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Supporting Mental Health in Missoula

In Missoula, the Riverwalk Crisis Center plays a vital role in providing compassionate care to adults experiencing mental health crises. We sat down with Dr. Ann Douglas, the center’s Director, to learn more about the services they offer, the impact of their work, and their vision for the future.

About the Organization

Q: Can you introduce yourself and give an overview of the services Riverwalk Crisis Center offers?

Dr. Douglas: I’m Dr. Ann Douglas, Director of Riverwalk Crisis Receiving Center. We are a voluntary crisis receiving center for adults aged 18 and older. Our role is to provide immediate support for individuals who define themselves as being in crisis, whatever that crisis may be. Our focus is on helping guests stabilize and then connecting them with community resources for ongoing support.

Q: What are the criteria for being seen at Riverwalk?

Dr. Douglas: The only requirement is that the individual be 18 or older. Beyond that, anyone who feels they’re in crisis can come to us for help. It’s entirely self-referral, based on how the person feels.

Q: Can you walk us through the process when someone arrives at Riverwalk?

Dr. Douglas: When someone arrives, they’re greeted by our security specialist, who provides an orientation and explains the behavioral norms. From there, they meet with a nurse for a general medical assessment to ensure the crisis is not a medical emergency. If everything checks out, they work with a mental health professional to create a treatment plan, focusing on their strengths and using culturally appropriate care to empower them through the crisis.

Q: What makes Riverwalk unique in addressing mental health crises?

Dr. Douglas: The environment sets us apart. Our facility is designed for those in mental health crises, and we prioritize empathetic care. We have the time and space to truly listen to our guests and tailor our support to their needs, creating a calm, open, and supportive atmosphere.

Q: How long can a guest stay?

Dr. Douglas: Currently, we’re open 12 hours a day, from 9 a.m. to 9 p.m., seven days a week. Guests can stay for those 12 hours. Once we expand to 24/7, guests will be able to stay for up to 23 hours and 59 minutes.

Collaboration & Impact

Q: Riverwalk was the result of a community effort. Can you talk more about the collaboration that made this possible?

Dr. Douglas: Absolutely. Riverwalk was developed through the Behavioral Health Strategic Alliance in Missoula. Key partners included Providence, Western Montana Mental Health Partnership, All Nations Health Center, Community Medical Center, the Mobile Support Team, and 988 Lifeline. Together, we recognized the need for a receiving center where individuals could access short-term stabilization that wasn’t the ER or jail.

Q: Can you share a success story from Riverwalk?

Dr. Douglas: There are many stories. For instance, we’ve had guests who, after a few hours with us, leave visibly calmer and more in control. We’ve also connected people to services they’ve struggled to access for months. The combination of compassionate support and tangible resources makes a real difference.

Q: How do you measure the effectiveness of your interventions?

Dr. Douglas: We follow up with every guest 72 hours after discharge through an exit survey. This allows us to track their progress and gather feedback on how we can improve our services.

Challenges & Opportunities

Q: What challenges does Riverwalk face, especially with the current 12-hour operational window?

Dr. Douglas: I think the 12-hour limit is currently the greatest challenge. My goal is to get to a 24/7 model. Additionally, we need more staff, especially nurses and LPNs for night shifts. In regard to funding, we need to secure more grant funding to ensure we can provide care without financial barriers for guests. We currently bill Medicaid as well as private insurance, but I want people to know that if they cannot pay, they will not be turned away. 

Q: What are your funding sources, and how is Riverwalk structured?

Dr. Douglas: Riverwalk operates under Western Montana Mental Health’s license, with Providence covering my wages and Western funding the rest of the staff. Missoula County provided initial funding for the building renovation, but moving forward, we will continue to rely on Medicaid reimbursements, private insurance, and grants.

Q: Where does the state fit into the picture in terms of supporting Riverwalk?

Dr. Douglas: The state plays a role through Medicaid. We operate under policy 450, which governs Medicaid reimbursement for receiving and stabilization services.

Q: Montana has been in the national spotlight due to its high suicide rate. Do you think the state could help address service gaps in facilities like Riverwalk?

Dr. Douglas: Absolutely. Increased funding and awareness would be incredibly beneficial, particularly for suicide prevention. Our center plays a critical role in intervening at the stage of suicidal ideation, helping people before they reach the point of an attempt. Expanding receiving centers across the state would not only improve outcomes but also help destigmatize mental health treatment. When people see that mental health facilities like ours exist, it sends a message that it’s okay to seek help.

