‘It Just Happens Here:’ In a Perfect Storm of Risk Factors, Montanans Grapple with Barriers to Mental Health Care

MONTANA – The day Josie Libby’s guidance counselor killed himself is seared into her memory.

It was Monday, Nov. 18, 2019, shortly after classes had ended at Glacier High School. Libby was driving home to pick something up for jazz band class and got a text from her mom. Traffic was going to be bad around the overpass. Libby didn’t think anything of it.

She didn’t anticipate how bad it was. There were cars everywhere, backed up so far she couldn’t see the problem. As she was redirected, she saw ambulances.

It was the talk of class when she finally got back to school. The tension rose as the students waited for their teacher, abnormally late. 

“My mom’s friend is a first responder,” one kid said. In a small town like Kalispell, Libby believed them. “She said it was a suicide.”

A long pause, some speculation. A quiet student spoke up.

“I heard it was Mr. Avery,” he said. Every band kid’s head snapped towards him.

“Dude, that’s not funny. You don’t joke about that,” Libby remembers saying. 

Jerad Avery was the head guidance counselor and a basketball coach at the school. Students remembered him as an overwhelming force of support and care. 

The student stood his ground, and the band collectively denied it. They looked at the clock as they talked. Where was their band teacher?

Then, the door opened. The teacher stepped in, and he didn’t need to say a word. He had a look Libby had never seen on him before, like the blood had drained from his face.

At that moment, everyone knew, Libby said. Mr. Avery had died. It would be the start of a hard season of life that she didn’t know how to fix.

She hadn’t been the closest with Mr. Avery, but she knew he was important. She had friends he had helped. She couldn’t stop any of the emotion, but she could walk with her friends around the school. She took them to Target and wandered the aisles, driven by an instinct to distract and escape from where it had happened.

And if she was helping her friends, then she wouldn’t be alone either.

Avery’s death was far from the first suicide death in Kalispell, but it rocked the town. He was an important symbol for students and families. Libby began to realize that if she mourned every death like she had Avery’s, she would never be happy.

“If you fall apart because of one suicide, you won’t be able to live in Montana,” she said. “It just happens here.”

It shouldn’t be, but in Montana, suicide is almost normal.

For the past 40 years, Montana has been one of the most at-risk states for suicide, with the second highest suicide death rate in the nation in 2022 at 32 deaths per 100,000 people. That’s consistently twice the national average of 13 deaths per 100,000 people.

However, action on the mental health crisis itself has been lacking, most experts agree. Until the COVID-19 pandemic, there hadn’t been a strong central conversation about mental health driven by political and cultural action. Libby never remembered any talk of suicide or mental health until she became a student at the University of Montana in fall 2020.

    Josie Libby sits on her dorm room bed and glances out of her window that overlooks the University of Montana’s campus. (Ava Rosvold/UM Byline Magazine)
  

It’s in part due to lack of awareness and an undercurrent of stigma around mental health in Montana. Combined with several overlapping risk factors that minimize access to resources and maximize isolation, the Treasure State becomes a death trap for mental health crises.

The question is, with causes baked into the geography and culture of Montana, what can be done to stop the epidemic?

The perfect storm

Jerad Keith Avery was 50 when he died. He was born Feb. 2, 1969 in Nebraska, moving often as a child before settling near Joliet, Montana. When he attended Joliet High School, he found a deep passion for basketball. He thanked his coach for that. Weldon Amundsen was an important person in his life, Jerad’s wife Leila remembered, and he inspired Jerad to become a coach himself.

Jerad later enlisted in the Navy and served during the first Gulf War on the USS Midway. Six years of service later, he attended Oklahoma State University and earned a bachelor of arts in history-secondary education, before returning to Montana to teach and coach at Geraldine High School. That’s where he met Leila Brown, and they had two kids together.

Leila was accepted at the University of Montana’s pharmacy school, and she moved to Missoula, Jerad joining her two years later. Jerad pursued his master’s degree while assistant coaching men’s and women’s basketball, and they both graduated in 2003. He accepted a position at Flathead High School in Kalispell as a guidance counselor and transferred to Glacier High School when it opened in 2007.

He was loved as a guidance counselor and a basketball coach, his daughter Teigan Avery remembers. She was 21 years old when he died. She sees the irony.

“He wasn’t himself when he died,” Teigan said. “That day, that hour, he wasn’t my dad.”

Jerad didn’t talk much about mental health when he was home, but since his death, Teigan has become something of an advocate. 

She came to the University of Montana as an economics and political science major, and when she signed on as a golf student athlete, the theme of the athletics advisory committee was mental health. A year after her dad’s death, she gave a speech at Glacier High School to raise awareness about mental health.

She began to see cracks in the perception of mental health support.

“I think people don’t want to be seen as weak,” Teigan said. “Like, I want to help my neighbor. I’ll build their fence for them, but I couldn’t ask them to help build mine.”

