Farm Stress and Emotional Well-Being, Part II

By Karen Crowley, Farm First, with Andy Pressman, NCAT FRSAN-NE Project Leader

Agriculture is an economic and social bedrock of the United States, yet for decades, farmers, ranchers, and farmworkers have endured growing challenges that increase their levels of stress. The Farm and Ranch Stress Assistance Network Northeast (FRSAN-NE) aims to improve behavioral health awareness, literacy, access, and outcomes for farmers, ranchers, and farmworkers in the Northeast by developing a service provider network that can assist and meet the unique needs of agricultural workers. FRSAN-NE Network members developed a Resource Working Group to focus specifically on providing information and materials designed to inform those who interact with this population. The resources provided here were created to provide information needed by those who want to offer support but don’t have expertise in the mental health profession.

Abstract

This is the second part of a two-part guide that briefly describes some of the issues contributing to the challenges of farming and provides helpful strategies and resources to aid farmers in building and maintaining the resilience needed to be successful.  It was developed to be used by anyone who lives or works in the world of farming. This publication addresses substance-use disorder, family relationships, suicide, and therapy.

Counseling: When Prevention and Maintenance Are Not Enough

Sometimes, the difficulties a person has been struggling with become overwhelming, and strategies that usually work well to maintain well-being and prevent mental health challenges are no longer sufficient.  The situation can become dangerous or unsafe and calls for intervention, often including professional support.  Several situations of this type are briefly explored below, and more about these types of challenges can be found in the publication Preventing Farm-related Stress, Depression, Substance Abuse, and Suicide (Dudensing et al., no date). It’s important to be aware of the likely benefits of professional counseling and have a basic understanding of how it works.

In addition to learning and practicing resilience-building skills on one’s own or with someone who has experience in a particular strategy (yoga, mindfulness, etc.), many people decide to consider a professional therapist for help dealing with stress or other struggles.   Indeed, as stated above, this may be essential for some. Counseling can be helpful, whether the goal is to learn some new skills for managing day-to-day life as effectively as possible, to obtain help with overwhelming emotions, or to deal with behaviors that feel out of control and destructive.

Signals that outside help should be sought include:

• Panic attacks
• Difficulty concentrating due to anxiety or depression
• Excessive drinking or the use of other drugs
• Thoughts of suicide
• Frequent crying
• Frequent fatigue
• Physical fighting where one spouse hits, shoves, or kicks the other
• Frequent physical ailments
• Frequent despondency
• Difficulty sleeping

Although any of these signs warrant referral to a counselor, realize that almost anyone can benefit from speaking with a counselor, even when these signs may not be apparent. The decision to seek counseling can feel complicated for farmers and their families. The free online publication When Do You Need a Counselor? provides more information. Although it’s an older study, the research done for the journal article “Farm Families’ Preferences Toward Personal Social Services” provides a helpful exploration of the factors still causing reluctance in the farm families of today as they consider seeking mental health support (Martinez-Brawley and Blundell, 1989).

One way to counteract this reluctance is to provide farmers with some basic information about what they can expect from counseling. There are numerous forms and styles of counseling, but with any type, the help is provided by a trained mental-health professional who works with people to help them learn how to improve aspects of their lives. Someone going to counseling for the first time should expect to spend some time discussing challenging situations, emotions, and behaviors that are adversely affecting them. It can feel uncomfortable to discuss mental-health symptoms and personal thoughts with a stranger. This often gets easier with time. As the experience will likely involve working through some negative events or distressing thoughts, it may be difficult in the moment, but the result is usually a happier, more fulfilling life.

Ultimately, whether to seek counseling, what type, and with whom, are all choices that the person getting counseling should be allowed to make, excepting situations where someone is in immediate danger of harming themselves or someone else.  Whether it’s in response to going through a rough time or to having a mental-health issue that causes serious distress, therapists are trained to help without judgment. People should be encouraged to let their counselor know if they are not finding the experience helpful. If that doesn’t improve the situation, it’s time to consider seeking something (or someone) different.

Some of the typical areas of focus in therapy include:

• Stronger communication skills – Most of us can benefit from strengthening our communication skills. Individual therapy helps people learn how to communicate more effectively by both speaking and listening.
• Develop problem-solving skills – Individual counseling helps to develop problem-solving skills that may have been missing previously. During sessions, there is an opportunity to partner with the therapist to dissect a problem and determine how to solve it. Doing this allows people to learn and practice, so they can develop and use these skills to solve problems on their own in the future.
• Mental health management – Stress, anxiety, and depression can affect anyone. Even if issues don’t seem to be having a huge impact, it’s always helpful for people to know more about managing mental health appropriately. Individual counseling can teach skills for handling stress in healthy ways to avoid the situation becoming worse.

For more information related to sorting through options and deciding about whether counseling is a good next step, and to learn more about finding a therapist, health insurance, and different types of counseling, consult Appendix A: Paths to Finding the Right Therapist.

Anxiety and Depression

Anxiety and depression are two of the most common mental health issues and they frequently are factors in the decision to seek professional help.  Sometimes people struggle with one or the other, but they are also often called “co-occurring,” meaning that they are experienced together.  It is not unusual for the emotions and symptoms connected with depression and anxiety to “feed one another.”  For instance, if farmers are depressed and don’t have the energy or focus to address needed farm repairs, they are likely to worry about them more and become anxious.  If they are anxious and that stress keeps them from sleeping or eating well, they are more likely to get overwhelmed and begin to suffer from depression.

Everyone feels anxious, worried, sad, or depressed sometimes.  However, if someone feels anxious or depressed all or most of the time, and the feelings are significantly impacting their work, relationships, or health, they may have developed an anxiety disorder or some form of clinical depression.  Life may feel more and more difficult to manage and they may need help to begin to feel better.

The ideas and suggestions in this publication have all been shown to be helpful in decreasing anxiety levels and alleviating depression.  The most effective approach for treating anxiety and/or depression is often a combination of counseling and self-care. In addition to the strategies in this guide, exercise is an important self-care option.  It’s possible that a farmer is getting a tremendous amount of physical activity already, but it is worth noting that exercise is a well-researched strategy for reducing both anxiety and depression symptoms (Mayo Clinic, 2017).  Nutrition is also an important part of mental well-being, and there are easy tweaks that can be made to improve diet (Tello, 2020).

