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Healing is a vocation. It's consistently ranked right up there with ministers and teachers in our society. But so often is the case, those who are caregivers or healers for others rarely can or do take time to attend to their own needs: physical, mental, emotional and spiritual. "It is kind of how we're hardwired, actually." smiled Cristy Cobb knowingly, head of Nursing and Quality at Memorial Hospital of Converse County.

This hardwiring can mean a tireless dedication to the patient; a rightly patient-centric atmosphere throughout every level of the MHCC organization. These are excellent results, and the growth of this community mindset has set our hospital apart from many others in our state and region. However, the Book of Proverbs gives us the saying: "Physician, heal thyself." And never can that be truer when looking at the trauma and stressors that can happen within the vocation of health care.

Often when patients are at the hospital, it's not their best day. But for providers in that same setting, their care and focus can't show the same life stresses, worries, or concerns we all have in our day to day. These are routinely placed on a shelf to allow for the patient's needs rightly to come first. As well our staff and providers see and attend to many aspects of patient care: from the joy of delivering a new baby to the trauma of losing a patient and everywhere in between. It is the emotional reality for the healer, to be present in every facet of the human health experience.

Healthcare is indeed a human industry: it both serves and is served by humans. "There's always an emotional portion of what we do in health care, especially in a small community like Douglas," said Felicia Masterson Smith, noting that quite often in our community hospital those who work at MHCC find they are caring for family, friends, neighbors. Realizing the need for more access and awareness to mental and behavioral health, the providers at MHCC in a continued fashion focused on the patient's' need first. "I think we're fairly proficient and fairly consistent at entering in to help people when they are identified in the patient role," said Cobb. "I see the unconditional care and love of patients being applied. That's pretty reflective of our patient satisfaction scores. We're not perfect, but I think we do that better than most."

And with this in mind, several factors were put in play in the last couple of years and even recent months by the administration at Memorial Hospital of Converse County, where access to mental and behavioral health tools have been made available to providers for their patients. The most important point is that it became a topic of discussion in the wake of the economic downturn in early 2016, the hospital looked further at providing a more ample bridge to mental health. "I think that most of the providers feel very ill-prepared to treat people with mental illness, so they have a judgment that it's complicated and I agree it is," added Cobb. "But, they're not qualified to make these differential diagnoses in psychiatry and then what type of medications they use to treat that."

"We have facilitated inpatient tele-psychiatry for several years now with intensivist "E-ICU" live video and backup monitoring done by multiple sub-specialists including Psychiatrists for patients in our hospital that our Hospitalist Specialists request help with from the Avera System in Sioux Falls, SD," stated Dr. James Morgan, Chief Medical Officer at MHCC. "Our outpatient clinicians who work with pediatric patients (under 16 years of age) have also had for at least the last five years a tele-psychiatry back-up/consultation system for younger patients with the University of Washington in Seattle as part of our W. W. A. M. I. (Washington, Wyoming, Alaska, Montana, Idaho) Medical School partnership in which we in return serve as outpatient preceptors for W.W.A.M.I. students doing family medicine and internal medicine outpatient clerkships."

Noting the need for further services and support in Wyoming Dr. Morgan continued, "Historically, it has been my opinion, that the state of Wyoming has been underserved by the psychiatric specialty mostly because of our State's fear of the costs of requiring coverage for psychiatric problems by the insurance industry and because of the blurring of self-medication problems which can be ascribed to poor choices and inherited mental illnesses which have only partially successful treatments and increased costs. In my experience, most self-medication and drug abuse problems stem from poorly managed chronic pain and a smaller, but still, a significant number come from an untreated mental illness that often has nothing to do with drug abuse."

In conclusion, Dr. Morgan stated, "I am proud that our hospital system has come up with many different and partially self-funded mechanisms to compensate for the poor coverage of mental illness problems that exist in our state,"

"Mental health is a vast topic of discussion, but the long and short of it for me is that suicide is the number 10 leading cause of death in the United States," stated Dr. Nathan Ker, a provider at Memorial Hospital of Converse County. "Per capita, it is a cause of death in Wyoming at even greater rates than other parts of the country." According to Cobb, Dr. Ker's passion on this subject is what also led to the inclusion of further screening processes in the outpatient setting.

Dr. Ker added "We have implemented screening of depression for our patients to try to identify those that might be at risk for depression to help them get to the resources they need. It might include referral to a physician at the MOB, a provider there, or Solutions for Life." Both the PHQ-2 and PHQ-9 have been implemented since August 15th at MHCC. These questionnaires designed by the American Psychological Association assist providers in assessing depression in their patients. "This is a standard tool. It's deployed in the outpatient setting, but we decided to take the standard tool and try it here," stated Cobb. "Questions on the PHQ-2 start with 'Little interest or pleasure in doing things.' to "Felt down and depressed or hopeless." The responses are scaled, and if the tally is more than 6, the PHQ-9 then is administered with seven additional questions." Cobb then showed an example anonymous screening noting "This person had a 19. So, the nurse contacted the physician and then wrote a note, 'Has a history of family anxiety/depression, not working right now, extreme fatigue, decreased appetite. Medical issues.' The physician is now aware."

Since August the PHQ Screening process has been employed in 105 cases to help better assess the mental health and possibility of depression in the outpatient environ at the Medical Office Building. "It seems like the depression screening scores have gone up, that I've seen in the numbers. We're getting busier, a little bit, and we're also heading into dark and seasonal affective depression," added Cobb. "In the time span from August and September, six people screened above a nine and all but one refused. We'll ask the patient, if they're not identified as a risk to self, as a suicide, then we ask them if we can ask Solutions for Life to come over. Everybody in that subgroup denied that, but one that didn't was a suicide attempt. At that point, you don't get a choice. You have to get screened from Solutions for Life to determine what to do next."

