In a small rural community you know everyone and their story, says Steve McCullough, who’s spent the past 15 years as an administrator for the sole pre-K-12 public school in the tiny northeast Washington town of Curlew. He’s seen students and their families struggle with poverty, unemployment, mental illness, substance abuse and other risk factors for suicide. As in most rural areas, it’s easy to access a gun but hard to get help for—or even talk about—issues related to suicide or mental illness.

Experts link all these factors to higher suicide rates in rural areas. Nationally, all of the states with highest rates of suicide have many rural counties, says Sigrid Reinert, Washington State Department of Health suicide prevention specialist. For young people between the ages of 10 and 24, death by suicide is twice as common in rural America as in urban areas, according to a recent study.

Washington is no exception. Eleven of its 31 rural counties (those with 100 or fewer people per square mile) have rates higher than the statewide rate of 14.7 per 100,000 residents, according to Reinert. By contrast, the rates in Snohomish, King and Kitsap counties all are below the state average.

Challenges and opportunities

Rural counties have many challenges, but also some unique opportunities for suicide prevention. In particular, Reinert cites a spirit of cooperation and looking out for one another that she rarely sees in urban areas. The Suicide Prevention Resource Center (SPRC) praises that culture of shared responsibility and concern as “fertile ground for building prevention practices” in its recommendations on Preventing Youth Suicide in Rural Areas.

Efforts are underway throughout the state—and elsewhere—to leverage the opportunities and overcome the challenges. Forefront recently received a $100,000 Pooled Fund Grant from the Washington Women’s Foundation (WWF) to expand its outreach to under-served parts of rural Washington over the next two years.

Matt Taylor, Forefront’s new executive director who recently moved to Seattle from Montana, is pleased by the opportunities the grant creates. “There are good initiatives underway in Washington, from the work of the Spokane-based QPR Institute to grassroots coalitions to state-funded outreach.” Taylor feels that the grant’s comprehensive approach represents a unique addition. “Our work will complement these activities because in underserved, rural communities a multi-pronged approach that touches on issues of prevention, policy, multi-agency response, advocacy and bereavement support is key.”

Forefront’s team approach

Under the WWF grant, Forefront teams will travel to six high-need rural areas over the next two years. They will work with local professionals, community members and individuals affected by suicide to build a comprehensive and sustainable suicide prevention program.

Reinert and McCullough praise Forefront’s plan to send trainers to communities where local resources are scarce and training opportunities are hours away. Among its numerous objectives, the grant will enable teachers and health-care providers to fulfill their state suicide prevention training requirements without taking time out for travel.

The grant also provides suicide alertness professional development for schools, targeted outreach to parents and mental health first aid training for both schools and community groups. It will provide enhanced grief support for those affected by suicide, and offer advocacy training to help people safely share their personal stories of loss and recovery, and explain the importance of prevention to legislators and journalists.

“There’s so much need for education in the community to break down the stigma around suicide and mental health treatment,” says McCullough, who makes a point of speaking openly about his own loss of a grandfather, uncle and brother to suicide. “I’ve told the story to lots of families and kids, and it’s been very powerful.”

Now starting as superintendent of the slightly larger Tonasket School District in north central Washington, McCullough is enthusiastic about having a mental health expert on school grounds so that students and, he hopes, parents can access services on the spot. One of the down sides of everyone knowing everyone is that people worry about being seen going into a behavioral health clinic, says Reinert, recalling people’s reluctance to park outside her counseling office in Morton, a small logging town in southwest Washington. McCullough has known families to drive to the next county for behavioral health care in order to preserve their anonymity.

Primary care

For many, a primary care provider is the logical alternative. In fact, according to the Suicide Prevention Resource Center’s Guide for Rural Primary Care Providers, more than 75% the people who die by suicide have visited their primary care doctors within the month prior to their death and they were more than twice as likely to see this physician than a mental health professional. In some rural communities, the Collaborative Care model of integrated care developed at the University of Washington enables treatment for basic mental health issues in primary care settings. Under this arrangement, a psychiatrist or other mental health professional confers by telephone and thus can provide services across a wide geographic range.

Last year Washington became the first state to require suicide risk assessment and prevention training for all primary care providers. A related bill passed this year requires the trainings to include information on how to talk to patients and families about keeping guns and stockpiles of prescription drugs away from people in crisis. Paul Quinnett, Forefront advisory board member and founder of the QPR Institute, noted on a recent Seattle Public Radio interview that gun safety in times of emotional crisis is critical and is not to be confused with the controversial issue of gun control. Similarly, according to Seattle pediatrician and injury prevention expert Fred Rivara in a May 2015 editorial in JAMA Pediatrics, lock boxes and other devices could reduce youth’s deaths by suicide and unintentional injury by as much to 70 percent.

Grief support training

Silence and scarcity of services also add to the hardship for people newly bereaved by suicide and grappling with the complicated feelings and questions that go along with this “grief like no other.” To that end, rural outreach through the WWF grant will include training and support for individuals who are ready to share their own experience and growth by serving as Forefront Cares peer telephone supporters.

Guellermo DeHollander, who lives outside Ellensburg in Kittitas County, speaks gratefully about the difference peer phone support has made for him. When his 18-year-old son died by suicide, the grieving father’s rural community rallied around, but he still needed help with his pain and questions. His small loss survivors’ support group dissolved after six sessions, but he found a deep and relevant connection with a Forefront Cares peer phone supporter who also had lost a son to suicide. “We were very close in experience.  It meant a lot to be able to talk with him,” DeHollander says.

“Suicide is often about isolation.” Taylor says. “Rural communities know that feeling, but they also know how to pull together in times of need. Our job at Forefront is to help provide training that complements and builds on local knowledge and which also facilitates opportunities for individuals to rally together, support one another, improve information sharing and advocate for change.”