Alcohol and Other Drug Use  

One especially common behavioral health issue is Substance-Use Disorder (SUD).  More common terms might be alcoholism, drug abuse, misuse of prescriptions, or addiction.  SUD is a broader term used to describe situations in which the recurrent use of alcohol and/or drugs has significant negative impacts.  The impacts may include health problems, disability, and failure to meet major responsibilities at work, school, or home. 

Our culture has historically supported drinking or the use of other substances to “relax” or feel better. This has led to many people mis-using such substances through no fault of their own. Yet the risks of a substance-use disorder going unaddressed are significant. These can include risk of accidents and injury, family relationship problems, diminishing health, struggles with work, and legal complications.

Information is key in helping to identify problems early and in decreasing the chances of serious consequences.

Science now offers a public-health-oriented approach to translate the available science into effective, practical, and sustainable policies and practices to prevent substance “use” before it starts, identify and intervene early with emerging cases of substance “misuse,” and effectively treat serious substance-use disorders (McLellan, 2017).

It can be hard to know where to start when faced with these issues. Problems don’t look the same for everyone, and the most observable behaviors don’t necessarily give us the most pertinent information.  It may be easy to observe how much and how often a substance is being used, but these factors provide only basic clues regarding the severity of the problem.  A person’s age, weight, gender, experience with the substance, current environment, and countless other things will factor into the equation.  The most informative signs of a substance problem are the negative impacts, and these are often obscured.  Sometimes, even the person experiencing the problem may not recognize the indications that they have developed a problem.  If the issues are unrecognized, they will go unaddressed.  This is unfortunate, because scientific research has equipped us with effective strategies to support successful recovery.

Stigma can interfere with addressing the topic of substance use, even when it is recognized as a potential problem.  For some, talking about substance use can seem intrusive, and there may be concern that doing so will cause a defensive reaction.  One way to overcome this barrier is to make talking about substance use part of your conversations with farmers as a matter of course.  You may have noticed that many health care providers have adopted this practice, and it has proven to be a highly effective intervention (Agerwala and McCance-Katz, 2012).

The concept of the “universal approach” is that if a specific problem is common enough in a population—and serious enough that missing out on a chance to identify it is risky—it is easier to check on everyone than to try to figure out who to check. Universal approaches can play a role in reducing stigma.  Bringing up the topic in a relaxed and easygoing way can convey several things:

• I am comfortable with this topic if someone wants to talk about it.
• I won’t be surprised or shocked if substance use is a problem.
• Substance-use problems are common and not an unexpected response to stress.

These messages can help people be more comfortable sharing any concerns they may have.  If someone is concerned about their use of substances, there are steps they can take.

For help in determining if a problem exists or is developing, and to learn more about how to connect with support, including treatment options and resources for ongoing recovery from substance-use problems, see Appendix B: More on Substance-Use Disorder.

Opioid Crisis

The opioid crisis has been a frequent focus in the news and in our communities, and there is good reason for the topic to be a concern. Opioids are potent drugs with high risk of addiction and overdose. The National Institutes of Health provide information on overdose death rates (NIH, 2021).

Unfortunately, opioids are easy to access, and their potency can seem very attractive to anyone looking for a way to feel better when they are not doing well for one reason or another.  Farmers have been particularly hard-hit by this crisis, and overdose deaths have become common enough that it’s unusual for people not to know someone who has been impacted.  You can find more information about the opioid crisis in the United States in Appendix B: More about Substance-Use Disorder.

Family and Relationship Problems

One of the most rewarding parts of life is connections with other people. Relationships are important to physical and emotional health, and they can make good times better and bad times a little easier.   There are many kinds of relationships, all of which are important to wellbeing.  Most people find it helpful to have a good balance of relationships in their lives. For instance, being a parent may be extremely rewarding, but it doesn’t take the place of reminiscing with an old friend.  It’s helpful to have relationships with people who can be called on in an emergency, no matter what time of day it is, as well as people to have fun with on a Saturday night. The quality of relationships and the approach to forming and sustaining them are important to one’s sense of self and confidence.

As rewarding as connections with others often are, when these important relationships become challenging, there can be negative impacts on many parts of life, including moods and disposition. No one is immune from the challenges that relationships bring. Problems with communication, differences of opinion or values, fears and anger, disappointments, a lack of time and energy – these are all things that can challenge a relationship, but they don’t have to put a relationship at risk or keep it locked in constant struggles. When a relationship is struggling, intentionally nurturing it can make all the difference in the world. Strong relationships don’t just magically happen – they require constant feeding, self-awareness, and generosity of time, thought, and care.

As in so many other situations, regularly practicing resilience-building will provide a solid foundation for relationships.  It can be impossible for someone who is feeling drained to give care and attention to others.

Whether the relationship is with a spouse, life partner, children, or parents, family relationships are particularly important, and they are often the most challenging ones, as well. Sometimes, people mistakenly believe that family relationships should be easier than others, but the opposite is usually true. Family problems can trigger strong feelings, such as discouragement, fear, anger, and hopelessness.  Thinking sometimes seems to get off track, too, either because the same thoughts repeat or because the ability to form a coherent thought disappears. Between the swirling emotions and the compromised thinking, distraction can become a risk factor for accidents and injuries, as well as behaviors that make the problem worse rather than better. Learning and practicing some of the stress-management approaches presented throughout this guide can be important in carrying farmers through challenging times safely and in helping the relationship return to thriving.  Iowa State University Extension and Outreach offers a resource on farm stress and marriage (Tranel, 2019). 

A relationship is like a house. When a light bulb burns out you do not go and buy a new house, you fix the light bulb.– Bernajoy Vaa

To learn more about improving relationships, consult Appendix C: More on Families and Relationships.