Coupled with access to screenings, and therapy, QPR training has been enlisted to assist with both patients and staff who are facing suicidal thoughts or ideation. "I got voluntold this was part of my responsibility. I went and did the eight-hour training to become a trainer and I never really thought I would ever use this," reflected Smith head of Hospitality Services for the Arbor Cafe. "After I did my training, I think I talked to three different people that I recognized the signs in, and they all said, 'yes.' I have lost track of how many interventions I was pulled in on that people were either at risk or dealing with a stressor and didn't know which way to turn."

QPR stands for question, persuade, refer. Memorial Hospital of Converse County started training its staff in the Fall of 2016 with Smith at the helm of the program. So far 138 staff members and some members of the Douglas community as well have been trained in the offering from MHCC. "It's been very eye-opening on how many people here who have either been impacted by it or themselves have been on that tightrope of whether or not they should take their lives," stated Smith. "It's very humbling but very overwhelming, too, to realize that we don't take care of ourselves as healthcare providers. We're always full-bore while we're here that we're the last people we think of, and I saw that a lot in training, that they let themselves get sucked down that rabbit hole."

Statistics show that eight out of ten people will suffer from depression at some point in their lifetime. Depression, substance abuse, a cycle of economic boom and bust in our communities, isolation all can be factors that lead to long-term mental health concerns in Wyoming. "I don't know that you can scientifically measure these things, but the people that live in Wyoming, we're the descendants of pioneers, and there's an independent spirit. Well, if we're made to be social creatures, this independence works against us in mental health," stated Chief Culture Officer Frank Wiederrecht. "Several people mentioned the wind and the barrenness and everything and, also, what is there to do around here on a Friday night except go to the bar? Whereas, the alcohol just accentuates the problem."

But the mind can't be healed like a broken bone or cut. It takes time and trust. Emotional health must be processed, given space to work through a myriad of complexities, to find solutions. In short, the mind takes specialized therapy to help cope and heal. We can often tease about "safe spaces" or become "triggered," but these are the realities of our community that our staff has a need for a safe environ and a person to talk through trauma or life concerns. It's in these situations that Frank comes in quite often.

"Karl [Hertz] has a quote he often shares: 'Being listened to is so close to being loved that, for most people, there's no difference.'" So, the question I'm always asking myself is, "How can I best love this person here in front of me right now?" Most of the time, it's listening," stated Wiederrecht. "I see insecurities and low self-esteem and a lack of self-identity. That's probably the number one issue. There are also some folks around here probably with some borderline personality types because they're just in society. So, if there's undiagnosed or unrecognized, or maybe they've been diagnosed elsewhere, but their supervisor isn't aware, or their teammates aren't, then there is friction, and they're trying to figure out why. Well, fundamentally, there's a part of each of us that's broken. It's just a matter of how much. Some are profoundly broken, and it's amazing that they're as functional as they are."

Wiederrecht, who emphatically states he is not a psychiatrist, tries to meet both staff and patient where they are to process traumas, bring them closer to the surface and closure. "Dr. David Burns has a really good handbook. He talks about this broken thinking that I get into, these cycles of thinking, and if I get in the cycle of thinking, I'm not gonna get out of it by myself," he said. "It's like a record that has a blip on it, and he needs somebody else to move the needle a little bit and say, 'You know, there might be another way to think about this.' So, he's got all these exercises and assessments in there. If we can change our thinking, then we can change our behavior."

"If the brain is not the most important organ in the body it is up there, right along there with the heart. But we know everything about the heart. We can take your heart out, stop it, do everything possible. We're still trying to figure out the brain, and there is fear and bias with some providers, against psychiatry. But we need to treat the brain and illnesses of the brain with every bit of acuteness and seriousness as we do other parts of the body."

Further stigma still exists between medical providers who work primarily on the body and those who work on the mind and emotions, that's an age-old problem in the industry. But as well there exists in our community and our society still a stigma against the access to and need for mental health therapy and use, that it can be a signal of weakness. "One of my mentors that helped me with the training said clients [who were there for therapy] would park down the street or they'd go to Casper," added Smith. "They didn't want to be seen parked in front of that building. So, there's still that stigma of mental health and then the next part of it is, they don't want to be judged. So, like [Frank] said, they want a safe place to talk, but they're always afraid they're going to be judged."

In addition to PHQ screening, QPR training and staff and patients having the ability to be served with a safe space to talk through concerns is a focus on providing for the families of these individuals. A postvention program is in a process that will assist families coping in the wake of the completion of or attempted suicide.

"Statistics show that has a domino effect to that family, their friends. So, if we're not doing anything to help that family transition or deal with that loss or that attempt, we're really setting them up for that to be repeated. The postvention gets them the resources that they need. If it's calling in their pastor or getting them to a counselor or whatever, it's getting them the resources for them to deal with that so that there's not that domino effect," said Smith. "Once it is put into place, that will include the coroner, our EMS crews. That's going to go community wide because these are the resources we're going to have to pull from to make that effective."

Smith continued, "Statewide PMO law has lost funding for suicide prevention, but funding is still available for resources. They are working with us to continue our training by partnering with the Episcopal Church. So, we've got a lot of support. It's just trying to get the right people in the right place."

And that, like everything, takes time.

Does Memorial Hospital of Converse County have all of the answers yet to the question of mental health in the state of Wyoming? No. Are we as an organization aware of this complex problem and trying to fill a need, however, we can? Yes. It's a dynamic concern for our state, for our community, and one where there isn't a perfect ready-made solution. The takeaway is that conversations are happening; the process of finding assistance for these needs has begun at Memorial Hospital of Converse County.

It is all part of caring for our community, of making our patients the center of what we do.