When Dr. Jeff Hardwig started his job as a psychiatrist in his hometown near the Canadian border, he wasn’t sure there was enough work for him.
Pretty soon, it became clear that there was, in fact, plenty of work in International Falls, Minn., a town of 6,000 people. He split his time between a group family practice and community mental health center and also saw patients in nearby communities.
“Within two or three years, it was clear I was too busy to go out of town anymore,” he said.
After nearly 30 years working as the town’s sole psychiatrist, Hardwig retired in September, leaving no psychiatrists for more than 100 miles around. His departure underscores a difficult reality: A national shortage of psychiatrists is much more acute in rural and remote areas, which leaves many people without access to the kind of services they need.
And the demand for Hardwig’s services has never let up.
Wendy Dougherty, the nurse who worked with him at the clinic, said his calendar was always full.
“He never ever … in the five years I worked with him, ever had an empty slot,” she said. “And one thing about his patients, if they called and canceled, that empty slot was filled by somebody that had been waiting two months to get in.”
But, she said, he was also the kind of doctor who would always find a way to squeeze in somebody in a crisis, even if it meant missing lunch or canceling his own meetings.
‘You take all comers’
The clinic where Hardwig worked is a primary care center on the outskirts of town, part of the Duluth-based Essentia Health system. It’s a low-slung building across the street from a Menards and a Dollar Tree that offers all the basic services, including annual checkups and mammograms.
Hardwig and others agree that the need for a psychiatrist in town was there, but until he arrived, people mostly counted on their primary care doctors to handle it.
His patients’ diagnoses over the years ran the spectrum of diseases, including anxiety, depression, bipolar disorder and schizophrenia.
“I had to take care of people of all ages — all the way through to the nursing home,” he said. “You can’t really specialize if you’re in a small town. You take all comers.”
And working in a small town, he also couldn’t avoid running into his patients frequently. It might have been hard for some doctors — psychiatry is a profession that particularly prizes its discretion — but Hardwig says he didn’t mind.
“I just had sort of an agreement with my patients if they say ‘hi’ to me, I’ll say ‘hi’ back, but I won’t otherwise out them. And my wife knew not to ask, ‘How do you know that person?’” he said.
He said his patients were respectful of him, too, and didn’t try to squeeze in consultations in line at the grocery store or when he was out to dinner.
One of his longtime patients was a man named Daniel Carr, whom I met at a clubhouse run by a community mental health center where people with serious mental illness can spend their time. The cozy house has battered couches and an armchair in the living room. A Christmas tree sparkles near the front window.
Carr, who has paranoid schizophrenia, was Hardwig’s patient for 25 years. He says he misses Hardwig.
“He knew exactly about how to treat me,” Carr said.
“I had some trouble with my medicine changing a little one way or the other, but he usually knew what was best. I’d tell him what I was experiencing and he knew what to do.”
Hardwig wouldn’t talk about specific patients, including Carr. Carr said his psychiatric care has been transferred back to his primary care doctor, and that it’s been going OK so far.
But Wendy Dougherty, the nurse who worked with Hardwig, said some of the primary care doctors have been less than enthusiastic about taking on the psychiatrist role.
“Jeff took care of the hard ones,” she said. “The schizophrenics, the bipolars … these docs kind of put up their hands and say, ‘Oh, my God, I don’t know what meds to give them.’”
The psychiatric nurse practitioner Hardwig worked with is still at the clinic and handles some of the harder cases, but she’s planning to retire soon, too.
A shortage in nearly every county
International Falls is hardly alone in not having a psychiatrist — particularly in remote areas.
More than 90 percent of psychiatrists only work in urban areas, even though more than 20 percent of Americans live in rural areas. In Minnesota, nearly every county — aside from the Twin Cities metro and Rochester area — is considered to have a shortage of mental-health professionals as determined by federal guidelines.
Hardwig said the hardest part of working in such a remote area was that he didn’t have a continuum of care to work with.
“There just isn’t that inpatient bed when you need it. We have only one crisis bed and we haven’t had that the whole time I’ve lived here. We don’t have residential treatment,” he said.
And International Falls is luckier than some places because there’s a community mental health clinic in town. (Hardwig partnered with it until his retirement, and the nurse practitioner still does.) The clinic is looking to expand in the near future. There’s also a mobile crisis team in town that can help with emergencies.