Q: Is Riverwalk the only facility of its kind in Montana?

Dr. Douglas: No, Riverwalk is the second of its kind in the state. The first is the Billings Crisis Center, which has been operating for about 17 years. I’ve worked closely with MarCee [Neary], the director there, and she’s been doing incredible work in this field for a long time.

Looking Forward

Q: What are Riverwalk’s future goals?

Dr. Douglas: Our primary goal is to expand to 24/7 operations. This would help us reach more people in crisis and make our services sustainable long-term. We’re also exploring the possibility of opening a crisis receiving center for youth, as this is a frequent request from the community.

Q: Is there anything else you’d like to share about Riverwalk’s role in mental health crisis intervention?

Dr. Douglas: Just that Riverwalk wouldn’t exist without the community’s support. We’re here because Missoula saw the need and worked together to fill it. Our mission is to be the calm in the chaos for those in crisis, and we’ll continue to grow and adapt to meet the community’s needs.

New Crisis Receiving Center Opens in Missoula, Montana

Montana’s suicide rate has been the highest in the U.S. for the past three years. Most of the deaths involved firearms.
But suicide rarely registers in the national debate over guns.

{In Montana, a state of 1.1 million people, 955 people died by suicide from January 2021 through November 2023.}

By Michael Corkery
Photographs by Tailyr Irvine
Reporting from Helena, Montana
Published June 10, 2024, Updated June 14, 2024 (New York Times)

On a typical day, Ali Mullen races from her job at the county health department in Helena, Mont., to pick up dinner for her three children, heads home to feed them and then goes back out for a violin lesson or a school play, crisscrossing the small city in her aging S.U.V., with a rainbow bumper sticker that reads “You Are Loved.”

A big pack of gummy bears keeps her going, stashed in her handbag next to a different sort of lifesaver: a gun lock that she carries almost everywhere she goes.

In a sparsely populated state where many people own firearms, the small metal contraptions, which fit around a trigger and cost less than $10 on Amazon, are one way Montanans are trying to reduce the high rate of people who kill themselves.

For the past year, Ali, 46, has been giving gun locks away to anyone who wants one, her piece of trying to solve the puzzle of suicide in Montana. “It’s in the culture,” she said one afternoon in Helena. “If you don’t know someone, you know of someone who has died.”

Murder rates and mass shootings make national headlines, defining the discussion over pervasive gun violence. But most gun deaths in America are self-inflicted. There were about 27,000 gun suicides in 2022. That was a record, and far higher than the 19,500 gun homicides documented that year.

There have been more gun suicides than gun homicides in the United States every year for the past 25 years. Yet the harm inflicted on communities by suicides rarely registers in the national debate over guns.

Over the past three years, Montana’s typically elevated suicide rate was the highest in the nation, according to an analysis of federal mortality data by The New York Times. In a state of 1.1 million people, 955 people died by suicide from January 2021 through November 2023. Other states in the Mountain West, including Wyoming and New Mexico, have also struggled with high suicide rates and face many of the same challenges as Montana.

Last year, suicides in Montana and the nation declined to near pre-pandemic levels. But the rate of suicides in Montana remained one of the worst in the country, and a source of widespread grief across the state.

Many of these deaths are felt but not seen. Suicide, despite its frequency, can still be steeped in secrecy and shame. The deaths often come after a struggle with mental health issues or substance abuse.

Suicidal impulses can last only briefly, but easy access to a gun makes the urges more difficult to survive. In Montana, 67 percent of suicides in 2022 involved a gun, according to the Times analysis. Nationally, guns were used in about 55 percent of such deaths.

But in a place where guns are embedded in the rugged, frontier ethos, there is little political will to prevent people who are at risk of harming themselves from owning a gun. A proposal to create a “red flag” law, which would prohibit a person determined to be a danger to himself or others from possessing a firearm, died in a committee of the State Legislature last year.

Several years ago, Ali’s husband’s family passed down some firearms that were considered heirlooms, and she agreed they could be stored at her house.

At the time, suicide did not cross her mind.

***

The first time Ali drove through Montana, she was in college on a road trip in the late 1990s. She remembers how the clouds cast giant shadows on the open plains, revealing the state’s “Big Sky.”

She was hooked.

She transferred to the University of Montana from a college in Illinois. After graduation, she worked as a 911 dispatcher in Glacier National Park, fielding calls for “bear-jams,” when traffic would stop because a grizzly wandered out into the middle of the road.

John Mullen was working as a handyman at what is now the Whitefish Mountain Resort when they met.

