Last fall, after years of fruitless recruiting drives and
ad placements, the center finally snagged a recently gradu-
ated psychiatrist to oversee the unit. This spring, not long after
the local newspaper celebrated her arrival, she quit. “I think
maybe it was just a little too much for someone without expe-
rience to take on, and I don’t blame her,” says Shanks, who as
marketing director is part of the recruitment team. “There’s
such a huge need out here, and I can see the burnout in mental
health providers that comes out of that.”
In much of America, and especially in places like Glendive,
mental health care is a profession defined by severe imbal-
ances. Overall demand for psychiatric services has never been
higher, yet the number of providers has been falling since the
1960s. Psychiatrists are generally paid less than other medical
doctors, they’re reimbursed by insurance companies at lower
rates for many of the same services, and they absorb more
mental stress than practitioners in most specialties. There’s
been a slight uptick in psychiatric residencies in the past five
years, but more psychiatrists are leaving the profession than
entering it, and about 60% are over the age of 55, according to
the Association of American Medical Colleges.
This is coming to a head at a terrible time. Suicide rates
across all demographics in the U.S. are rising dramatically.
Since 1999 the overall national rate has jumped 33%, and the
spike has been especially sharp in rural counties—52% com-
pared to about 15% in urban areas. Rural Americans are twiceas likely as their urban counterparts to kill themselves, and
many of the stresses they face are getting more intense. In the
past year, farm incomes have dropped, and debt levels have
risen at rates not seen since the farm crisis of the 1980s. Even
so, today about two-thirds of all rural counties in America lack
a psychiatrist, and nearly half lack a psychotherapist.
A woman who’s as intimately familiar with these dynamics
as anyone in the U.S. lives a half-block from Glendive’s aban-
doned psych unit. Her name is Dr. Joan “Mutt” Dickson, and
she was the unit’s founding director. After four years on the
job, she hit her limit. Every single night, she says, she’d get
at least two calls from emergency rooms or law enforcement
agencies scattered across the region’s 17 counties, and she’d
be expected to help them handle and harbor a troubled citi-
zen who seemed truly suicidal.
“I’m tired now,” she told the Billings Gazette when she
resigned in 2006.
After taking almost a year off to drive across the U.S.
and clear her head, she returned to Glendive and opened a
dual-specialty private practice—she’s a general family practi-
tioner and a psychiatrist. She also works 20 hours a week as
the regional psychiatrist for the Veterans Administration, and
she serves—for a salary of $1 a year—as the medical director
for the Eastern Montana Community Mental Health Center, a
network of clinics.
“If you look at a map of the United States,” she says, “I am
the only psychiatrist between Bismarck, North Dakota,
and Billings, Montana.” That’s 400-plus miles. It’s like
having one psychiatrist between New York City and
Akron, Ohio.2
GLENDIVE IS IN A STRING OF
old railroad towns that cling to the banks
of the Yellowstone River. The Burlington
Northern still comes through daily, rattling past
wheat fields and layered clay hills as it hauls coal from
Wyoming to North Dakota. Just outside of Glendive,
these hills undergo dramatic contortions, erupting into
fossil-studded buttes, natural bridges, and gumbo ped-
estals. These are the badlands.
Most small towns here conform to a template: a hard-
ware store, a Stockman Bank branch, a thrift shop, a
casino (a bar with slot machines), and a local history
museum of some sort. Glendive, with 5,000 residents,
is bigger than most and commensurately curated: It has
two full-time museums, the Frontier Gateway Museum,
built around a collection of dinosaur fossils found
nearby, and the Glendive Dinosaur & Fossil Museum,
which presents paleontology within a Biblical, creation-
ist perspective.
Follow Glendive’s main street past the museums, and
you’ll come to Dickson’s office in the center of town. Her
five-room suite shares the second floor of a 19th cen-
tury building with a stationery store, a tattoo parlor, and42
DICKSONBloomberg Businessweek August 19, 2019