Housing insecurity. Winter boredom. Money getting tight as the cold days stretch into weeks and months.

All these triggers can play into the most common mental health issues, according to Dahl Memorial Clinic Behavioral Health Clinician John Hischer.

Local Issues

Across the United States, the most common health issues are anxiety, depression and substance abuse – the same three which are also common in Skagway, as well.

Out of those, anxiety is the most prevalent.

The mental disorder affects 18 percent of adults in America’s population, according to the National Alliance on Mental Illness (NAMI). It is usually accompanied by feelings of apprehension or dread, feeling tense, jumpy, restless or irritable, and anticipating the worst and being watchful for signs of danger.

“Sometimes it’s generalized anxiety, where they are healthy but they worry about their health excessively, or they’re doing okay financially, but they over-worry about finances – they worry about everything with generalized anxiety,” Hischer said.

Specific stressors can also cause a more focused type of anxiety, according to the Hischer. One example is housing insecurity in the area, with the limited housing pool throughout the year, and especially, in the summer. The pressures of the Skagway seasonal economy also can create unique stressors that build negative pressure at the back of a person’s mind.

“They have to make all their money in this really tight window, and then they have to live off that for a while, especially those with families,” Hischer said.

But depression is also an issue in the region.

Hischer said this mental disorder is the second-most common nationwide and locally. It can cause changes in sleep and appetite, as well as a lack of energy and concentration, according to NAMI.

“A lot of folks suffer from that sense of hopelessness, feeling disconnected to folks and feeling like there is no purpose for things … and that’s exasperated by the winter,” Hischer said. “January, February are particularly tough on people.”

Long hours of darkness can contribute to this, according to Hischer, but so can a lack of structure during the winter days in Skagway.

“That can get really nebulous – they don’t wake up at the same time, it’s dark all the time, days just kind of bleed into each other and then they may start drinking a little more and that may add on to things,” he continued.

Depression can lead to suicidal thoughts, as well, though Hischer said he’s only aware of two who have died by suicide in Skagway since 2009. Harboring thoughts about self-harm, however, is more common.

“I have people daily say, ‘yeah, I’m thinking about it. I’m not going to do it, but I think about it. I just want the pain to end,’” he added. “Whether that’s the emotional pain or physical pain sometimes.”

Suicide is a scary thought to have in your head, Hischer said, so openly discussing it can actually be a relief to people considering taking their own life.

Challenges to Treatment

Although the rugged lifestyle may be a point of pride for many residents of the Last Frontier, the challenges of life in the region can create problems for those suffering from mental illness.

Within Southeast Alaska, having access to care is the greatest need, according to Crystal Bourland, executive director for the Juneau NAMI affiliate.

“Specifically, access to psychiatrists,” Bourland said. “For Juneau, we really see a need for child and adolescent psychiatrists. There always tends to be a provider shortage, and we see that all across the country, especially in rural communities. We face even more difficult barriers in Southeast and rural Alaska, because of transportation and those types of logistics.”

Turnover of those providers at the community level is also an issue, Bourland said, as it takes time for a psychiatrist or clinician to build a rapport with patients.

“It’s like any kind of medical care,” Bourland added. “You always prefer to have someone that you’re working with stay around. They know your history, they know you, it’s comfortable, and especially, I think when we are talking about mental health or substance use, just building a trusting relationship is kind of important.”

When Hischer first started working in Lynn Canal in 2009, he said treatment for Skagway patients was sometimes inconsistent because he was with a nonprofit based out of Haines.

“That was kind of like, ‘oh, is this guy staying? Why should we talk to him? He’s not going to stay,’” he said.

Now that he’s become a more permanent fixture in the community as an employee with the Dahl Clinic, Hischer talked about how he’s noticed less hesitation from people seeking help.

However, provider turnover comes in more ways than a mental health specialist leaving an area. For someone on Medicaid or Medicare whose doctor goes into private practice, this can present a financial barrier in accessing care, too.

“I think southeast Alaska outside of Juneau is experiencing more of all of that,” Bourland said. “More provider services lack of treatment options and wraparound services. We’re pretty lucky in Juneau to have a pretty large continuum of care, but I know that’s a challenge for a lot of communities throughout this region.”

Overcoming the stigma associated with mental illness is can be another ongoing struggle for those who need treatment.

For those dealing with depression or anxiety, getting treatment can be viewed as a moral failing or a weakness, according to Hischer.

It takes a lot of strength to come in here and address these issues.”

Sometimes, others experience feelings of guilt or shame – they think they should be able to handle it themselves and that they are just complaining. For these cases, Hischer said he tries to explain that these issues are something many people deal with.

The sole behavioral health clinician for Skagway also takes the confidentiality between him and his patients very seriously. He discussed how this is a scared bond – especially in a small community, where patients may fear others will figure out that they want treatment.

“[They may think] ‘what if they think that’s weird, or what if they start judging me for it?’” Hischer said. “I say, if people are judging you for helping yourself, I would really analyze what that relationship is like. If people are kind of getting on you for seeking help, I’d probably take a look at that relationship, is it healthy or not?”

Show You Care

Outside of his role at the clinic, Hischer also focuses on educating the public about mental illness.

The Mental Health First Aid workshops with the police department, teachers at Skagway School and with the public are eight-hour crash courses designed to teach the warning signs related to mental health issues, and how to approach someone who might be in pain. The workshops are relevant to everyone, Hischer said, because almost everyone can draw some line of connection to someone suffering from one of these issues.

“I don’t know anyone who hasn’t been impacted – if it’s not them, then it’s a family member or friend who’s suffered from some sort of mental health issue or substance abuse issue,” he continued. He added in the programs, everyone has a story to tell and is there for a reason.

One of the first steps in taking action is letting the person in pain know that someone noticed, and what they noticed, according to Hischer.

“‘Hey, I’ve seen you haven’t been hanging out lately,’ or ‘I’ve seen that you’ve been posting a lot of things on Facebook where you’re really sad and I’m really concerned,’” he said. “Let them know what you’ve seen and that you’re concerned, and that you want to know what’s going on, in your own language.”

This can get that person to discuss what’s going on with them, and help them realize someone cares, which is “an important part for folks, especially with depression,” Hischer said.

“A lot of times, it’s that mindset of depression, ‘no one cares, I’m all alone,’” he continued. He noted that part of the mental disorder is the tendency to push other away, so avoiding being aggressive and not pestering a person is critical when opening a dialogue.

In fact, directness in these situations can be counterproductive.

“You don’t want to go in saying like, ‘I know you’re depressed,’” Hischer said. “That kind of shuts people down.”

However, this rule doesn’t apply when it comes to suicide. In these cases, Hischer said it’s important to be direct.

“You want to be self-assured and say it confidently, because people will say ‘no’ just because they don’t want to bother you if you say it like you don’t really want to know,” Hischer added. “That’s something that we practice a lot [in Mental Health First Aid].”

Because suicidal thoughts can be very scary to deal with, Hischer said opening discussing it can actually be a relief to those considering taking their own life.

“Most people I’ve talked to who have thought about suicide, it’s a relief when someone notices,” Hischer said.

• • •

If you need someone to speak to, call the Alaska Careline at 1-877-266-HELP, or visit the suicidepreventionlifeline.org or juneausuicideprevention.org.

The Dahl Memorial Clinic’s number is (907) 983-2255. The on-call provider at the Dahl

Memorial Clinic (907-983-2025) or Skagway Police Department (907) 983-2232 can contact John Hischer after hours.