They married in Glacier. A pair of bald eagles circled overhead as they exchanged their vows. “It’s the greatest place on earth,” she said of Glacier.

After their first child, a daughter, was born in 2006, they moved to the Helena area to be closer to John’s parents.

The vice president of a community bank took a liking to John and hired him as mortgage loan officer. He was a natural, tapping his connections across greater Helena where he had lived since he was a boy.

Montana is a vast state. Yet, somehow, Ali said, it could feel intimate.

“Montana is a string of small towns connected by one or two highways,” she said. “We all know each other.”

But that closeness can also amplify the fallout from suicides.

Research has shown that 135 people can be “exposed” to a single suicide and that some of those closest to the person who dies can be at greater risk of contemplating suicide themselves.

“There is a lot of strength in a small-town structure, but the downside is that if you lose one person to suicide, it can have a large impact on the community,” said Janet Lindow, chief executive of the Rural Behavioral Health Institute in Livingston, Mont., which screens children for suicide risk and connects them with mental health care.

Researchers say numerous issues contribute to Montana’s suicide problem. A report by the state’s suicide prevention coordinator points to a combination of factors, including access to firearms, the isolation of rural living and the relatively large number of veterans and Native Americans in Montana, groups that have had higher rates of suicides.

The Rev. Keith Johnson, the pastor of the Life Covenant Church in Helena and a friend of Ali’s, used to avoid talking openly with congregants about suicide.

But faced with such regular deaths in the community, he now talks about the issue with middle school and high school students at his church, which is not far from the State Capitol building and blocks of Victorian homes, some dating back to Helena’s boom during the gold rush.

***

If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources. Go here for resources outside the United States.

Author: April Smith, Associate Professor of Psychological Sciences, Auburn University

Disclosure Statement:
This work was in part supported by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award No. (W81XWH-16-2-0003; ARS). Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the MSRC or the Department of Defense.

Although service members know they may lose their lives in combat in service of their country, they may not expect to lose their lives – or those they love – to suicide. A 2021 study estimated that four times as many active duty service members and veterans died by suicide as died in battle since 9/11.

Despite recent calls to action to improve suicide prevention within the military, suicide rates remain elevated among service members. In particular, active duty Army suicide rates were nearly two times higher than other active duty military services and more than two and a half times higher than the general population. Suicide rates are even more elevated in veterans, with an estimated 17 or more dying by suicide each day in 2021.

My research is aimed at identifying what drives high rates of suicide among certain groups. Better understanding what causes active-duty service members and veterans to think about and plan suicide is imperative for efforts to prevent it.

Risk factors for suicide within the military.

There are many reasons why service members and veterans may have elevated rates of thoughts of suicide and death. Notably, risk factors for active-duty service members can be different from those of veterans.

Some factors linked to suicide in active duty service members include loneliness, relationship issues, workplace difficulties, trauma, disrupted schedules, increased stress, poor sleep, injury and chronic pain. On top of these same factors, veterans may also experience difficulties transitioning to civilian life.

Additionally, service members may have an elevated capability for suicide, meaning a decreased fear of death, high pain tolerance and familiarity with using highly lethal means like firearms.

Rethinking suicide research in the military.

Increasing rates of suicide suggest that researchers need to study suicide differently in order to save more lives. Fortunately, several research advances are helping scientists rethink the way people study suicide within and outside the military.

In my lab’s recent study, we harnessed some of these innovations to study what drives thoughts of suicide among service members. We asked 92 participants to download an app on their phones and take short surveys assessing suicide risk factors four times per day for one month. Using a newer type of statistical method called network analysis, we were able to pinpoint which symptoms related to suicide risk had the greatest influence on other symptoms at one moment in time as well as over time.

Overall, we found that feeling ineffective or like a burden to others, a sense of low belonging or feeling disconnected from others, and agitation are important drivers of moment-to-moment and longer-term risk for thoughts of suicide among service members and veterans.

Increasing effectiveness and belonging.

Based on our study results, considering how the military both fosters and hinders a sense of belonging and effectiveness could help address suicide risk factors. This may become even more important as demands created by technology, such as drone pilots operating in siloed facilities, may lead active duty service members to be less connected to one another.

Additionally, some active-duty service members report task saturation – feeling like they have too much to do without enough time, resources or tools to get tasks done. They also report working an unbalanced amount of hours that precludes rest and reflection. Allowing soldiers more time to do their work and reflect on it could renew their sense of effectiveness and improve their understanding of how they contribute to overall goals.

