One by one, the three men from the same close-knit community took their own lives.

Their deaths spanned a two-year stretch starting in mid-2015 and shook the village of Georgetown, Ohio, about 40 miles southeast of Cincinnati.

All of the men were in their 50s and 60s.

All were farmers. 

Heather Utter, whose husband’s cousin was the third to die by suicide, worries that her father could be next. The longtime dairy farmer, who for years struggled to keep his operation afloat, sold the last of his cows in January amid his declining health and dwindling finances. The decision crushed him. 

“He’s done nothing but milk cows all his life,” said Utter, whose father declined to be interviewed.  

“It was a big decision, a sad decision. But at what point do you say enough is enough?”

American farmers produce nearly all of the country’s food and contribute some $133 billion annually to the gross domestic product. 

But U.S. farmers are saddled with near-record debt, declaring bankruptcy at rising rates and selling off their farms amid an uncertain future clouded by climate change and whipsawed by tariffs and bailouts. 

For some, the burden is too much. 

Farmers are among the most likely to die by suicide, compared with other occupations, according to a January study by the Centers for Disease Control and Prevention. The study also found that suicide rates overall had increased by 40% in less than two decades.

The problem has plagued agricultural communities across the nation, but perhaps nowhere more so than the Midwest, where extreme weather and falling prices have bludgeoned dairy and crop producers in recent years.

More than 450 farmers killed themselves across nine Midwestern states from 2014 to 2018, according to data collected by the USA TODAY Network and the Midwest Center for Investigative Reporting. The real total is likely to be higher because not every state provided suicide data for every year and some redacted portions of the data. 

The deaths coincide with the near-doubling of calls to a crisis hotline operated by Farm Aid, a nonprofit agency whose mission is to help farmers keep their land. More than a thousand people dialed the number in 2018 alone, said spokeswoman Jennifer Fahy. 

No one economic crisis takes full blame. Instead, a cascade of events has plagued farmers in recent years: 

• Key commodity prices have plummeted by about 50% since 2012. 
• Farm debt jumped by about a third since 2007, to levels last seen in the 1980s. 
• Bad weather prevented farmers from planting nearly 20 million acres in 2019 alone.
• U.S. soybean exports to China dropped 75 percent from 2017 to 2018 amid festering trade tensions. 

Even the $28 billion in federal aid provided by the Trump administration over two years wasn’t enough to erase the fallout from the trade war with China, many farmers said.

It’s not the first time that Washington’s efforts to help farmers have fallen short.  

In 2008, Congress approved the Farm and Ranch Stress Assistance Network Act to provide behavioral health programs to agricultural workers via grants to states.

But it appropriated no money for the legislation until last year — more than one decade and hundreds of suicides later. 

Some of the first four pilot programs awarded funding still have not seen any money.  

“Farmers, ranchers and agriculture workers are experiencing severe stress and high rates of suicide,” said U.S. Sen. Tammy Baldwin, D-Wisconsin, who sponsored the bipartisan bill to fund the initiative. “Unfortunately, Washington has been slow to recognize the challenges that farmers are facing.”

Reporters spoke to more than two dozen farmers, mental health professionals and other experts across the Midwest who said the problem needs attention now.

How to get help

• The National Suicide Prevention Lifeline is a hotline for individuals in crisis or for those looking to help someone else.
• To speak with a certified listener, call 1-800-273-8255.
• The Crisis Text Line is a texting service for emotional crisis support. Text HELLO to 741741. It is free, available 24/7, and confidential.

Devastating economic events on their own do not cause suicides, experts said, but can be the last straw for a person already suffering from depression or under long-term stress. 

“We like to identify something as the cause,” said Ted Matthews, a psychologist who works exclusively with farm families in Minnesota. “Right now, they talk about commodity prices being the cause, and it’s definitely a cause, but it is not the only one by any stretch.”

Case in point: After her family shuttered the dairy farm, Utter said, it relieved the immediate pressures — including those on her sister and brother-in-law, who helped milk her father’s cows daily despite their own full-time jobs. 

But it created a different kind of stress for her father, said Utter, who serves as the Ohio Farm Bureau’s director for a four-county region including Georgetown.