Suicide

Suicide can be difficult to talk about, yet it has become one of the leading causes of death in the United Sates (Crosby et al., 2011), and it must be understood if that trend is to be reversed.

Some Important Facts

Considering the prevalence of suicide in the United States, many of us can expect to be impacted by a suicide in our lifetime. In fact, according to the Centers for Disease Control and Prevention (CDC) WISQARS Leading Causes of Death Reports (2020), in 2018:

• Suicide was the tenth-leading cause of death overall in the United States, claiming the lives of more than 48,000 people.
• Suicide was the second-leading cause of death among individuals between the ages of 10 and 34, and the fourth-leading cause of death among individuals between the ages of 35 and 54.

According to the CDC, suicide rates overall have increased by 40% in less than two decades (Peterson et al., 2020).

The same study showed that farmers are among the most likely to die by suicide, compared to other occupations. One likely factor in this is that most common means of suicide are generally easy to access on a farms, such as firearms and poison.

The Centers for Disease Control and Prevention (CDC) WISQARS Leading Causes of Death Reports  reveals that firearms are used in over half of all male suicides (2020). The means used in suicide for women change over time. Although younger women are most likely to die by suffocation, poisoning becomes a more common means of suicide as women age. Farmers are often isolated, as well, another key risk factor in suicide.

One of the reasons these statistics are news to many people is that suicide carries a great deal of stigma in our society. This encourages people to hide problems and try to keep them secret. It also often discourages people from seeking help. Much of that stigma is the result of commonly held beliefs that are not accurate. Learning accurate information about suicide can reduce the shame and fear of judgement often experienced both by people considering suicide and by their families and others who are concerned.  More information about myths related to suicide is available from the National Alliance on Mental Illness (Fuller, 2020).

Suicide Prevention for Everyone

Learn about suicide prevention before there is a need to know:

• Understand suicide in the community. How is it similar to or different from national statistics?
• Find out what local resources are available to provide support.
• Find a warmline. The term hotlines has become commonplace, and most people recognize them as places to reach out to in a crisis. The term warmline may be less familiar; it is a resource available when a person just needs someone to talk with while upset or struggling emotionally.  Warmlines are answered by people who are trained to provide immediate and confidential support to callers, prior to a crisis.  Sometimes talking to someone who understands can make all the difference (Mental Health America, no date).
• Hope is an essential element to providing support. It’s important that anyone in the role of offering comfort and assistance believe that things can improve. Find stories of hope and recovery and examples of people overcoming difficulties and finding new meaning in their lives at the National Suicide Prevention Lifeline (listed in the Further Resources section).
• Consider getting guidance by attending a training session. There are several trainings designed specifically for the typical family and community member. Often called “gateway” trainings, they are not meant for teaching professionals how to treat a suicidal person, but instead provide basic information and focus on helping anyone feel better-equipped to deal with the topic of suicide. For more information about training opportunities, consult Appendix D: More about Suicide Prevention.
• Know the options for emergency help.
• If danger for self-harm seems imminent, call 911.
• If danger does not seem imminent, you need to consider the best resource for the situation.
• If you know the person is working with a counselor or psychiatrist, they may want you to reach out to that person.
• You may want to consider the availability of farming-specific resources that provide crisis support. It is always helpful to be supported by someone who understands the issues at hand.
• The Farm First program provides Vermont farmers with 24/7 access to licensed clinicians trained to respond to just such situations. They can be reached at 877- 493-6216. Other states may offer similar resources.
• The hotline at 800-FARM-AID (800-327-6243) has trained Farmer Services staff answering Monday through Friday from 9:00 a.m. to 5:00 p.m. Eastern Time.
• A veteran may want to talk with someone who is specifically trained with that population. Call 800-273-8255 and press 1 or text 838255.
• Many communities have mental health centers that publish a hotline number.
• You can also call the National Suicide Prevention Lifeline at 800-273-TALK (8255) and follow their guidance. They may provide you with assistance or help you to locate a local resource.

More information specific to these steps within an agricultural context can be found in the publication Preventing Farm-related Stress, Depression, Substance Abuse, and Suicide (Dudensing et al., no date).

Steps to help someone who may be considering suicide:

• Ask the person if they are thinking about killing themselves.
• Listen without judging and demonstrate caring.
• Stay with the person (or make sure the person is in a private, secure place with another caring person) until further help is engaged.
• Remove any objects that could be used in a suicide attempt.
• Connect them with a friend, family member, or loved one who can stay with them.
• Get them connected to a counselor.

Given the prevalence of suicide, it is reasonable to consider the possibility that you may find yourself in an emergency at some point. It is critical to have a plan of what to do should such a situation arise.

Preventing Farmer Suicide: Collaboration and Communication, a five-minute video from Rural Health Information Hub, covers a great deal of information specific to farmers and suicide.

Talk about it!

• Talking openly about suicide helps break down stigma.
• Some word choices, such as referring to someone “committing suicide” can sound judgmental and be stigmatizing. Learning language that conveys support and hope is important. Words Matter, from the Centre for Addiction and Mental Health, offers recommendations.
• Play a role in ensuring everyone in the community knows how significant a problem suicide is.
• There are many ways for people to learn more and be prepared to be helpful.
• Put an editorial in the newspaper.
• Invite a speaker to a community meeting.
• Make sure the topic of suicide is appropriately discussed in schools.

Asking someone if they are suicidal will not make them decide to kill themselves. It does not plant the idea in anyone’s head.  Asking lets them know that someone sees they are hurting; someone cares and is not afraid to know the truth.

It doesn’t have to be complicated or formal. For example, someone might ask: “You’ve been dealing with a lot and I’m concerned about you. Sometimes people in these hard situations find themselves feeling hopeless and may think about suicide. Have you found yourself thinking of hurting or killing yourself?”

What not to do:

• Trying to “fix” the person contemplating suicide is unlikely to be helpful. It’s not the job of anyone but a trained professional to assess risk and respond appropriately.
• A person who cares and wants to be helpful should follow the steps above for responding to an emergency. The objective is to keep the person safe while waiting for further response.  Engaging in discussion about the suicidal thoughts is very rarely appropriate.
• Ignoring indications that someone might be suicidal is extremely risky.