Still, recruiting mental-health care providers, even those who aren’t psychiatrists, to remote areas is challenging. Paul Mackie, a professor at Minnesota State University, Mankato, has studied the problem. And he said the only way to recruit and retain people in remote areas is to grow them from scratch. That is how Hardwig, who grew up in International Falls, ended up there.
Mackie said there are already physical medicine programs that train people for practice in rural areas. And he said now we need to do the same for mental health, too.
“We need to be a lot more thoughtful about who we’re recruiting and how we’re recruiting them,” he said. “We can have that conversation around what does a rural practitioner look like and look for that person and encourage them.”
But that takes time. People who graduated from high school this year won’t be done with medical school until 2027. And then they still have to complete their residency and any other specialty training.
So in the meantime, International Falls — and communities like it — are doing what they can. Hardwig’s old clinic has hired a child psychiatrist who sees her patients remotely over Skype-like technology.
Finding people to work on-site is proving much trickier, though. It was two years ago that Hardwig told the clinic he was planning to retire. It’s been looking for a replacement since then. But nobody has applied for the job.
The group of parents now raising tweens is the last to grow up — basically — without the Internet.
The good news is that, having received our first email addresses on dinosaur systems as college students, we DO know how the web works.
We all have Facebook (well almost all of us), plus most of its cousins. We’re hooked on getting answers to questions instantly as well as the ease of texting versus calling or — oh, please — talking face to face.
We know, too, of the web’s dark corners — limitless pornography, angry gamers, false information, lurkers and trolls.
This puts today’s parents in a crazy sort of limbo: I get it, I use it, I’m scared to death of it when it comes to my kids.
There’s also inappropriate content, predators, cyberbullying and technology addiction. And that’s not to mention the risk of growing up without knowing how to communicate verbally and always needing to know an answer or order that product — instantly, now, yesterday, if possible.
What’s a parent to do?
While you can and should limit use of the Internet in a way that’s age-appropriate and encourages other activities — such as participating in sports, reading books and playing outside — you can’t keep your child from going online forever.
In fact, complete avoidance could do more harm than good.
“Parents shouldn’t focus on instilling fear of the Internet in the child. Instead, start a conversation about technology and the Internet in today’s world,” said Karina Hedinger, a training and education coordinator for the Minnesota Crimes Against Children Task Force, a group led by the Minnesota Bureau of Criminal Apprehension.
Much like your family rules for exploring the neighborhood, true online safety comes from preparation and communication. (Check out the AAP’s new screen-time recommendations in this article’s sidebar.)
Tips for parents
Don’t freak out. Teaching your kids to fear the Internet isn’t going to keep them safe.
Do talk. Discuss the proper use of websites and what behaviors are inappropriate. Discuss the dangers in a non-threatening way.
Ask. Get your kids talking, too, so you’re not just in boring lecture mode. What do you most like to do online? What if someone online asked you to meet?
Befriend! Sure, you can have a Facebook or Instagram account … if you make me your first friend.
Be a watchdog. “Monitor, monitor, monitor. Monitor what your children are doing on all technology. Have daily conversations about being safe and keeping information safe,” Hedinger said. Be aware that you can set up “restrictions” on various devices (under Settings) to block or allow specific websites or types of content. You can also set blanket permissions based on age ranges. Also know that the top three internet browsers — Mozilla Firefox, Google Chrome and Apple Safari — offer settings and add-ons to help make your kids’ online experience’ more age-appropriate. There are even kid-safe browsers for a variety of age ranges. (See Page 33 to learn more.)
Limit locations. Keep the family computer in a communal space in the home. Insist that all phones go to charge or “rest” in a designated location at a certain time each night (not your kid’s bedroom).
Get an all-access pass. Though most parents wouldn’t read a child’s diary (at least not without cause for concern), many parents today reserve the right to read their kids’ phones each night after they’re placed in a designated “rest” location. Why? A diary is private by nature, and one might argue that everyone is entitled to his or her own private thoughts. But when it comes to living life on Instagram — where children can easily “go public” with things that perhaps should be private — the rules are bit different. Phone reading not only keeps parents involved, but it also helps kids practice better behavior (or self-censoring) if they know Mom or Dad might take a peek.
