant risk of depression that trickles down through families, impacting youths as well as adults.

Research suggests high levels of gun ownership in rural areas contribute to higher suicide rates, too. A 2014 Pew Research Center report found 51 percent of rural households own a gun, compared with 36 percent of suburban and 25 percent of urban homes. The American Foundation for Suicide Prevention reports firearms were the most common suicide method in 2014, accounting for half of U.S. suicide deaths.

Gun owners are not more likely to try to kill themselves, but guns are especially lethal so there’s less opportunity for rescue, says Kimberly Myers, co-chair of the Utah Suicide Prevention Coalition and prevention coordinator in Utah’s Division of Substance Abuse and Mental Health.

Ludlow insists suicide prevention efforts won’t work unless rural counties address guns. “We’re not going to take away people’s guns,” he says, but rural parents can prevent some suicides by locking up their guns or separating bullets from the guns.

Other experts are unsure of a correlation between culture and higher rural suicide rates. Mackie points out some urban areas have high rates of poverty, isolation and gun ownership without increased suicides.

Age of uncertainty

Teen suicide rarely results from a single event; it is often preceded by a complex tangle of factors.

The teenage brain is a work in progress, powerful and unpredictable. It isn’t fully developed until one’s mid-20s. While the National Institute of Mental Health says a teen’s brainpower may never be greater, it adds the brain sections that control impulse and planning ahead — “hallmarks of adult behavior” — mature more slowly. Not only can’t youths plan ahead; they have trouble even seeing ahead. They have not yet survived a few breakups or bad grades or disappointments. Problems mature adults shrug off seem life-shattering. Meanwhile, hormones drive relationships. It’s a mixed-up time.

Experts who study teen suicide say a variety of factors, including pressure to excel, bullying, mental health conditions such as anxiety, a parent’s problems — and problems getting along with parents — all add to a teen’s sense of being overwhelmed or lost. And Ludlow notes youths often lack language skills to express distress. “If we’re not communicating on their level, we’re sending mixed signals,” he says. “If you can’t look at an adolescent and say, ‘This kid is suffering,’ then we’re in trouble.”

Nathan Strait, clinical director at CUCC in Ephraim, says studies repeatedly show a sense of being a burden plays a large role in teen suicide. The thought “It would be better if I were dead” makes so much noise teens miss what others try to tell them: “I love you. I would hate to see you do that.” A sense of burdening others weighs youths down so much that Myers considers it the most significant suicide risk, alongside a “sense of thwarted belongingness.”

“As human beings we need to belong,” says Myers. “You don’t belong if you don’t have a place, purpose or community.”

Mental illness is often involved, too; depression is a risk factor, Strait says. But Bryan suggests thinking of depression as an iceberg’s tip: One can see depression and mood disturbance in suicidal individuals, but the bulk of their problems lies beneath the surface. He says most people who attempt or die by suicide have difficulty with emotion regulation or problem-solving. Confronted with a stressful situation, they can’t generate options. Lack of options can lead to depression or to substance abuse, but often those are just symptoms of a perceived inability to improve difficult situations and manage negative emotions.

Small world

Kids enter and leave the main office at Gunnison Valley High School through a door beneath the stenciled words: “If you don’t know where you’re going, you’ll end up someplace else.” Inspirational or humorous words are etched on plaques throughout the room, including the reminder that the deadline to complain was yesterday. Students pop in and out, asking the women behind the counter questions, an air of easy familiarity apparent.

Close to 340 students are Gunnison Bulldogs, coming from five communities to attend the school, which boasts a 17-to-1 student-to-teacher ratio. When the Deseret News visited in early November, teens were buzzing in tight clusters about everything from an upcoming football game to the prospect of Donald Trump pulling off the election. A few of them high-fived a teacher passing in the hallway. They exhibited a similarly casual rapport with Wimmer, walking into his office unannounced.

Tightknit rural communities can offer teens warm inclusion or lonely isolation, depending on whether a kid finds friendship among small peer groups. Mackie describes strong, “informal helping networks” bound by family, church and community ties that quickly rally when someone needs support in small towns. Relationships can be tremendously comforting and protective for one experiencing suicidal thoughts, or they can lead him to avoid seeking treatment because neighbors might see, creating what Mackie calls a “culture of quiet.”

The fact that adults may regularly assume different roles in small towns takes on different meaning for youths who suffer mental pain. It is a fact of rural life that a math teacher may also teach kids ballroom dancing and their coach could be their church youth leader, says Manti High counselor Kris Pogroszewski.