For more information about suicide, including learning warning signs, training opportunities, and risk factors related to suicide, read Appendix D: More about Suicide Prevention.

Grief and Loss

Grief and loss are part of all lives.  Loss comes in many forms, and the range of grief responses is just as varied. It helps to know that there is no right or wrong way for people to respond to loss, and no one has the answer about what is “right.” People suffering a loss should be encouraged to be kind and gentle with themselves and to discount any well-meaning advice that doesn’t seem right to them.

Here are some tips that may be helpful when you’re with anyone grieving a significant loss:

• Don’t ignore the person grieving, or their loss, because you don’t know what to say or you’re afraid to say the wrong thing. In fact, a person deeply grieving will likely remember only whether you showed up for them. It is unlikely they will remember what you said. A simple statement that says, “I see your pain and I care” is all that is needed.
• Conversation is not always necessary. Sometimes it’s important to just listen, and sometimes it’s just about being present even when someone doesn’t want to talk.
• It may be uncomfortable to witness pain and grief, but don’t try to fix it. If a saturation point is reached, take a break and come back later.
• If you want to be supportive, asking about what the grieving person would find helpful is fine, but the question may not get an answer.  It’s best to pay attention and try to determine what specific and practical things may need to be done. Do the cows need to get in?  Is there an area that needs cultivating? “Can I pick the kids up from school for you today?”  “I’m going to the store — do you need bread?”
• Keep in mind that grief is dealt with differently from one culture to another.  Some things may be unfamiliar. There may be traditions, behaviors, and reactions that seem strange. Consider this an opportunity to learn something new.

Here are some guidelines that others have found helpful and that you may want to share with a person grieving a significant loss.

• People may be surprised at their emotional responses. It is not odd if they find themselves having feelings other than sadness. Anger, relief, denial, numbness, fear, and guilt are all “normal” responses.
• It may be especially hard for people to accept their emotional responses when they include positive feelings. Relief is not an unusual reaction.  It may arise from situations where the relationship or situation has been very challenging or because the loss has been slow and difficult and now that part has ended. People may feel joy when losing a loved one if that person’s suffering has ended or their faith tells them the person is now in a better place.
• Don’t be confused if the “stages of grief” that people talk about don’t seem to fit. The so-called “stages,” often referred to as denial, sadness, bargaining, anger, and acceptance, are responses experienced by some people. Some may experience all and others may experience just one or none. People don’t travel from one stage to another in a neat sequence where one feeling replaces another until crossing some invisible finish line. They may come in an order different than described, and some are revisited multiple times or may not be experienced at all. The process is messy. Many have described it more like rolling waves than stages. Stages can be a helpful way to understand some reactions, but they are just a concept and have not been definitively established by scientific research.
• When a loss is experienced by a family, it is likely that each family member will have a different grieving process. Each family member is likely to have their own timeline, needs, capacity to provide support to others, and potentially many other differences. This can be a disappointing surprise for people who assume that those who suffered the same loss will be able to understand better than an outsider.
• Expect that people grieving profound loss may experience changes in their sleep patterns and appetite.
• When it’s possible, it can be important for grieving individuals to let others know what they need – no one is a mind reader and able to know what someone else needs. It is not unusual for the grieving person to feel like they don’t know what they need either. When their needs become clear to them, they can articulate them.
• It’s helpful to encourage grieving individuals to keep regular routines of self-care in place, when possible.

Hallucinations are another common response to grief, but they may be unexpected because it is an occurrence that is not frequently discussed.  It can be surprising or alarming if someone hears or sees a loved one who has died. Sometimes people don’t raise the issue for fear they may seem “crazy.”  For this reason, it can be helpful to normalize the situation by including it in any conversations about what someone might face.  For many, it is a comfort to have these experiences.

Loss of a Farm

Losing a farm, or a portion of it, or the potential risk of such a loss, is complex and challenging. This is partly because there are many other losses wrapped up within it. Losing the farm may be traumatic if it also portends the loss of the means to earn a living, a daily routine, social relationships, animals, a place to live, or a connection to the past. For many families, the farm has been a significant part of their identity and how they interact with the world.

Like all grief, this misfortune will likely involve a multitude of feelings, and the strategies for understanding and coping with emotions that are recommended for other losses will also be helpful for this situation.  It may, however, be especially important for a farmer or farm family in this position to connect with others who have had suffered through the same circumstance. Although guilt and shame are common in grief, they may play a particularly strong role in farm loss.  The message that others have found ways to survive such a loss is important.

It is crucial that anyone in this situation have access to the professional support they need.  This may include expertise in financial, legal, and disaster assistance, and, of course, counseling. For some practical information about managing such a loss, consult the publication Coping with Restructuring or Sale of the Family Farm. This guide includes helpful sections related to legal and financial issues.

Anger

Everyone experiences anger, and it is a normal and healthy emotion.  Anger can help a person  recognize when something in life is not working. However, out-of-control anger responses can be devastating to an individual, their family, and those with whom they work.  It can be very frightening to those who feel out of control and difficult to know that they may be scaring those they care about, or maybe even hurting them. This type of anger is more likely when stress levels are high and when there is a feeling of being trapped and having no way out of a situation. People who grew up in homes where anger was expressed in hurtful ways are more likely to experience anger problems as adults.  Substance-use problems and mental illness often co-exist with anger problems.

It’s important for people to be aware that there are skills to help them manage anger in ways that don’t cause problems. Two specific resources that may be helpful are 11 Anger Management Strategies to Help You Calm Down and Anger Management: Your Questions Answered.

The strategies suggested in other sections of this document can be highly effective for helping to keep anger from being harmful. For example, counseling is often used to treat anger issues.

Violent Behavior

Embarrassment and shame may make it difficult for someone to reach out for help with anger issues. This can be especially true if the circumstances have included violent behavior. Resistance to asking for help may be present for both the person acting out violently and anyone who is being subjected to the violence.  Other factors that prevent reaching out for help may include isolation, lack of a trusted source of help, and fear of potential consequences.  Two particularly common types of violence in the United States are domestic violence and child abuse.

