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About a dozen loudly colored paintings featuring moose, forests and beaches are proudly mounted on one of the mint-colored walls in Sindy Filler’s Libby office.

The art, novice in nature but pleasant to look at, is of her own making. And upon further inspection of the cozy office, similar paintings created by coworkers are scattered throughout the home-turned-business on the corner of California Avenue and West Lincoln Boulevard.

Filler is many things, but her primary title is practice manager for the office of Randy Guinard LCSW, a private therapy and counseling practice that serves dozens of people across Lincoln County. As practice manager her duties are widespread, but in recent years her tasks have involved brainstorming ways in which the office staff can monitor their own mental health and wellness, such as participating in therapeutic group painting nights.

“I had to implement a self-care program here,” Filler said. “We are not helpful to others if we are in crisis ourselves.”

Their private practice is just one that was inundated with patients in need of mental-health services after other local providers — namely the local Western Montana Mental Health Center — closed in the wake of major state budget cuts in 2017.

Nearly $100 million was stripped from the state’s Department of Public Health and Human Services as part of an effort to buffer shortages in revenue. The cuts included a substantial slash to reimbursement rates for case managers — the employees that help patients navigate the health-care system by connecting them to vital community resources and establishing treatment plans.

By the spring of 2018 nonprofit organizations, clinics and practices statewide — particularly those rich in case management offerings — were forced to alter or completely cease operations. And according to multiple mental-health providers in Lake, Lincoln and Sanders counties, those most-affected were the frontier communities occupying the spaces between Montana’s larger cities.

“Some of the unique things about Libby and communities like Libby, is that people here experience isolation,” said Maria Clemons, executive director for the Northwest Community Health Center in Libby. “You could call Kalispell or Butte rural, but this is a different frontier rural.”

ALMOST two years after the cutbacks, providers remaining in remote locations such as Ronan, Libby, St. Ignatius, Hot Springs, Thompson Falls and others have varied answers for how they fared.

In Lincoln County, Filler said the office’s two providers began working longer shifts, extra days and sacrificed lunch hours to accommodate growing patient loads after some 200 patients were discharged when Western closed. And down the road from their office, Rita Billow with the Northwest Community Health Center said the office’s wait time for intake patients is “still a few weeks out.” However, that list, she explained, varies, depending how many clinicians are available, what specific services patients are in need of, and other factors.

In Sanders County, Kate Whipple-Kilmer with the Clark Fork Valley Hospital and Family Medicine Network said patient loads have been steadily growing since she came on board as a therapist a few years ago. She and one other therapist travel for the Network to communities between Trout Creek and Lonepine, supplying much of the county with mental-health services. They are currently the only providers of their kind in the Hot Springs/Lonepine area.

In Lake County, the local Sunburst Mental Health branch in St. Ignatius saw a slight uptick in patients after other nearby resources fell.

“That was a challenging time,” said Julie Fleck, executive director for the nonprofit. “We were very busy and struggling financially.”

Fleck said the branch currently serves about 50 to 75 patients per month, ranging from ages 3 to 90. She said the nonprofit’s two part-time therapists are currently able to juggle the patients, but that will become more challenging as winter approaches and more people need services.

Kim Harding, who opened her own private practice in Polson after recognizing a severe need in Lake County, quickly reached her patient capacity. Harding is one of three dually licensed therapists in the county that can holistically provide patients with mental-health and drug and alcohol addiction services — two health-care challenges that often go hand in hand. She works several days a week seeing 30 patients that travel from as far as Arlee and Plains for her expertise.

“In a rural setting with very limited resources, integrated mental-health and addiction services are very important,” Harding said. “Generally it’s hard enough to find an LAC (licensed addiction counselor) or licensed mental-health counselor and even more difficult to find one that is licensed in both.”

While impacts from the cuts vary from provider to provider, there were two messages consistently relayed by every subject interviewed by the Daily Inter Lake.

The first, and more obvious, is that the needs in Montana continue to outstrip resources, as they have done for years. More providers and more facilities are needed now more than ever.

The need has always lingered, as is evident by Montana’s consistent ranking as one of the most suicide-prone states in the nation, according to the American Association of Suicidology. The state experienced 311 suicides in 2017, or almost 29 suicides per 100,000 residents — that number is up from 267 suicides in 2016.

A 2018 report from the state health department describes Montana’s high rate of suicide as a “cultural issue.” It points out multiple factors impacting the rates, including social isolation, high concentrations of veterans and American Indians and socioeconomic issues such as one out of five Montana children living at more than 100% below the federal poverty level.

And it’s those socioeconomic issues that make up the second — and loudest — consensus from providers who all say strides toward effectively addressing the mental-health needs in frontier locations are being stunted by societal issues that exist outside of behavioral health facilities.

“We need to be looking for opportunities to not just treat the patient while they are here [at the health center], but also look at what’s going on in the community and how we can support people actually getting well and staying well,” said Billow, who assisted the launch of Northwest Community Health Center’s behavioral-health program.