The mental health risk factors for Montana, according to the National Alliance on Mental Illness, almost seem countless: social isolation, lack of access to mental health care, substance misuse, racial trauma, access to means, high altitude, vitamin D deficiency, long winters, homelessness, high veteran population, high rural population, high mental illness rates, high poverty rates, high alcohol consumption, and so on – a mix of physical and cultural factors.

Physically, there are geographical features and trends that make getting to mental health services challenging. Stretching 147,040 square miles, and with a population of just over 1.1 million, Montanans are spread far apart. 

The distance makes it hard to find, access and support mental health care. Some have to drive hours to find the first medical health care provider, let alone a mental health care provider. Without a state medical school and limited training opportunities, psychiatrists, therapists and other professionals are not coming to Montana at the rate it needs. Of the state’s 56 counties, 39 of them had no psychiatrists in 2015, according to Centers for Disease Control data.

Veterans and Indigenous people see strikingly low appropriate mental health care support for a long list of reasons, one of the most notable being incompatibility with standard western health care practices. 

Veterans often need help breaking through self-isolation, and face overwhelming financial barriers such as confusing insurance requirements. Many Indigenous tribes have their own care practices that have been shunned by colonizers or racial trauma associated with western health care systems.

Even in places where professionals are available, there’s a deep-seated stigma against seeking treatment. Some have described it as a remnant of the rancher lifestyle where being resilient was the only choice. Others have described it as being proud and not wanting to use mental health issues as an excuse.

“Everyone knows everyone,” Libby said, thinking of Kalispell. “I had no issue with it, but if someone got therapy, people would know.”

Combined with substance abuse, income struggles and other risk factors, the few existing mental health support resources looks less than ideal. There are lots of reasons someone might be struggling, Teigan said, but reaching out seems to be the hardest part. She could see some people thinking it’s just not worth the risk.

“I’m not sure people think their issues are hard enough for therapy,” Teigan said. “Or, they think their issues are too deep.”

The National Alliance on Mental Illness estimated 163,000 Montana adults had a mental health condition in 2021. 

Each completed suicide yields around six severely affected people, according to studies from the Department of Health, each of which are three times as likely to attempt suicide themselves. At around 300 completed suicide deaths every year in Montana, around 1,800 more people become at risk.

According to the National Alliance for Mental Illness, around half of the 47,000 Montana adults who needed, but didn’t receive, mental health care in 2020 weren’t able to access it because of costs. 

In 2020, 573,811 people in Montana lived in a community that does not have enough mental health professionals, and 51.3% of Montana teenagers who had depression did not receive any care. According to NAMI, 42,000 adults had thoughts of suicide. 

At least 265 people completed suicide.

$300 million pledge

The Covid-19 pandemic brought unique public attention to mental health conversations. This, combined with a lucky budget surplus at the state level, laid the groundwork for change.

Now, it’s a matter of what to do.

On May 22, 2023, Gov. Greg Gianforte pledged $300 million to mental health support through House Bill 872, $225 million to be put in a new, separate account for behavioral health networks and the remaining $75 million going to a long-term facilities fund.

“After decades of previous administrations applying Band-Aids and kicking the can down the road, we’re making a generational investment in our behavioral health and developmental disabilities service delivery systems,” Gianforte said in a July 2023 press release. “With it, we’ll expand intensive and community-based services so Montanans have access to the care they deserve.”

It was named the Behavioral Health System for Future Generations commission. Everything is still in the planning phase, and will likely remain so until July 2024. Of the $225 in a separate account, the commission needs to decide where the first $70 million will be spent in the next two years, leaving $155 million for 2025 legislators to work with. 

A commission was created of four Republican and two Democrat legislators, plus Charlie Brereton, director of the Montana Department of Public Health and Human Services; Patrick Maddison, CEO of Flathead Industries, a company aiming to provide opportunity for Montanans with disabilities; and Janet Lindow, executive director and co-founder of the Rural Behavioral Health Institute, all appointed under Gianforte.

Over the next several months, they met with experts and took comments at public meetings to determine how the money would be distributed. 

At the monthly meetings, some commenters simply started with a tearful thank you to the commission for recognizing the crisis Montana was facing. Others told stories of a lost loved one and implored the commission to use the money wisely.

However, there was a theme in some of the commenters’ statements: This money came partially through luck and circumstances. The chance to make substantial change can’t be wasted.

When it was first passed, nay-sayers wondered if a commission would be the wisest way to think about the money. Joel Peden, a public commenter representing Disability Rights Montana at the session when HB 872 was voted on, worried that people with disabilites and behavioral health diagnoses didn’t have a seat on the commission.

For the people arguably most impacted by the delicate funding decisions, it seems strange they would not make up a large portion of leadership, he argued.

Others pointed out additional voices missing from the commission — namely Indigenous people, who make up the highest at-risk group for suicidality.

However, juvenile psychiatrist Lisa Ponfick explained money is one of the biggest things holding mental health care back in Montana.

While obviously not the first monetary gift to mental and behavioral health, HB 872 stood out to Ponfick for its size and ambiguity. She’s far from a legislator, she prefaces, but she’s seen firsthand how a lack of funding has kept Montanans from critical mental health care.