Additionally, military leadership could find ways to prioritize and reward group-level achievements over individual accomplishments. This could lead to both increased belonging and reduced feelings of ineffectiveness, in turn reducing thoughts of suicide.

Finally, relaxation techniques, including progressive muscle relaxation, massage and gentle movement, could be beneficial in reducing agitation.

There is still much work to do to turn the tides in the fight against suicide and help those who serve and protect us. If you or someone you love is thinking about suicide, know that you are not alone and there is help. For military-specific resources, you can call 988 and then press 1, or text 838255. You can also visit www.veteranscrisisline.net.

APRIL 16, 2024 5:02 AM ET
HEARD ON MORNING EDITION
By Destinee Adams, Michel Martin, Ana Perez, H.J. Mai

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It was an early summer morning in 2018, and Alex Patrick Umble’s family hadn’t heard from him. His mother, Maura Condon Umble, thought his absence was strange, but she didn’t panic.

“I had this important meeting that I needed to go to, I thought, and so I went to work,” Maura said.

While Maura was at work, her boss was on the phone with the Director of Public Safety at a nearby college, who reported that a young man had shot himself on the school’s athletic field.

“My boss came running down the hall, but my boss didn’t tell me,” Maura said. “He just said, ‘Maura, you need to go home right now. You need to go home. Rob needs you at home.’ And my boss kissed me on my forehead, which was very bizarre.”

Once she made it home, Maura learned that the reports were about her son. Twenty-four year old Alex had shot and killed himself days after purchasing a gun.

When gun violence in America is discussed, people typically think about mass shootings, homicides or even domestic violence. But, in fact, the majority of gun-related deaths in the United States are suicides.

In 2023, more than 42,967 people died from gun related injuries. Over half of those deaths were suicides.

Alex is one of the tens of thousands of Americans who lose their lives to suicide every year.

Adam Garber, executive director of CeaseFirePA, a research group that advocates for stricter gun laws, says big cities have typically had the highest gun death rates. But that trend has started to shift. Last year, York, a small city in Pennsylvania, had a higher per capita gun death rate than Philadelphia, Garber said.

“It is really everywhere right now,” Garber said.

Every year, more than 900 people in Pennsylvania die by gun suicides and 48 are wounded by gun suicide attempts. Suicides make up the majority of gun deaths in Pennsylvania.

“Most people who make a suicide attempt are anyone of us,” Garber said. “They’re in a moment of crisis, they got laid off from a job, they go through a divorce or a bad breakup.”

Paul Nestadt, a psychiatrist and professor at Johns Hopkins University, is one of the country’s leading researchers in suicide and what leads to it. He says most people don’t know how prevalent suicide is because we shy away from the topic in our personal relationships and in the media.

“When there’s a mass shooting or homicides, there’s a lot more coverage, and of course, those are very tragic, but suicides kind of kind of slip under the radar a little bit,” Nestadt said. “There’s not as much willingness to talk about them. I think that’s changing. It becomes hard to ignore as the rates climb.”

Easy access to guns in America has also worsened the issue, Nestadt said.

Pills are more often used in suicide attempts—though most attempts involving pills are not fatal. Yet, the smaller fraction of people who use guns to try to take their lives almost never survive.

“Most suicide attempts in the U.S. are by overdose or poisoning things like sleeping pills or Tylenol or opiates,” Nestadt said. “And yet those are usually non-fatal. Only about 2% of people that make an attempt by overdose die. But firearms, which are only used in about five or 6% of attempts, are so lethal that if you happen to have access to a firearm, when that impulse comes and you use that firearm, the chance of death is 90%.”

Nestadt says the time between the impulse and act to take one’s own life is short.

“There’s a study that finds 87% of people make that decision and act on it in the same day, about a quarter of people within 5 minutes.” Nestadt said. “And so what happens in those impulsive moments is people use what they have available to them. It comes on very quickly. If there’s nothing available, the impulse can pass.”

There is another fallacy Nestadt wants to dispel.

“There’s this myth that if someone is suicidal and is thwarted in some way or is able to survive the attempt, that they’ll just keep trying, that they’ll just find some other way. But that’s not what the data shows,” Nestadt said. “In fact, the majority of people, about 94% of people who survive a serious suicide attempt continue to survive.”

As with other forms of gun violence, raising awareness around suicide means having conversations about the very sensitive and often uncomfortable topic.

And Maura is committed to talking openly about how her son’s suicide has affected herself and her family.