Clemons and Billow say the issues surrounding mental health would better stabilize if communities could address the factors that prompt some of those issues.

“If your focus is on the symptom of a crisis, I think you’re being misguided,” Clemons said. “We don’t want to just keep catching people in crisis.”

DIFFERENCES IN health are “striking” in communities that exhibit poor social determinants of health (SDOH), such as unstable housing, low income, unsafe neighborhoods and drug and alcohol abuse, according to the Centers for Disease Control and Prevention. The organization’s website states “by applying what we know about SDOH, we can not only improve individual and population health but also advance health equity.”

The most recent Montana State Health Assessment also lists social determinants of health as being one of the state’s leading community health concerns in addition to an identified lack of behavioral health providers and facilities. The document provides a broad overview of the current state of the health of Montanans based on information from various sources, including assessments compiled by individual counties.

The Montana Healthcare Foundation uses the same county-level health assessments to identify unique challenges in communities, as well as what challenges they may share with neighboring areas.

“I think it’s consistent throughout the state that behavioral-health resources is a top priority that people identify,” said Scott Malloy, director for the foundation’s behavioral-health program. “That need tends to be at the top of most assessments.”

Poor determinants of health identified by providers, including food insecurity, lack of access to care, substance abuse, unaffordable housing and poor living wages, align with findings in some of the most recently available health assessments for Lake, Lincoln and Sanders counties.

For example, Harding, a Lake County resident of 46 years, said the area struggles more than most with drug and alcohol abuse and homelessness. That comment is backed by a 2018 health assessment for the county in which Lake County residents listed drug and alcohol abuse, access to substance-abuse services and homeless populations as each being “a problem” or “a big problem.”

In Lincoln County, Billow and Clemons say lack of affordable housing is a major hurdle, while Filler pointed to a need for reliable public transportation and a crisis center. The county’s 2016 assessment states “housing conditions affect health in Lincoln County” and “a small but high-risk portion of the county’s population (5%or less) has no vehicle available and no telephone service.” The document shows 23% of properties in the county are vacant, 2% lack adequate plumbing and only 15% reside in homes that were built in 2000 or later.

“It creates a whole cycle for folks when they don’t have a good stable place to live. We see a lot of people who don’t consider themselves homeless, but you have multiple generations living in one dwelling that may or may not have water — there is basically a roof and four walls and little else,” Clemons said.

WHILE PROVIDERS identified poor social determinants of health as the chief concern for treating Montana’s mental-health crisis in remote spaces, tackling the longstanding stigma surrounding mental health and the recruitment and retention of qualified staff also topped the list.

“Stigma is more common in acute rural areas,” Filler said. “Using mental-health services or taking medication for a mental-health condition is no different than having to wear glasses to see.”

Although negative attitudes and beliefs toward people who suffer from various mental-health conditions is still a problem, providers say the stigma has subsided in the last five to 10 years, especially as conversations regarding mental health become more commonplace.

Multiple providers explain that as treatment becomes less taboo, folks who have needed services for quite some time are coming forward in search of them — a transition that has made answering the question of whether or not there is more need now than before, a difficult one.

“I think there is more acceptance that it’s OK and so it’s really hard to say the need has actually increased, I just feel like there is more of a willingness to access these services,” Billow said.

Fleck, who has been with Sunburst for 25 years, said she has recognized a slow, but hopeful change in Lake County, with people becoming more accepting of mental health as a whole.

“Hopefully over time the stigma will continue to go down and people will start realizing that this isn’t about personal failing or personal inability to achieve, but really brain chemistry,” Fleck said.

Addressing stigma and workforce development are two of Fleck’s largest priorities for St. Ignatius and surrounding towns such as Pablo, Arlee and Ronan.

For the recruitment and retention of staff, she said it’s “primarily a funding issue.”

“A lot of people graduating with a degree who can provide therapy, like social workers and psychologists, they go to other states because the pay is higher, so that limits our ability to bring up the next generation,” Fleck explained.

Many organizations and health centers have been advertising for therapists, counselors and other staff for months and, in some cases, more than a year. Multiple providers described the process as a “constant revolving door.”

“Working and providing services in a rural areas definitely takes a special person, right? Not everyone can live in some of these isolated areas,” said Addy Harnett, Region 3 director for Western Montana Mental Health Center.

But Holly Schleicher, the director of the integrated behavioral-health program at the University of Montana, said there are multiple positive trends to keep an eye on regarding incoming generations of mental health professionals.

“Every year we see more students entering into the program and learning about what integrated behavioral health can do for rural communities,” Schleicher said. “And the college is good at presenting opportunities across the state for them to see exactly how their field can benefit Montana.”

Integrated behavioral health, also known as “whole-person care,” blends care in one setting for medical conditions and related behavioral-health factors that affect one’s health and well-being. For acute rural areas especially, providers say the adoption of integrated behavioral-health models will be a boon to aching communities in the coming years.