45August 19, 2019rugged self-reliance. Although the mindset certainly has its
virtues, Dickson has learned that few of them intersect with
the world of mental health care. The prevalence of the atti-
tude is one reason her office is in a multi-use building and not
a standalone structure, so her patients can park their cars out-
side without giving away that they’re seeing a shrink. It’s also
why the Glendive Medical Center psych unit, during those
rare times when it’s operational, allows outpatient clients to
enter through the back door, where their friends and neigh-
bors are less likely to spot them. “Most people I know would
tell people they have chlamydia before they’d tell someone
they had a mental illness,” Dickson says.
The man who said he doesn’t believe in mental illness was
a farmer, the line of work that still drives eastern Montana’s
economy. The region doesn’t get much rain—10 to 15 inches
a year, about a third of the national average—making agricul-
ture a nerve-shredding business. “It’s tough,” Dickson says.
“People tend to drink a fair amount of alcohol when you don’t
have many other sources of entertainment. Everybody has
guns. You get the stress of a poor crop, of tariffs, and you can’t
sell your wheat for what it costs to put in the ground. Cattle
prices may or may not be good. The bank’s knocking at your
door. Your kids are moving away because of brain drain. So
people a lot of times tend to deal with it with a single bullet.”
Money is always high on the list of mental stressors, and
more often than not, when people list possible causes for the
spiking of the suicide rate, the economy dominates the discus-
sion. Since the Great Recession of 2008, the nation’s economic
recovery has been concentrated in what the Department of
Commerce defines as metropolitan areas—counties with a
central city of at least 50,000 and the neighboring counties
that are economically dependent on them. According to
David Swenson, an economist at Iowa State University who
specializes in analysis of the rural economy, these urban-
ized zones make up about 36% of all U.S. counties, but they
enjoyed almost 99% of all job and population growth from
2008 to 2017.
“There’s more and more farm stress, and imagine if that’s
your livelihood,” says former Democratic Senator Heidi
Heitkamp, who represented neighboring North Dakota from
2013 to 2019. “It may be something you’ve been doing for your
whole life—it’s not like you can just go out and look for another
job running another farm.” Heitkamp this year co-founded
the One Country Project, which aims to increase political
engagement with rural communities, and she believes rural
mental health, particularly among seniors who feel isolated
and alone, has become a crisis. “There’s the stigma, but the
solution to that is to embed mental health into health care,”
she says. Offering basic behavioral health services at commu-
nity health centers is one way to do that, she says. “And more
primary-care physicians are starting to be trained to do more
behavioral health.”
It’s not just doctors. Across rural America, agricultural
extension offices have begun providing basic mental health
training to rural lenders, farm-equipment dealers, and other
agricultural professionals to teach them to recognize and
respond to symptoms of depression among their clients.
The internet might collapse distances and make the world
smaller, yet sometimes it feels like the opposite applies in a
place like Glendive. About a century before Amazon.com, the
Sears, Roebuck catalog was a retail lifeline for rural America.
But throughout most of those decades, small, far-flung com-
munities generally could depend on at least a few local retail
outlets to provide the basics. That’s not always true today. In
2017, Glendive’s last department store, a Kmart, closed, part
of a nationwide constriction blamed on the rise of internet
retailing. That closure meant the closest general retailer was
a Shopko in Sydney, about 50 miles away. In June, Shopko
Stores Inc., a discount chain with stores in 24 states, went
bankrupt, abandoning all of its locations.
The day after Shopko folded, a few of the therapists in
Glendive’s branch of the Eastern Montana Community Mental
Health Center—where Dickson serves as medical director—
speculate that the news would add a little more stress to the
lives of the people they see. “All the Shopkos are going down,”
says Pam Liccardi, the clinic’s substance abuse counselor,
shaking her head. “Every one of them.”
“So now we don’t have a place to go to buy clothes,”
observes Al Heidt, a retired therapist whose wife, Cindy, still
works at the facility. “You can’t buy underwear in Glendive.”
“Well, yeah, you can,” Liccardi says. “At the hardware
store. If I was willing to wear men’s boxers, I’d be in business.”
There’s still Amazon, of course, and a resale shop down-
town. But consider the added pressure the closures put on