Maura and her family decided to disclose Alex’s struggles with depression in his obituary. She is disappointed that suicide is a taboo topic. However, she wants to hold her local government officials accountable for having these conversations, too. So, when Pennsylvania’s Democratic Lt. Gov. Austin Davis announced plans to fund a state gun violence prevention office, she realized the proposal was missing a component.

“He did not mention gun suicide as part of the issue. I was really disappointed,” Maura said.

She thinks about what she could have done and what the state could’ve done to prevent Alex’s death. And she struggles to come up with an answer.

“I have to really give myself a pep talk that, slowly but surely, we can make some progress,” Maura said. “Maybe it will help others, even if it wouldn’t have helped Alex.”

If you or someone you know may be considering suicide or is in crisis, call or text 9-8-8 to reach the Suicide & Crisis Lifeline.

To read the original article on NPR.org, click here.

By Ellen Barry

We look at promising, evidence-based efforts to prevent suicide.

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“The bridge is sealed up.” Last month, with those words, the general manager of the Golden Gate Bridge announced the completion of a suicide barrier — stainless steel netting that extends about 20 feet out from the walkway for the length of the bridge, making a jump into the water below extraordinarily difficult.

For decades, friends and family members of people who had jumped pleaded for a barrier. And for decades, my colleague John Branch recently reported, officials found reasons — the cost, the aesthetics — not to build one.

But something is changing in the United States, where the suicide rate has risen by about 35 percent over two decades, with deaths approaching 50,000 annually. The U.S. is a glaring exception among wealthy countries; globally, the suicide rate has been dropping steeply and steadily.

Barriers are in the works on the William Howard Taft Bridge in Washington, D.C., the Penobscot Narrows Bridge in Maine and several Rhode Island bridges. Universities in Texas and Florida have budgeted millions of dollars for barriers on high structures. Scores of communities are debating similar steps.

Research has demonstrated that suicide is most often an impulsive act, with a period of acute risk that passes in hours, or even minutes. Contrary to what many assume, people who survive suicide attempts often go on to do well: Nine out of 10 of them do not die by suicide.

Policymakers, it seems, are paying attention. I have been reporting on mental health for The New York Times for two years, and in today’s newsletter I will look at promising, evidence-based efforts to prevent suicide.

A single element

For generations, psychiatrists believed that, in the words of the British researcher Norman Kreitman, “anyone bent on self-destruction must eventually succeed.”

Then something strange and wonderful happened: Midway through the 1960s, the annual number of suicides in Britain began dropping — by 35 percent in the following years — even as tolls crept up in other parts of Europe.

No one could say why. Had medicine improved, so that more people survived poisoning? Were antidepressant medications bringing down levels of despair? Had life in Britain just gotten better?

The real explanation, Kreitman discovered, was none of these. The drop in suicides had come about almost by accident: As the United Kingdom phased out coal gas from its supply to household stoves, levels of carbon monoxide decreased. Suicide by gas accounted for almost half of the suicides in 1960.

It turns out that blocking access to a single lethal means — if it is the right one — can make a huge difference. The strategy that arose from this realization is known as “means restriction” or “means safety,” and vast natural experiments have borne it out. When Sri Lanka restricted the import of toxic pesticides, which people had ingested in moments of crisis, its suicide rate dropped by half over the next decade.

Arresting an urge

Other countries, like Israel, have brought down suicide rates dramatically by restricting access to guns. But in the U.S., about 400 million guns are circulating in private hands, said Michael Anestis, who leads the New Jersey Gun Violence Research Center. “We don’t know where they are, and even if we did, we would have no way of getting them,” he said.

Twenty-one states have passed red flag laws, which allow the authorities to remove firearms temporarily from individuals identified as dangerous to themselves or others. A follow-up study found that firearm suicides dropped 7.5 percent in Indiana in the decade after the law’s passage; Connecticut saw a 13.7 percent drop over eight years as the state began to enforce the law in earnest.

Another promising approach is to change gun storage habits, which Anestis likened to public health campaigns around smoking or drunken driving. He threw out some ideas, including financial incentives, such as providing gun owners with a hefty coupon for a gun safe, and encouraging gun shops to install lockers so people could temporarily store their guns outside of the home.

Even brief counseling sessions can change a gun owner’s habits, trials show. Anestis recalled one subject who was particularly dismissive of the counselor’s advice but returned six months later with a different outlook. “Since I was last here, I broke up with my fiancé and I let my brother hold my guns. If I hadn’t done that, I’m pretty sure I’d be dead,” the subject told researchers.

If you are having thoughts of suicide, call or text 988 to reach a lifeline for help.
More resources are available here.