It’s one felt by many farmers.

“When your farm doesn’t succeed or you have to sell off some property, not only are you letting you and your family down, you’re letting your family legacy down,” said Ty Higgins, spokesman for the Ohio Farm Bureau.     

“‘My great-grandpa started this farm, and now I’m the one that’s causing it to cease?’ Boy that’s a tough thought. But a lot of farmers are going through that right now.”Ohio farmer Nathan Brown overcame depression.Show

‘It’s a problem now’

Farmers have been among the most at-risk populations for years. 

More than 900 farmers died by suicide in five upper Midwest states during the 1980s farm crisis, the National Farm Medicine Center, found. During that crisis, mental-health counseling and suicide hotlines sprang up across the country. But after the crisis passed, the programs dried up.

The deaths subsided somewhat in the years that followed, but University of Iowa researchers found that farmers and other agricultural workers still had the highest suicide rate among all occupations from 1992 to 2010, the years they examined in a 2017 study. 

Farmers and ranchers had a suicide rate that was, on average, 3.5 times that of the general population, the study found.

There are similarities between the 1980s farm crisis and the situation plaguing farmers today, said Brandi Janssen, a University of Iowa professor and director of Iowa’s Center for Agricultural Safety and Health. But the thinking around mental health has changed. 

“I think it’s become more obvious to people,” she said. “Whether the rates or the numbers are higher or lower (compared with the 1980s), sometimes I don’t know if that matters. We know it’s a problem now.”Keith Henneman’s parents became advocates after his suicide.Show

Federal, state and local governments must provide funding to help struggling farmers, said Janssen, but she cautioned that it will take more than just mental-health counseling and hotlines. 

“It’s a lot more complicated than that,” she said. “It’s related to larger structures in the ag economy and climate and isolating work and rural areas that are being depopulated.”

Part of the problem, experts say, is that farmers are a tough bunch to reach – both geographically and emotionally.

Most live in rural areas far from mental health professionals. Urban counties in the United States average 10 psychiatrists per 100,000 people, but rural counties have only three per that many people, a 2018 University of Michigan study found.

Even when help is available, stigma prevents many in the largely male-dominated profession of farming from reaching out. 

“In general, when men feel stressed, they pull back,” Matthews said. 

Counselors have advised farmers to alleviate stress by finding a different job — something many find impossible to contemplate, said Fahy, the spokesperson for Farm Aid, which runs the crisis hotline whose calls jumped by 92% between 2013 and 2018. 

“It’s essential,” Fahy said, “that farmers are talking to people that understand the unique aspects of agriculture.”

‘My heart hurts so bad’

Keith Gillie rarely slept or ate in the spring of 2017.

He was stressed about the family farm in Minnesota, which he and his wife, Theresia, bought from his grandfather in the 1980s. After pouring their lives into the operation, they found they couldn’t turn a profit anymore.

The couple talked about selling the farm and their equipment.

On the last Friday in April, Theresia reached out to her marketing manager and a loan officer to come up with a plan. But before she could finalize the details, Keith had taken his own life. He died by suicide the next day. He was 53.

“The day Keith died, part of me died, too,” she said. “Sometimes my heart hurts so bad that my whole body aches.”

Theresia ultimately sold the farm equipment but kept the property. She now operates the farm alone. And she speaks publicly about suicide. The Kittson County commissioner and former president of the Minnesota Soybean Growers Association has one goal in sharing her own experiences:

“I want growers to understand you’re not alone in this boat,” she said. “There’s others that are really struggling, too. And we’re going to find an avenue through this.” 

At least 75 farmers died by suicide across six Midwestern states that same year, 2017, the USA TODAY Network’s data analysis shows. 

An additional 76 farmers took their lives in 2018: Eighteen in Missouri. Eighteen in Kansas. Fifteen in Wisconsin. Thirteen in Illinois. Twelve in North Dakota.

But the trend started years earlier.

Keith Henneman of Grant County, Wisconsin, took his own life at age 29 after losing heifers to Johne’s disease in the mid-2000s. 

Larry Ruhland killed himself on the Minnesota farm he operated with his wife, Barbara, in 2006 as they were working to renegotiate their contract to raise heifers for a local dairy.