Ludlow sees intricate webs of connection as “both a hindrance and a help.” Some people won’t seek therapy from him because they know him, while others seek him precisely for that reason.

Religion is another helpful-hurtful dichotomy, the “big elephant in the room” in discussions of suicide in rural Utah, says Carl Cox, counselor at Gunnison Valley Hospital. Most Sanpete residents are members of The Church of Jesus Christ of Latter-day Saints, and research shows that strong adherence to any religion can help deter suicide. But it’s not always helpful.

“Being LDS is a wonderful thing,” Cox says, “but a lot of problems come with that because everyone feels they should be perfect.” Depression and discouragement can haunt those who feel they fall short of religious ideals. Plus, the suffocating feeling of being monitored in a small town is heightened when neighbors track whether you were in church. Something as simple as handing out party invitations at church can leave out the kids who don’t worship there, an unintentionally painful oversight.

Wimmer believes religion bites hardest the Sanpete teens who aren’t practicing Mormons. He says the kids he’s seen struggle most are those who feel like “an outcast.” They may not be intentionally excluded by Mormon peers, but their feelings of rejection are real and painful.

First line of defense

Wimmer knows each kid at Gunnison’s schools by name and estimates half the students at Gunnison Valley High have his cellphone number. “Nowadays, the vast majority of kids who are having depression issues, suicidal issues, drug problems, whatever — they will come to me.”

Coby Hazel and his mom, Jackie Peacock, in Gunnison, Utah, on Nov. 9, 2016. | Lois M. Collins, Deseret News

Jackie Peacock, whose 13-year-old son Anthony killed himself last year, says “kids go to (Wimmer) with their problems, even if it’s just to be like, ‘I’m having a bad day.’ He listens.”

Wimmer is part of the front-line safety net for suicidal teens. Along with a few significant adults and schools, peers are also important.

Carra Ward, prevention specialist at Snow College in Ephraim, says 87 percent of those ages 10 to 24 talk to a friend about suicidal thoughts before going to school counselors or mental health professionals. Pogroszewski reports that two-thirds of the time, struggling students come to her office because friends suggested it.

Because students are a powerful resource to suicidal youth, all three Sanpete high schools have Hope Squads — groups of students nominated by peers and trained to identify at-risk students, provide friendship and seek help from adults.

Sometimes, individual youths become outspoken advocates for the mental health of peers. That’s how Addie Brotherson chose MISS Addie’s Team as her platform for Miss Utah's Outstanding Teen: MISS is an acronym for Mental Illness Silently Suffering.

Addie says her father’s childhood anxiety inspired her to focus on mental illness. After a truck ran him over as a kindergartener, Jared Brotherson experienced hearing and vision problems that, combined with his vivid red hair, led to merciless teasing. The bullying became so intense that as a second-grader, Jared tried to jump from a moving vehicle to avoid attending school.

By high school, he suffered panic attacks, so he quit the sports he loved. “He didn’t know what he was suffering from, so he was suffering silently,” Addie explains.

She speaks statewide at school assemblies and church groups, informing teens that mental illness is actually quite common and encouraging them to feel comfortable seeking help. She talks about bullying, too. She’s experienced it herself.

Like Addie, when NcKisha Ford, 14, sees something that could be a warning sign of suicide — like isolation, self-harm (which may not reflect suicidal intentions) or behavior changes — she asks flat-out: “Are you thinking of killing yourself?” She’s learned from her mom, Renna Ford, who works for the American Foundation for Suicide Prevention, and prevention talk is sometimes dinner-table chatter in their Richfield home.

Experts say asking that single question signals one is willing to have a frank, nonjudgmental conversation and opens communication.

Read more about how to talk about suicide.

Stronger together

When the Deseret News asked Gunnison school counselor Andy Peterson for help understanding how teen suicide and rural communities intersect, he did what professionals in Sanpete County have done for quite some time: He got a group of them together. They packed around a table in a small conference room at Snow College: counselors from Gunnison and Manti high schools, a prevention specialist from Snow, a social worker and therapist from two area hospitals, and a student intern from Gunnison.

They didn’t need to introduce themselves to each other, the conversation flowing easily from a shared community. Even though they represent competing institutions, the group often works together for the sake of struggling teens.

They review the interventions that have been tried and the impacts made. One collaboration is Sanpete Children, Adolescents, Resources Enhancement Services (Sanpete CARES), a subcommittee of Sanpete Behavioral Community Health Network comprising various community partners, some at the discussion, some not. They connect youths and their parents with mental health providers and funding resources and educate the community on issues like suicide prevention.