Research and explore. The list of apps you should know (and perhaps even know how to use) is honestly too long to name and goes beyond what you might think (SnapChat, Tinder, Musical.ly, Kik and the like). Did you know there are actually apps to hide apps? Yep. And there’s also a whole language developed to keep parents clueless. Deep breath. It’s going to be OK. But do study up! Talk to other parents as often as you can (ideally with kids a bit older than yours) and make friends with commonsensemedia.org, an indispensable website and app for evaluating all media.
Think beyond your home. Which friends have smartphones? Which friends use SnapChat? Would your child’s friends be willing to create an account in your child’s name to get around your rules? What are the rules at the neighbors’ house, where your kid spends half his time?
Make your expectations clear. Setting up formal house rules can help you stand firm in your decisions around digital media. Check out the new, free Family Media Plan tool from the American Academy of Pediatrics — at healthychildren.org — for help creating written guidelines for your entire family. If your child is receiving a smartphone this year for the holidays, you might want to customize one of the many mobile phone contracts online such as those at connectsafely.org and joshshipp.com as well as Gregory’s iPhone Contract written by author Janell Burley Hofmann for her 13-year-old son. Hofmann is the author of iRules: What Every Tech-Healthy Family Needs to Know About Selfies, Sexting, Gaming and Growing Up (janellburleyhofmann.com).
Tips for teens and tweens
Be discrete. The saying goes, “If you would feel uncomfortable with something plastered on a billboard, don’t share it on the Internet.” Personal information should never be shared in public forums. Turn off location services for most apps, and set them to “On While App is Running” for things that make sense, like navigation programs.
Be private. Gaining scores of fans and followers might feel like popularity — but it’s really just broadcasting a bunch of stuff that could embarrass you someday. Would you invite your whole block over to watch you lip sync in your pajamas? If the answer is “no,” reevaluate your public social media “brand.”
Know real people. You should be friends with someone in real life before being friends online. And you should spend screen-free time with your real-life friends.
Trust your gut. If something feels scary, weird or inappropriate, it probably is. If you feel tempted to hide something on a technological device from your parents, you probably shouldn’t.
Tell. If you see something inappropriate, violent, suspicious or mean online, talk to your parents or another adult you trust.
Be skeptical. It might be normal for an adult to mentor a child or teen, but it’s never normal for an adult to seek a relationship as a peer or romantic partner with a child or teen. Also note that online, a person can say they’re anyone or anything. An adult can easily claim to be 15.
Shut it down. In cases of cyberbullying, be a heroic bystander and report bad behavior when you see it. If you’re the victim of cyberbullying, shut down your device, walk away and talk face to face with someone who cares about you.
Role models and the benefits of therapy
Why Don’t Teachers Get Mental Health Disorder Training
I love teaching writing; it’s where revelations happen, where children plumb the dark corners, nudge the sleeping dogs, and work out solutions to their most convoluted dilemmas. As much as I adore reading student work, I still get a little nervous about what I’ll find there. Among the stories of what my teenage students did last summer and what they want to be when they grow up are the more emotionally loaded accounts: firsts (periods, kisses, or failures), transitions (moves, their parents’ divorces, or custody disputes), and departures (dropouts, graduations, or suicide attempts).
Over the years, my students have entrusted me with their most harrowing moments: psychotic hallucinations, sexual molestation, physical abuse, substance abuse, HIV exposures, and all sorts of self-injurious behavior ranging from cutting to starvation to trichotillomania. When students write about delicate and dangerous experiences, there are decisions to be made and judgments to be called. And yet, for much of my career, I have been horribly unprepared and have failed to secure the services my students needed as a result.
Teachers are often the first person children turn to when they are in crisis, and yet they are, as a profession, woefully unprepared to identify students’ mental-health issues and connect them with the services they need—even when those services are provided by schools. Aside from the obligatory professional-development session on mandatory reporting laws for child abuse and neglect we have to attend during new faculty orientation, teachers receive little or no education in evidence-based mental-health interventions. According to Darcy Gruttadaro, Director of Advocacy and Public Policy at the National Alliance on Mental Illness, “Most teachers are not trained about mental health in their formal education and degree programs, and yet an unidentified mental-health condition often interferes with a student’s ability to learn and reach their full academic potential.”