“I didn’t put it together because I didn’t even think of the fact that Larry was under as much stress as he was under,” Barbara Ruhland said. 

Matthews, the Minnesota farm psychologist, helped Ruhland through the turmoil after her husband’s suicide, and again when she lost a son to an aneurysm in 2014. 

Too often, he said, he gets calls after the fact. 

“It truly saddens me,” he said. “The person has committed suicide, and now I’m working with that family.” 

It’s why training more people to spot the red flags of suicidal thinking is a crucial part of his mission. That includes anyone who interacts with farmers regularly: the ag management workers who set production goals, the auction folks who arrange the equipment sale, the bankers who deny the loan.

“That banker is at the kitchen table,” Ruhland said. “Those people are on the frontlines every day.”Barbara Ruhland remembers her husband, Larry.Show

Minnesota has added a second psychologist to split the work with Matthews. The program costs $228,000 annually. 

“We don’t have anything like that,” said Jim Birge with the Sangamon Farm Bureau in Illinois. He’s heard about Matthews’ work and would love to see a in his state.

“I don’t want to see this discussion fade,” he said. “I want to keep it alive.”

‘A tough bunch’

University extensions, Farm Bureau chapters and others have started to take notice, creating crisis hotlines specific to farmers and training people in farm communities to spot signs of depression or suicidal thinking.

Iowa recently funded a program to pay for psychiatrists to provide mental health services in rural, underserved areas. 

Wisconsin approved $200,000 for vouchers so that farmers could attend counseling, and the Wisconsin Farm Center offers advice on finances. It also has training on how to identify suicidal thoughts and how to help.

“Farmers feel that they’re most helped by someone who understands them,” said Wisconsin state Rep. Joan Ballweg, a Republican from Markesan, chairwoman of the suicide prevention task force. “I’d like to see something that is dedicated (to farmers), like the national hotline number has a function for veterans.”

In Ohio, the state Department of Agriculture launched a campaign last year called “Got Your Back” to reduce stigma and encourage farmers to ask for help.They hand out cards with the Ohio State University Extension crisis line as well as the National Suicide Hotline and online resources.

“We want farmers to know that they are so much more valuable than their next crop,” said Higgins with the Ohio Farm Bureau.Ashton Gebhard struggled to find mental-health care in rural Kansas.Show

Some programs host outreach efforts at events such as Nebraska’s Husker Harvest Days.

“Farmers are a tough bunch and they have thick skin and they don’t want to be seen pulling up to the counselor’s office,” said Susan Harris-Broomfield, the rural health, wellness and safety director at the University of Nebraska-Lincoln Extension. “That’s not their jam. However, we have one of the largest farm and ranch shows in the nation.”

She handed out wallet-sized cards with a help-line number and other resources — similar to those distributed in Ohio.

“We were actually surprised at how many of these, especially men – farmer men –  were absolutely open to taking it and they thanked us for what we were doing,” Harris-Broomfield said.

Her biggest tip: Make the conversation about stress instead of mental health. Neither their booth sign nor a survey they handed out mentions mental health.

“Stress is something we can all relate to,” she said.

Stress mixes with grief in Georgetown, Ohio, where Heather Utter’s father is adjusting to life after farming, and her father-in-law farms 1,500 acres — a combination of the land he grew up on and the adjacent property that his cousin had tended until his death. 

“If you don’t farm, you just don’t understand it,” Charlie Utter said of the stress and despair to which so many local farmers have succumbed. “There’s just so many ups and downs and variables you can’t control. It wears on you.” 

Charlie Utter said he regrets not talking to his cousin sooner; he knew something was bothering him in the days before his death. Family members need to watch one another closely, he said. 

“If you see somebody is down, go talk to them, and don’t put it off,” he said. “If people were more educated, it couldn’t hurt. One person might catch something.” 

This story is a collaboration between the USA TODAY Network and the Midwest Center for Investigative Reporting. The Center is an independent, nonprofit newsroom based in Illinois offering investigative and enterprise coverage of agribusiness, Big Ag and related issues. Gannett is funding a fellowship at the center for expanded coverage of agribusiness and its impact on communities.