It’s important to realize that attempting to confront or address these behaviors without the proper training and support can increase the risk of danger for all involved.  If violent behavior is suspected, the safest and most effective approach is to utilize the resources available to obtain help in creating a safe action plan.

Many resources are available to address these issues, and the best time to become familiar with options is before they are needed. It’s important to keep in mind that child abuse and domestic violence are often co-occurring.

• The National Domestic Violence Hotline, 800-799-7233
  The hotline can offer support and information, as well as provide connections to local resources.
• National Indigenous Women’s Resource Center
  
• Every state has a reporting system that is always available for people who need to report suspected child abuse.  Find your state’s information in the list of State Child Abuse and Neglect Reporting Numbers here.

States vary regarding regulations about the definition of suspected child abuse, who is mandated to report child abuse based on their profession, and other related topics.  Every state is required to make this information available to the public.

Medication Therapy

Whether medication should be an option for treating mental health problems can be a complicated subject. It’s important to have what is needed to make an informed decision, and that requires a consultation with someone who has expertise in the topic, so that the right choices are made and both potential side effects and effectiveness can be monitored.

Medication is often considered when counseling alone is not sufficient. Counseling is often the first step, as it can be as effective or more effective than medication, has a clear end point, and does not typically produce side effects. Ideally, an individual would seek a counselor who is skilled and experienced at assessing when medication is a viable option. The best scenario is one where the counselor has access to a consulting psychiatrist to whom they can refer clients seeking to further explore medication options.

If such a counselor is not available, then individuals can seek help from their primary care doctor. Unfortunately, many primary care doctors only have a cursory knowledge of how best to care for psychiatric needs. They are likely to have prescribed different medications, but there is much to know about getting the right medication for a particular person. Ideally, as with counselors, it is best if the doctor has a consulting relationship with a psychiatrist.

Some of the most commonly used medications for mental health symptoms are antidepressant, antianxiety, anti-psychotic, mood stabilizing, and stimulant medications (WebMD, 2020). Each type focuses on different symptoms.  Medication should be combined with counseling to be most effective. It’s important for anyone taking medication to know that the medications often take time—even many weeks—before they work fully, and it’s not unusual for people to need to try different dosages or other medications, before finding what works best.

A solid understanding of potential side effects is important, including what one might expect, situations that would require medical care, and activities that should be avoided while taking the medication. For example, drowsiness is a side effect of many medications, and it is essential that people steer clear of dangerous tasks when they are drowsy. Changes may be needed in dose or type of medication to keep a farmer safe.

One other important factor that prescribers should consider is whether there is a personal or family history of alcoholism or other drug addiction — even if it’s in the past. They should ask their patient about this, and if the prescriber does not ask, the patient should volunteer the information. The question, when unexpected, can be surprising or unsettling, so it can be helpful if the person seeking support has been told that revealing any such history is important. This is because some medications have a higher potential of causing problems when mixed with other substances, or of creating a dependence. An open and honest relationship between patient and prescriber will result in the most safe and effective plan.

Alert:

Some medications carry a high risk for abuse or addiction. This does not mean that the medication is not a good idea, but it is vital to consider when making decisions.

Peer Support

Peer support consists of individuals trained to provide support to others in the same profession who are having difficult experiences. Peer supporters offer emotional support, share knowledge, teach skills, provide practical assistance, and connect people with resources (such as professional counselors), opportunities, communities of support, and other people (Mead, 2003; Solomon, 2004).

This model is used as a strategy in dealing with many different situations, including substance-use disorders, mental health issues, parenting, caregiving, veterans, and chronic health issues such as diabetes.  By sharing experiences, peers share hope with one another and learn together how to move past the difficult situations in their lives. There are also support groups available that offer the opportunity to be with others who share their struggles.  An article from the Substance Abuse and Mental Health Services Administration,  “Who Are Peer Workers,“ is included in the Further Resources section.

Conclusion

Although there are many risk factors and situations that may cause concern for farmers, there are also many useful strategies that can help remediate emotional pain.  With the right information and resources, it becomes easier to understand these problems. Learning more about them also makes it easier to find strategies and supports that can alleviate them.  We hope that the information in this second volume, coupled with the strategies covered in Part I, provides a helpful guide for agricultural service providers, farmers, and others in the field.

Further Resources

11 Anger Management Strategies to Help You Calm Down. 2021. By Amy Morin. Very Well Mind.

Advocacy Curriculum, A Culturally-based Perspective on the Dynamics of Violence Against Native American Women and the Advocate’s Role. 2021. By National Indigenous Woman’s Resource Center.

Anger Management: Your questions answered. 2020. By Mayo Clinic staff. Mayo Clinic.

Child Welfare Information Gateway, State Child Abuse and Neglect Reporting Numbers 

Coping with Restructuring or Sale of the Family Farm. 2017. By Damona Doye. Oregon State University Extension.

Disabilities in the U.S. Farm Population. 2019. By Cristina Miller. Amber Waves. April 1.

The National Domestic Violence Hotline

National Suicide Prevention Lifeline

Peers. 2020. By Substance Abuse and Mental Health Services Administration. U.S. Department of Health and Human Services.

Preventing Farmer Suicide: Collaboration and Communication. 2019. By Rural Health Information Hub.

When Do You Need a Counselor? No date. By Randy R. Weige and Hattie Penny. University of Wyoming Extension. B1124.2.

Words Matter. No date. By Centre for Addiction and Mental Health.

Appendix A: Paths to Finding the Right Therapist

There are a variety of approaches to finding a therapist:

• One option is looking through the American Psychological Association’s database of therapists in private practice. The brief descriptions of their services can be informative, and they are categorized by location.
• Many areas have community mental health centers that offer an array of services, including counseling. These can be found in area phone directories or on the Internet.
• Counselors in private practice often advertise their services in these same ways.
• Probably the most common first step is a recommendation from a health care provider or from friends and family members.