According to the National Institute of Mental Health, approximately one in five children currently have or will experience a severe mental disorder. For some disorders, such as anxiety, the rates are even higher. For people who do experience mental-health disorders, most experienced their first symptoms before young adulthood. Half of all people with mental disorders experienced the onset of symptoms by age of 14; 75 percent by age 24. Half of these students will drop out of school. As suicide is the second-leading cause of death among adolescents and young adults, lack of appropriate mental-health interventions and treatment can mean the difference between life and death. Given the amount of time children spend at school, teachers are likely be the ones to identify and refer children for mental-health services. For children fortunate enough to be identified and given access to those services, treatment will mostly likely take place at school, as schools serve as the primary providers of mental services for children in this country.
However, all the mental-health services in the world won’t help if teachers don’t understand the nature of the services available in school and can’t identify the students in need of intervention.
In 2011, researchers at the University of Missouri looked at whether teachers understood the 10 evidence-based mental-health interventions or resources their schools employed. The results were disheartening, to say the least. While two-thirds of the surveyed teachers held graduate degrees, and the remaining third had earned undergraduate degrees, more than 80 percent had never heard of some of the interventions or strategies their own school utilized. Half of the teachers surveyed did not know if their schools provided functional behavioral assessment or intervention planning at all. Given that the response rate for this study was only 50 percent—and it’s likely that teachers with a heightened interest in student mental health would be more likely to respond to the survey—these results probably overstate teachers’ understanding of the tools their own school districts use to support students’ mental and emotional health.
As an increasing number of schools roll out evidence-based mental-health programs such as Positive Behavioral Interventions and Supports (PBIS), teaching that promotes appropriate student behavior by proactively defining, teaching, and supporting positive student conduct, and Trauma-Sensitive Schools, programs aimed at reducing the effects of trauma on children’s emotional and academic well-being, educators need to be at least minimally conversant in the terminology, methods, and thinking behind these strategies. These programs provide strategies that can be highly effective, but only if the teachers tasked with implementing them are sufficiently trained in the basics of mental-health interventions and treatment.
Teachers routinely receive first-aid training in CPR, EpiPen use, and safe body fluid cleanup, but it’s rare for schools to offer training in mental health, said Todd Giszack, Academic Dean of Fork Union Military Academy in Fork Union, Virginia. Recognizing that schools are responsible for their students’ mental, as well as physical health, Fork Union Military Academy designed and implemented its own curriculum with the help of two mental-health professionals, and now offers eight-hour certification programs in Mental Health First Aid. “It has taken two years, but nearly all of our faculty and staff has become certified in Mental Health First Aid. This has allowed our school community to become familiar with trends and warning signs associated with adolescent emotional and mental health” Giszack said.
Dr. Michael Hollander, Assistant Professor in Psychology at Harvard Medical School and director of Training and Consultations on the 3East Dialectical Behavioral Therapy program at McLean Hospital in Belmont, Massachusetts, urges teachers to use caution when intervening in students’ mental-health crises. “In my experience, teacher response tends to be bi-modal; either they get solicitous, over-involved, and in over their head, or they mistake mental health issues for behavioral problems that require in-class discipline.”
Programs such as NAMI’s Parents and Teachers as Allies presentation are beneficial, Dr. Hollander said, because they help teachers understand both the benefits and limitations of in-class interventions. Despite his worries about teacher-facilitated mental health interventions, he’s grateful for the trend toward a greater understanding of students’ mental health. “We have arrived at a place where we finally understand that teaching is not just about educating someone’s rational mind, but also educating their heart,” he said.
Children with untreated mental-health issues can get by. They can limp along toward adulthood until an inevitable, eventual mental-health crisis lands them in the hospital, in jail, or even at an inpatient drug and alcohol rehabilitation facility for adolescents, where I teach. But by then, a lot of damage has been done to their young minds and hearts—damage that could have been prevented if they had received support when their symptoms first appeared.
As I read their essays about crippling childhood anxiety, alcoholic parents, and/or domestic violence, I can’t help but mourn for all the lost opportunities and squandered potential that was wasted on the way.
I recently saw a meme on social media that said “It’s almost time for my normal anxiety to turn into my fancy holiday anxiety.” I had to chuckle when picturing anxiety showing up in a glittery ugly sweater or draped in all things sparkly. Humor aside, it shows that during the holidays, our existing anxiety (or depression) does not just “take a holiday” but rather increases due to stress and societal pressures.