Originally Published 6:00 a.m. EDT Mar. 9, 2020Updated 5:34 p.m. EDT Mar. 9, 2020

We tell suicidal people to go to therapy. So why are therapists rarely trained in suicide?

Alia E. Dastagir, USA TODAYUpdated 5:34 p.m. EDT Mar. 9, 2020

We tell virtually every suicidal person to do it. It’s part of most suicide prevention campaigns. When we don’t have the answers, it’s where we tell our loved ones they’ll find them. 

“See a therapist.”

And yet suicide prevention experts say outside of psychiatrists, the majority of mental health professionals have minimal to no formal training in how to effectively treat suicidal people. 

Suicide-specific training is not commonly offered as part of college curriculums, optional postgraduate training opportunities are limited, costly and time-consuming, and experts say some therapists may not be aware they even need the education.

“Any profession’s ethical standards require that you not treat a problem you don’t know, and yet every day thousands of untrained service providers see thousands of suicidal patients and perform uninformed interventions,” said Paul Quinnett, a clinical psychologist and founder of the QPR Institute, an organization that educates people on how to prevent suicide.

“People think if you send someone, a loved one, to a therapist, that therapist will be skilled in how to address … their risk for suicide. Nothing could be farther from the truth.”

Numbers released in January from the U.S. Centers for Disease Control and Prevention show 48,344 people died by suicide in 2018, a small increase from the year before, though the rise in deaths over time has been steady. Since 1999, the suicide rate has climbed 35%. 

How to find a therapist if you’re suicidal

Read the story

Suicide is the nation’s 10th-leading cause of death, yet experts say training for mental health practitioners who treat suicidal patients – psychologists, social workers, marriage and family therapists, among others – is dangerously inadequate.

Many suicide prevention experts say combating suicide requires a holistic approach that includes communities, families, educators and religious leaders working together. But society, they say, has placed the burden of caring for suicidal people on a mental health workforce woefully underprepared to help them. 

In Depth: Funding for suicide lags behind other top killers

There are no national standards that require mental health professionals be trained in how to treat suicidal people, either during their education or their career. Only nine states mandate training in suicide assessment, treatment and management for health professionals, according to the American Foundation for Suicide Prevention. TWEETSHAREWhitcomb Terpening, a licensed clinical social worker who works exclusively on suicide

Having someone on your side that gets what you’re going through, that can advocate for your needs, and that gives you the space to talk through your thoughts is a game-changer.

The American Psychological Association and the Council on Social Work Education, which accredit graduate programs in psychology and social work, have standards to prepare graduates to treat patients in crisis but do not require specific competencies regarding suicide.

For its 2014 report on guidelines to improve training among the clinical workforce, the National Action Alliance for Suicide Prevention assessed the state of education by sending surveys to 443 academic institutions. Of those, 69 responded, and 70% said no specific training for suicide was provided. 

A 2012 paperby the American Association of Suicidology cites decades of studies that underscore the training gap, and experts say not much has changed in the last several years. It found about half of psychology students receive formal classroom training on suicide during their graduate education. Only about 25% of social workers receive any suicide prevention training. Marriage and family therapists had even less. Most psychiatrists receive some instruction, but many experts agree it’s insufficient. 

“When people ask me, ‘Who should I see?’ the only thing I can say is ‘See a psychiatrist if you can,’ because … they’re supposed to cover that topic during the course of their training,” Quinnett said. “You have some assurance that they know something about it. But you can’t say that for any other (mental health) profession, which is astounding to me.”

Suicidal people have a spectrum of experiences with therapy, some harmful, some lifesaving. Many people living with suicidal thoughts say when they found the right clinician, someone who didn’t overreact and who made an earnest effort to understand their pain, they felt less suicidal.

“Having someone on your side that gets what you’re going through, that can advocate for your needs, and that gives you the space to talk through your thoughts is a game-changer,” said Whitcomb Terpening, a licensed clinical social worker and founder of The Semicolon Group, a therapy practice in Houston that works exclusively on suicide.

“They’ll have your best interest in mind, not just to keep you alive, but to help you find a life worth living.”