While it can be helpful to have a place to start, these options should be considered just the beginning of the process to determine if a particular counselor is the best choice in a specific situation. When someone decides to contact potential therapists, there are some things to explore in making good choices:

• What issues do they want to address? These can be specific or vague, but it’s important to ensure that the potential counselor is able to describe clearly what issues they are qualified and interested in addressing. Many counselors have specialties such as substance use disorder, family/relationship problems, struggles with chronic pain, etc.
• Are there any specific characteristics that are important? Gender?  Age?
• Does the potential choice under consideration offer a free initial session? Many do—especially if asked.
• Does the farmer have health insurance? University of Delaware Cooperative Extension offers online information about Farm Operations and Health Care Insurance Options.

When a person has a therapist in mind, there are some questions that should be asked during the decision-making process:

If a health insurance plan is in place, is it one that this counselor accepts?

• Does the plan include special processes (like a referral from a primary care doctor) to access a specialty service like counseling?
• If there is no health insurance plan in place, how much can the farmer realistically afford to spend? Even with insurance, there are often uncovered charges such as co-payments and/or deductibles. It’s important to gather the information that allows for an informed decision.
• Are sliding-scale prices or payment plans available? These are not unusual.
• Where will therapy fit into the farmer’s schedule? Do they need a therapist who can see them on a specific day of the week? Or someone who has evening sessions? What is the distance they’re able to travel for appointments?

Another consideration is the counseling approach or model used. Counselors may identify themselves as having a specific approach, such as cognitive or cognitive behavioral, solution-focused, psychodynamic, humanistic, etc. It’s okay to ask questions about what that all means. There is a considerable amount of research that compares models for different people or different situations. No single type of counseling is best for everyone, and exploration is worth the time spent. See the article 12 Popular Counseling Approaches to Consider, from Positive Psychology.com.

For stress management and overall well-being, many people find cognitive therapy or cognitive behavior therapy (CBT) to be effective.  Working with these models, counselors often take a focused, action-oriented approach. Some types of treatment rely heavily on gaining insight into why a person thinks, feels, and acts as they do.  Cognitive therapies focus more on working to change those things.  This can be very appealing for people who dislike the idea of “touchy-feely” work. These approaches to counseling are often short-term and focus on building skills and learning to reframe negative thinking to be more realistic. CBT has been particularly well-researched and has a strong basis in evidence.  Learn more from the American Psychological Association’s post, What is Cognitive Behavioral Therapy?

As stated earlier, the relationship between the client and counselor is an important component of success. People should be encouraged to try out one or two counselors to be sure the fit is a good one. It may seem like wasted time in the beginning, but it can save a lot of time in the long run. 

Appendix A: Further Resources

12 Popular Counseling Approaches to Consider. 2021. By Heather S. Lonczak. PositivePsychology.com.

Farm Operations and Health Care Insurance Options. No date. University of Delaware Cooperative Extension.

Psychologist Locator. American Psychological Association.

What is Cognitive Behavioral Therapy? 2017. By American Psychological Association.

Appendix B: More on Substance-Use Disorder

I’m Not Sure if I Have a Problem

Take our simple and confidential self-assessment. It will help you answer the question of whether or not you have a problem. Better yet, you can call a licensed drug and alcohol counselor who can confidentially help you explore your relationship with alcohol or other substances.

Getting Assistance

Treatment and help are often a lot easier than people think. You may have heard of residential 30-day treatment programs, and although such programs exist, most people can be helped through simple outpatient counseling. This kind of counseling can even happen remotely, through the computer. A licensed counselor can help you sort through options. For more information about counseling in general, review the counseling section of this publication.

More on the Opioid Crisis

• A 2017 survey of U.S. farmers revealed the alarming scope of the problem:
  • 74% of farmers or farm workers are or have been impacted by opioid misuse.
  • 26% of farmers and farm workers have abused, been addicted, or have taken an opioid without a prescription.
  • 77% of farmers or farm workers believe it would be easy to access opioid painkillers without a prescription.

Some examples of opioids that can be prescribed by a doctor include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Lortab, Lorcet, Norco), hydromorphone (Dilaudid), meperidine, Demerol), oxymorphone (Opana), fentanyl, morphine, and codeine.

Historically, U.S. healthcare providers routinely overprescribed opioids because they were less aware of the risk of dependence. Between 2006 and 2015, the prescription dispensing rate per 100,000 people ranged from 72.4 per to as high as 81.3. By 2016, the rates began to trend down as new research and policies began to impact prescribing customs. This trend has continued, with each year showing a decrease, and the most recent data available showed a rate of 46.7 in 2019 (CDC, 2021).

Learn more about the national response strategy in Epidemic: Responding to America’s Prescription Drug Abuse Crisis.

Information on the extent of the problem is critical, as it demonstrates the degree to which the problem can be effectively addressed, and this awareness can spark advocacy for targeting a reduction in prescribing rates or farmers. It is still common for these drugs to be prescribed for pain, and farmers commonly experience pain as the years of heavy work take their toll on the body. The Centers for Disease Control and Prevention states that opioids are prescribed for about 20% of farmers and the farm workforce who are injured and unable to work on any given day.

The more these drugs are used, the greater the risk of addiction and overdose. In addition, drugs like heroin and fentanyl are readily available in most places, even if prescription drugs are not. Find information on non-prescription opioid use in the publication Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.

The reasons for the high rates of overdose are complex and it can be helpful to understand the waves the epidemic has experienced in the United States. CDC offers a post, Understanding the Opioid Overdose Epidemic that can help. Fortunately, there are successful interventions if an overdose is recognized quickly and the right preparation is made. Anyone working with the public in any capacity is encouraged to learn effective overdose response so that they have the capacity to recognize a potential overdose victim and know what actions to take. The U.S. Department of Health and Human Services offers information on How to Respond to an Opioid Overdose.

According to the American Farm Bureau Federation and the National Farmers Union, the opioid crisis has struck farm and ranch families much harder than the rest of rural America. These organizations have teamed up to bring attention to the epidemic in farm country and provide information and resources to help those struggling with opioids. The initiative is called Farm Town Strong and more information is available online.