Gunnison Valley High Counselor Andy Peterson demonstrates how students use their iPads to access grade information during a school day in Gunnison on Nov. 22, 2016. | Nick Wagner, Deseret News

Peterson is excited about another program that lets students at Gunnison and Manti high schools experience Snow College and picture themselves in college. Students are paired with mentors who guide them through a day of college life, attending classes, talking with administrators and visiting the dorms.

Peterson says many students who participate are those with middling grades who lack academic support from parents. The experience “gives them hope and resilience,” which he insists helps prevent suicide.

Several people around the table recall a funeral that was decidedly different. Instead of glorifying a teen who had died by suicide, a father talked to the kids in the audience about how tragic and unnecessary his son’s death was, how it cheated his family, his friends — and himself. It was a message about choosing life.

There are other interventions, too. Intermountain Healthcare is tackling the distance challenge with crisis counseling via a high-definition telehealth connection to 11 rural Utah medical facilities. Someone in crisis can go to the emergency department that has the equipment, where staff notify clinical operations manager Jason Cox in Salt Lake County to turn on the remote-site closed-circuit television. Within minutes, a skilled clinician can assess if the individual is safe to go home or needs more intensive care, then help arrange it.

Hope and resilience

Teen suicide is complicated, rural or urban, and we don’t yet understand all the contributing factors, but we know it’s preventable. One common warning sign is behavior changes, says Andrea Hood, Utah Health Department suicide prevention coordinator. If teens suddenly become withdrawn, lose interest in activities they once enjoyed, or begin making comments about feeling helpless, hopeless or worthless, they may be at risk.

A sudden switch from sadness to appearing happy or calm is another little-known yet critical warning. When suicidal individuals settle on a plan to take their lives, they often feel more at ease because their period of painful indecision has ended.

Peacock saw that seemingly positive change in her son Anthony. Shortly before he killed himself, he became “the perfect child.” She realizes now Anthony had made his decision.

Read more about recognizing and addressing warning signs of suicide.

Helping suicidal kids find hope and cope with problems often requires helping them envision a better future. Strait recommends parents always give their children something to look forward to, whether it’s an upcoming trip or an afternoon hike. Wimmer tries to encourage kids burdened by poverty or family dysfunction by explaining education can change their lives.

For most teens fighting thoughts of suicide, recovery combines a delicate balance of maintaining hope for the future while approaching challenges one day at a time. If discouraged teens fixate on every future goal, they often conclude they will never achieve them.

Ludlow tells kids to “focus on the test you have today. Focus on leaving this assembly and going to football practice or band practice. You don’t have to win the Super Bowl or marathon right now; you have to take two steps forward every day.”

Moving the needle

Legislators and policymakers have a big role in suicide prevention but must often choose to shift resources from something else that’s important.

Hood says all Utah secondary schools have a small amount of funding for suicide prevention; many choose programs like Hope Squads and Signs of Suicide. Existing efforts need more funding and prevention experts would like to add programs, Hood says, such as those that teach suicide’s warning signs and how to help responsibly. Prevention experts also long to see suicide and depression screening in schools, but privacy issues often get in the way.

“It’s expensive upfront, but you save when it comes to emergency care, lives lost and damage to families,” Hood says.

On her list of “incredibly helpful” future actions is expanding mobile crisis services into rural areas. A trained community crisis team of a clinician and someone who’s had a personal mental health challenge “is really powerful and people respond really well to that.” Drop-in crisis centers where someone could see a specialist instead of visiting an emergency room would also help. An early intervention gap due to inadequate funding is teaching kids social and emotional coping skills, which has the added benefits of less criminal or anti-social behavior and a boost in academic success, Hood adds.

Fortunately, the stigma surrounding mental illness in rural areas may be gradually lessening.

When Lundeberg moved to Sanpete four years ago, he often manned booths at health fairs and heard parents, after reading “suicide awareness” on his whiteboard, instruct their children not to talk to him. The community seems significantly more open to discussing the topic today. At a recent health fair, a parent said it was great to see someone bringing attention to suicide.

It’s the silent suffering that Addie Brotherson finds unbearable. So she talks to friends and strangers alike and hopes they'll talk to others. When you break the silence, things get better for everyone.

Email: lcollins@deseretnews.com, lfields@deseretnews.com; Twitter: @loisco, @lfieldsa