Facing suicide, patients are afraid, and therapists are lost

When someone who’s feeling suicidal opens up to a therapist, they do so expecting the person sitting across from them wants to understand their suffering. But Stacey Freedenthal, a suicide attempt survivor and associate professor at the University of Denver Graduate School of Social Work, says a common feeling among therapists when they realize they’re sitting across from a suicidal person is panic.

They worry the patient might try to kill themselves, could succeed and they may get sued or lose their license. Their reflex is to send the patient to an emergency room. 

“You’ve got this person who has taken weeks or months or more to work up the nerve to go to a professional and the professional is saying, ‘I can’t help you, you have to go somewhere else.’ And that can be very harmful,” Freedenthal said. 

Research shows emergency room visits and involuntary hospitalizations – triggered when a mental health professional believes someone is at imminent risk of killing themselves – can increase a person’s risk of suicide.

Susan Stefan, a scholar and litigator on behalf of people with psychiatric disabilities, says that in many cases, an emergency room can be the worst place for a suicidal person. 

“It’s loud, it’s hurried, people are in a rush,” she said. “There is no training, generally, for emergency physicians, or staff to deal with suicidal people. In many places, there’s not much sympathy.”

Even if a therapist doesn’t overreact, that doesn’t mean they know how to help. Freedenthal says she once had a therapist who made her “promise” she would never do anything to hurt herself. 

“That’s great in principle, but I kind of wouldn’t have been going for help if it was that easy,” she said.TWEETSHARESusan Stefan, a scholar and litigator

I think we as a society waste a lot of time trying to stop people from killing themselves as opposed to exploring why they want to die in the first place.

Some therapists try to avoid the question of suicide altogether. Freedenthal says she always asks her students and even colleagues with decades of experience, “What is your fear about asking someone if they’re thinking of suicide?”

The most common answer: “That they’ll say yes.” 

Some chronically suicidal people say they’ve been dropped by therapists who were unable to tolerate the intensity of their pain. Others say their clinicians were so fixated on predicting how likely they were to kill themselves, they didn’t spend enough time listening to why they were hurt or what they might need. 

“A lot of people who say they’re suicidal are trying to convey the depth of their despair,” Stefan said. “I think we as a society waste a lot of time trying to stop people from killing themselves as opposed to exploring why they want to die in the first place.” 

‘They didn’t even know how to ask the question’

Back in the 90s, Quinnett was the clinical director at a mental health center in Spokane, Washington. One year, they lost 13 patients to suicide. When Quinnett reviewed the death records, he realized his clinicians didn’t know how to treat suicidal patients.

“They were good people. They were goodhearted. They were crushed when their patients died, but they didn’t even know how to ask the question, let alone how to assess and manage the risk,” he said. 

Afterward, Quinnett said he helped put together a comprehensive, mandatory training program on suicide. Once it was fully up and running, he said clinic deaths plummeted, to one or none a year. Eventually a new CEO took over and Quinnett said he decided to shutter the program over cost concerns. Quinnett said suicides started up again, so he quit.

Almost all mental health professionals see suicidal patients at some point in their careers, experts say, yet only a small fraction seek out specialized training.

For those who do want it, it can be hard to come by. Some of the best therapies aren’t available for training at scale, and those that are require time and money. 

David Jobes is director of the Catholic University of America’s Suicide Prevention Lab and created CAMS – Collaborative Assessment and Management of Suicidality – widely regarded as one of the most effective approaches to treating suicidal patients. In the absence of training, Jobes said many clinicians spend most of their time trying to treat a patient’s underlying mental illness, rather than asking the person, “What makes you want to kill yourself?” 

CDC data published in 2018 shows 54% of people who died by suicide had no known mental health condition.

CAMS, Jobes said, is a model that endeavors to understand the sources of people’s suffering. But very few people are trained, he said, and those who could benefit from it most have probably never heard of it. 

Andrew Evans, president of CAMS-care, which trains practitioners on the CAMS approach, said last year that the company trained about 5,000 mental health professionals in the U.S. April Foreman, a clinician and board member of the American Association of Suicidology

Unless you seek out on your own specialized training, and most people do not get this, it will become exquisitely painful for you and impact your well-being.

“That’s a drop in the bucket, because millions of people have suicidal thoughts,” said Jobes, noting CDC data from 2017 that showed 10.6 million American adults seriously thought about suicide.