This time of year can be an incredibly stressful and frustrating time. On one hand, we fill our days to the brim with spending time with family and friends, social events, potlucks, baking, preparing meals, finding the right present within your means, and many other tasks guised in the name of the holidays. All of this “fun” can turn to chaotic quickly. Then on the other hand, some of us may have unwelcome reminders or memories associated with the holidays or feel more alone during this time as we watch others join together and celebrate. Whatever the reason for your distress, here are some helpful strategies to help manage the rise of our fancy anxiety (or depression) in finding ways to relax during the busy time of year or help with our perspective on the season.
- Self-soothe – Using all 5 senses, focus on what you notice. Cast any judgments away and focus on the experience in the moment. Here are some examples.
- Taste – slowly eat and notice different flavors in a favorite holiday treat or dish
- Smell – light a candle or smell a pine tree or cup of tea
- Sound – listen to your favorite holiday music, point our different instruments or lyrics you might have over looked
- Sight – watch the fireplace flicker with light or notice the holiday lights all around
- Touch – when baking or wrapping gifts, bring attention to the different textures you feel
- Pay it forward – doing something kind for others or contributing can make us feel good about ourselves and give perspective. This could be anything from holding a door open for someone, greeting someone with a smile, adopting a family for the holiday, or volunteering. It does not need to be a large act to bring a sense of contribution to your holiday.
- Be intentional about breaks – Set aside 15 minutes to check in with yourself and pause from all of the holiday excitement. Read a favorite book, do a meditation, sit in silence, or snuggle up with someone you love.
- Simplify and slow down – With your to-do list growing, it may feel like you need to be in multiple places at once; however, what we know about the brain is that it cannot think 2 things at once. So, focus your entire attention to the task at hand rather than jumping from task to task (aka multitasking).
- Follow traditions (or make your own new ones) – Partake in something that brings you meaning for the season, whether this be a family tradition, baking Grandma’s cookies, or finding something new to do this time of year (i.e., sledding, ice skating, driving around to see holiday lights, etc).
- Put down the phones – I know, I said it. Just hear me out. Often times social media can impact our level of stress by comparing ourselves to others, especially when those others seem to have it all together. They have the catalog ready decorations, Martha Stewarts holiday food spread, or gifts we cannot afford. This can lead us into a down spiral. So, try to limit your access to your phone and engage with those around you.
- Reach out to someone– The holidays can be a lonely time for some. Sometimes we can still feel lonely in a room full of people, feel so far away and disconnected from others, or feel forgotten. Use all of your willingness to reach out to someone or connect. Whether that be grabbing a cup of hot cocoa with a friend, attending a service, volunteering, or making a phone call to someone you have lost touch with in the past. We are social creatures and need human connection.
- Be real with yourself – This includes preparing to spend time with family or friends. You likely already know who is going to be the Grinch, who is going to over indulge in the holiday punch, who is going to bring up politics, and who is going to ask about your love life. Just because it is the holidays, does not mean we are going to change who we are or the roles we play. Have an action plan for how you are going to deal with the likely interactions or dynamics.
- Life in moderation – Life is about balance. Enjoy the holidays by partaking in the indulgences and socialization. Moderation is key. Listen to your body and the signals it is giving you.
- Gratitude– Research is growing on the importance and efficacy of practicing gratitude in daily life. Our brains are inherently negative so being intentional about shifting out of the holiday stress (and negativity) can help bring perspective and renew our enjoyment of the season.
- Write down things you are thankful for in life. Focus on the small things (i.e., clean water, fresh air, etc). Nothing is too small to be grateful for in life.
- Reflect one thing you believe you did well over the past year.
- Compare yourself to a time in your past when you might have handled the holiday stress less effectively.
- Permission grant yourself – The holidays are not always candy canes and sprinkles. Often times we hold ourselves to high expectations and forget we are in control of our own actions. Grant yourself permission to: take time outs/breaks, have fun, do things “out of order”, celebrate differently than family/friends/the past, start a project and stop, be honest with people (and yourself), or have days that are “humbug” or just okay.
Feel free to make these tips your own by adding your own personal flair to them. It is important to find what works for you and your fancy holiday distress.
Dr. Alison Dolan