Ponfick remembers working with actively suicidal children and being unable to send them to a psychiatric hospital.

“Hey, sorry, we don’t have a bed,” Ponfick would dread telling the parents. 

Additionally, every time a referral happens, there’s a risk of information loss between providers, Ponfick explained. Combined with a patient’s already delicate state, it creates a gamble that risks not only patient health but a patient’s trust in the health care system.

It’s both a lack of beds and a lack of service workers that create the scarcity, Ponfick said. When the money doesn’t support education or resources, the service dries up. Then, Ponfick explained, the families go home and they learn not to reach out for help again. She remembers a waitlist of 30 to 50 children who needed psychiatric help last year

It’s an example of how the stigma reinforces itself, she said. People are taught not to reach out because “their crisis isn’t bad enough,” she said. Even if it’s not true, that’s the message patients sometimes receive.

That’s one of the parts Teigan, Jerad Avery’s daughter, is most afraid of. 

Jerad defined his life by helping others, Teigan remembered. When she was nine, he introduced her and her brother to golf, and when he saw them swing, it was like he dropped everything to focus on them.

“You’ve got something special,” she remembered him saying. Golfing wasn’t about him anymore. It was about her and her brother.

He spent summers working with students’ schedules and futures, determined to make sure the band kids could also be in Advanced Placement classes, determined to help the slipping students apply for college and determined to help the weaker basketball player feel proud.

She knows he had a hard childhood and served in the Gulf War. She also knows he talked students down from suicide.

Looking back, she wonders if that was how her dad felt — the idea that one crisis couldn’t outweigh another.

“I think he was worried that if he couldn’t help himself, he wouldn’t be able to help others,” Teigan said. “I don’t know if he knew he could ask for help.”

Hesitation in practice

In the days, weeks and years after Jerad died, Teigan almost wished her dad’s death looked more like an accident.

It floats behind her. It comes up on dates and with new friendships. 

She doesn’t want to be the girl with a dead dad — she wants to be her own person, Teigan Avery, a smart woman living in her college town who’s good at golf and is considering a doctoral degree in economics.

It flares anytime there’s a suicide death. 

After her dad’s death, a cluster of teen suicides struck Flathead County in 2021 and 2022. She hopes it’s not connected.

The clusters scare Leila, Jerad’s wife, too.

“Until Jerad died, suicide didn’t feel like it was on the table,” she said. “I’m worried we can’t take it back.”

Leila wants to emphasize that he made the wrong decision and wasn’t a perfect person.

He could be stubborn. Jerad and Leila weren’t on the best terms in their marriage. He was kind, but they were different people when he proposed. After his death, Leila discovered there were problems at work he never told her about.

But she didn’t see any warning signs. He wasn’t giving away his possessions or speaking in extremes. It was as if nothing was wrong.

“He made an impulsive decision, and he made the wrong one,” Leila said. “He can’t take that back.”

And for Libby, a student who knew him, the days after Jerad’s death felt like they were in monochrome.

She spent her time following her friends around the school, watching for a moment she could dive in and fix the problem.

There were small moments of breakthrough. At Target, she found a ridiculous doll: a FunkoPop of SpongeBob, sitting with bulging eyes and a bizarre grin.

She and her friends gathered around the doll, and there was something about it. Through the tears, one friend burst into laughter. It was infectious and absurd. They felt something other than empty grief.

Libby said she saw color again and knew that as long as her friends were laughing, she’d be okay.

Now, she’s a senior fine arts student at the University of Montana, and she’s taken on jobs like being a resident assistant or student leader in the marching band. She describes herself as being “an emotional support human.”

Officially, she can’t talk about it, but the themes she sees in her peers are consistent: scared students who recently experienced something sad or dark or just need to talk to someone before they boil over.

“I want to keep people happy, healthy and sane,” Libby said. “Sometimes that’s making them food, and it’s also 4 a.m. chats.”

That’s what she does for herself, too, after all. When grades fall, friendships waver and life becomes overwhelming, she makes herself hot chocolate and watches a movie. She watches comfort shows like “The Muppets.” She draws or paints and is surprised when the images take a darker form than she expects.

She thinks in comfort and ignores the looming crisis until it goes away. Sometimes, her thumb will hover over a friend’s contact, and she’ll think about calling for help, opening up about what’s happening in her head.

Then, the sour guilt returns.

“Everyone has their stuff,” Libby said. “My friends need to work on theirs before I can give them mine.”

So if she does call, she invites them to watch a movie or get hot chocolate. That’s all.

“Everyone deserves a friend, and it shouldn’t always be me,” Libby said. “I’m trying to accept that not everyone will be okay.”

Libby never regrets her jobs, but she sees why it’d be hard to do forever. She can’t afford to see a therapist or be diagnosed for some of the things she knows she has. Sometimes she grieves for the people she helps long after they’ve shut her door. That’s when she thinks about her guidance counselor the most.

“I wonder who his therapist was,” Libby asked.