Terpening, who works with suicidal patients, says that as long as training for mental health providers is voluntary, patients won’t get the care they need.

“Everyone’s told ‘Reach out, there’s always somebody to talk to.’ But there isn’t. Because we’re not trained in graduate schools, we’re not trained in our clinical intern hours, we’re not offered those kinds of opportunities,” she said.

Lack of training, Terpening added, doesn’t just leave practitioners ill-equipped, it leaves them afraid.

“Therapists want to do well, they just don’t know how,” she said. “Fear is born out of the unknown.”

Many therapists are so frightened of treating suicidal people they’ll screen out potential patients who they think may be at risk, Quinnett said. Clinicians also are afraid of liability, though Stefan said the concern is far less real than most mental health professionals think. Even if a grieving family sues, she said, most cases are not successful. Facts, however, are not always persuasive when the undesired outcome feels so catastrophic. 

A survey of mental health providers in Colorado, which has one of the highest suicide rates in the nation, showed many do not think they need more training, but desire it, according to a 2018 article in the Journal of Public Health Policy. It found providers reported being “generally pleased with their existing training and felt prepared to address suicide within their practice,” though 80% supported mandating suicide-related continuing education. 

Training helps therapists care for their patients and for themselves

When confronted with the intensity of pain a suicidal person is feeling, some therapists find themselves overwhelmed – wanting to help, fearing they’re not capable, with stakes that feel enormously high. 

“It is emotionally painful,” said April Foreman, a clinician and board member of the American Association of Suicidology. “Remember, you’re a therapist because you’re emotionally sensitive, and then we give you training to be even more sensitive. Then we put you in a room with someone who has the kind of pain and despair and behaviors that put them at risk of dying.Anthony Pisani, associate professor of psychiatry and pediatrics

Addressing suicide risk is not something you can get trained in once and be done. This is such a hard problem with such serious consequences that people are going to feel and be unprepared unless they are engaged in an ongoing way.

“Unless you seek out on your own specialized training, and most people do not get this, it will become exquisitely painful for you and impact your well-being.” 

Foreman says therapists practicing Dialectical Behavior Therapy, another highly effective treatment approach for severe suicide risk, are expected to have a consultation team to help manage stress and burnout.

“I will tell you, having lost patients to suicide, the consultation group is invaluable,” she said.

Terpening says being able to talk with peers is a crucial part of her own self-care. 

“The work can be isolating,” she said, “so to be able to hear from other people is so helpful and so healing in ways that a spin class never could be.”

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Calls to fix broken system go unheeded

The issue of inadequate training has been documented for decades. In 2001, the National Strategy for Suicide Prevention said it was critical that “mental health personnel receive appropriate graduate school training on the subject of suicide while preparing for their professions.”

Nearly 20 years later, experts say not enough has changed. Anthony Pisani, associate professor of psychiatry and pediatrics at the Center for the Study and Prevention of Suicide at the University of Rochester, said it is essential the goal be met, and training must extend well beyond school. 

“Addressing suicide risk is not something you can get trained in once and be done,” he said. “This is such a hard problem with such serious consequences that people are going to feel and be unprepared unless they are engaged in an ongoing way.”

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The American Association of Suicidology report on gaps in mental health training made several recommendations for improving care. It said accrediting organizations must include suicide-specific education as part of their requirements so graduate programs have the training in their curriculum. State licensing boards, it said, must require clinicians be competent in suicide treatment.

And the report said government has a role to play, too, by requiring that health care systems receiving state or federal funds ensure their mental health professionals are trained in suicide risk detection, assessment, treatment and prevention. 

Maybe, most importantly, experts say clinicians have to overcome their fear of not knowing with certainty who may live or die. 

“I get the fear – our licenses are our livelihood, we need to be able to protect them,” Terpening said. “But we also have to be able to see past the risk to do what’s right for our patients.” 

If you or someone you know may be struggling with suicidal thoughts, you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) any time day or night, or chat online.

Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.

The American Foundation for Suicide Prevention has resources to help if you need to find support for yourself or a loved one. 

Alia E. Dastagir is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @alia_eDIG DEEPER