Appendix B: References

CDC (Centers for Disease Control and Prevention). 2021. U.S. Opioid Dispensing Rate Maps.

Appendix B: Further Resources

Epidemic: Responding to America’s Prescription Drug Abuse Crisis. 2011. By the Executive Office of the President of the United States.

Farm Town Strong

How to Respond to an Opioid Overdose. 2020. By U.S. Department of Health and Human Services.

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. 2017. Edited by J.K. Phillips, M.A. Ford, and R.J. Bonnie. National Academies Press, Washington, D.C.

Understanding the Opioid Overdose Epidemic. 2021. By Centers for Disease Control and Prevention.

Appendix C: More on Families and Relationships

To make relationships work, people must first recognize the value of them.  An exercise that can help people begin is to list all the relationships they have—family ones, work ones, friends and neighbors, and so on. As they take a moment to reflect on each of these, they will likely find that thinking of some immediately makes them smile. They might find it useful to try to remember the last time they told this person how they feel about them. Appreciating others is an important part of nurturing relationships. They may find that some relationships that come to their minds will more likely leave them feeling indifferent or unsettled. It can be helpful for them to realize whatever their reaction may be, it’s not a reason to judge themselves harshly. Determining if some relationships are troubling and others fulfilling can be very helpful in preparing for change.  Sometimes, relationships have become just habits and no longer add much to life. People may identify some trouble spots and consider whether they’d like to work on them, perhaps with a counselor. They may realize that some relationships bring so much joy that they decide they want to devote more time to them…and less to the non-fulfilling ones.  Concentrating on important relationships provides the time and emotional energy to work on them.

• This work can include:
• Appreciation
• Commitment
• Communication
• Humility – or acceptance of our own flaws
• Patience
• Thoughtfulness
• Understanding

These are not always easy things to do. Sometimes it becomes clear that to work on one relationship requires the aid of another. Perhaps, when struggling with a teen’s behavior or attitude, it can be very helpful to talk with their own parents or a trusted friend. These other relationships can yield support and a new perspective that, in turn, helps to improve the relationship that is under stress. At other times, it is important to seek the help of an objective, experienced professional in the form of counseling. See Appendix H for help in finding a counselor.

Creating space in life to focus on these ways of being with others is essential, because time is often the most important thing there is to offer to others. It can also be one of the hardest things for a farmer to find. People will often falter in their efforts because they mistakenly assume that worthwhile investments of time only happen when a large amount of time can be carved out. This is what is happening when one starts thinking “we’ll be able to spend time together once we save up enough for that trip to Disney World.” Or maybe, “I’ll be able to spend time once winter comes around again.” A useful strategy is to start by thinking small. It is much easier to dedicate a few minutes of time frequently, and it doesn’t have to be anything exotic. Family relationships are built on daily interactions. Consider the list below as a place to encourage someone to start.

• 10 ways to spend more time with your family.
• Eat dinner together. Or breakfast if that’s easier.
• Cut back on non-farm commitments.
• Go for a walk with the whole family.
• Take the family to an event at the grange.
• Run errands together.
• Ask a neighbor to care for your animals one day and get away with your spouse. You can return the favor.
• Have your kids invite their friends to spend time on your farm.
• Work on projects together.
• Decide to do some things routinely: coffee with a spouse/partner before the day begins, bedtime stories with the kids, pancakes on Sunday mornings, ice cream for dessert on Tuesdays, a family game night or maybe a movie and popcorn one…… simple things that can give life an important sense of rhythm.
• Ask your family for their ideas.

Parenting and Family Relationships, a resource that provides helpful information about family life throughout the lifespan, is available online from University of Wisconsin Extension.

Appendix D: More about Suicide Prevention

The National Centers for Disease Control and Prevention (CDC) has a program on suicide prevention, with information available online.

Training Programs

No amount of information in a resource guide is an adequate substitute for training. Anyone who works with a population that is at an unusually high risk of suicide (and this includes farmers) should be trained in the topic. One does not need to be a mental health professional to help prevent suicide.  Mental health professionals are trained to both recognize and treat people who are suicidal, but everyone can be trained to better recognize and respond.  Suicide training for lay people is often called “gatekeeper” training. It is readily available in most communities and often targets specific populations, such as youth or veterans.  A descriptive list of 40 different options is available from the Suicide Prevention Resource Center in Choosing a Suicide Prevention Gatekeeper Training Program: A Comparison Table.

These trainings are currently being used extensively in the field of agriculture:

• SafeTALK stands for “Tell Ask-Listen-Keep Safe.” Although used with broad audiences, the program has also been tailored specifically to meet the needs of those who work with farmers daily. Read more about this initiative on its website.
• QPR Gatekeeper Training stands for Question, Persuade, Refer. The QPR Institute also makes the course available online.

Other related trainings:

• Mental Health First Aid is a program that has many commonalities with gatekeeper trainings for suicide, in that it focuses on being able to identify a potential problem and respond appropriately by connecting the struggling person with the right resources. In this case, although the topics address suicide, the training focuses on a broad array of mental-health and substance-use issues. Many University Extension Service programs provide this training virtually or face-to-face and there is now also an online option.
• The Vermont Suicide Prevention Center offers a variety of trainings, including gatekeeper training, UMatter, for various populations. The center has demonstrated willingness and ability to work with specific communities (first responders, schools, faith communities, etc.) to tailor its trainings to be responsive to those needs.

Know the Warning Signs

It is not always possible to know that someone is considering ending or has decided to end their life, but there are often observable warning signs. These signs are particularly concerning when the onset is sudden, or there is an abrupt increase in them, especially closely following a loss or other painful event. Tuning in to notice warning signs takes deliberate focus.  Pay attention to what you hear and see.  Pay attention to your gut instincts when something just doesn’t feel right.

Of course, people may exhibit these signs without being suicidal, but the signs indicate that there is likely a problem of some sort.  It’s important not to ignore these signals, as they could be indicative of several serious situations.

Things you may hear:

• Talk about or hints at suicide
• A statement that they wish they were dead
• Talk of feeling hopeless or trapped
• Talk about feeling unbearable pain
• Talk about being a burden/that others would be better off without them
• Preoccupation with death

Things you may observe or discover:

• Making a will or other last arrangements, giving away possessions
• Looking for a way to kill oneself, such as getting a gun
• Withdrawing from family, friends, and routines that were pleasurable
• Behaving aggressively and disruptively; acting recklessly
• Exhibiting increased irritability and criticism
• Frequently thinking of suicide with a plan in mind
• Changing sleep and/or eating patterns
• Not taking medication as prescribed or hoarding medication
• Increasing use of alcohol or other drugs
• Sleeping too much or too little
• Showing rage or threatening revenge
• Displaying huge mood swings

Learn Risk Factors

Warning signs are observable and can indicate that suicide has been, or is being, planned. Risk factors for suicide, on the other hand, are characteristics of a person or his or her environment that increase the likelihood that he or she will die by suicide at some point. A person does not need to wait until warning signs emerge to recognize that they have a higher-than-average risk of becoming suicidal at some point. Because being aware of that allows for a proactive response, it’s important for people to consider risk and plan accordingly.

Major suicide risks include:

• Personal characteristics
• Prior suicide attempt(s)
• Mental disorders, particularly depression and other mood disorders
• Substance-use disorder (use of alcohol and/or other drugs that cause problems)
• Impulsive or aggressive tendencies
• Connection to someone who died by suicide, particularly a family member
• Social isolation, a feeling of being cut off from other people
• Chronic disease and disability
• Family history of child maltreatment
• Unwillingness to seek help because of the stigma attached to mental-health and substance-use disorders or to suicidal thoughts

Environmental factors:

• Access to lethal means
• Lack of access to behavioral health care
• Cultural and religious beliefs (a situation where suicide may be considered heroic self-sacrifice)
• Local epidemics of suicide
• Barriers to accessing mental health treatment

Many of these are considered “static” factors, meaning that if it becomes a risk, it will not change, although of course people can change their response to the factor. For instance, if a person has already exhibited suicidal behaviors, they will always be someone who has exhibited suicidal behaviors and it will have an impact of their risk level on an ongoing basis. Other factors are dynamic, because there are ways to reduce or even eliminate the impact on risk. Access to lethal means is a particularly poignant factor in this respect. Reducing access will reduce suicide.  For some people, this obstacle will only delay their actions or produce a decision to choose different means, although it’s important to note that for many people, that is not what happens.

Many people who attempt suicide act with little planning during a short-term crisis, and 90% of those who survive an attempt do NOT go on to die by suicide later. This indicates that anything that delays action can have a significant impact on the eventual outcome. We also know that some means are simply more lethal than others, and limiting access to those can have a dramatic impact. For example, about 85% of attempts with a firearm are fatal; that’s a much higher case fatality rate than for nearly every other method. Many of the most widely used suicide-attempt methods have case-fatality rates below 5% (Harvard, 2021).

It can also be helpful to be aware of common precipitating factors. These are stressful events that can trigger a suicidal crisis in a vulnerable person, often because they bring on thoughts that things will never get better now that “this” has happened. These thoughts can trigger a dangerous sense of hopelessness.

Examples include the following:

• End of a relationship or marriage
• Loss of the farm or business
• Death of a loved one
• An arrest or other serious legal problems, such as being sued
• Serious financial problems—especially when these problems have been kept relatively private but appear likely to become more well-known due to some new circumstance

Identify and Support Protective Factors

Protective factors are what help to balance out any risk factors that a person might have. In other words, in the case of suicide, they can buffer people from suicidal thoughts and behavior that risk factors may make more likely. Unfortunately, protective factors have not been studied as extensively as risk factors, but it is vital to recognize the importance of protective factors, as they can often be strengths to build upon.

The CDC identifies the following protective factors (2021):

• Coping and problem-solving skills
• Cultural and religious beliefs that discourage suicide
• Connections to friends, family, and community support
• Supportive relationships with care providers
• Availability of physical and mental health care
• Limited access to lethal means among people at risk

Special Issues in Suicide

The term suicide survivor is often used by people who have lost someone who is important to them through suicide. There are numerous ways in which a death by suicide can complicate the typical grief response, and it is important to be aware of these to be ready to support those in this situation. Harvard Medical School addressed this topic in a blog post (Harvard Women’s Health Watch, 2020).

Suicides among children and young people aged 10 to 24 rose 57% from 2007 to 2018, according to a report from the CDC. Although this is not the age band with the highest rates overall, it is by far the fastest growing. Theories and ongoing research to further understand this increase are also growing quickly. Adolescents and children are not just “little adults,” and there are special considerations that need to be understood to for suicide prevention in this group. Learn more about the situation and ways to be active in prevention at the websites listed in the Further Resources section.

Appendix D:  References

Centers for Disease Control and Prevention (CDC). 2021. Suicide Prevention: Risk and Protective Factors.

Harvard Women’s Health Watch. 2020. Suicide survivors face grief, questions, challenges. Harvard Health Blog.

Harvard T.H. Chan School of Public Health. 2021. Lethality of Suicide Methods.

Appendix D: Further Resources

Choosing a Suicide Prevention Gatekeeper Training Program: A Comparison Table. 2018. Suicide Prevention Resource Center.

Comprehensive Suicide Prevention. Centers for Disease Control and Prevention.

Mental Health First Aid

QPR Training

Vermont Suicide Prevention Center

Farm Stress And Emotional Well-Being, Part I
By Karen Crowley, Farm First, with Andy Pressman, NCAT FRSAN-NE Project Leader
Published November 2021
© NCAT
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Slot 651

This publication is produced by the National Center for Appropriate Technology through the ATTRA Sustainable Agriculture program, under a cooperative agreement with USDA Rural Development. This publication was also made possible in part by funding from the USDA’s National Institute of Food and Agriculture, Farm and Ranch Stress Assistance Network (FRSAN), projects 2019-70028-30464 and 2020-70028-32729. ATTRA.NCAT.ORG.