Cassandra Armas was already on the phone when she got the call.
A therapist who treats middle school students, Armas works from a small, cheerful office, with whitewashed brick walls at Homestake Peak School in Eagle-Vail, a rural resort mountain town in the Colorado Rockies.
The voice on the other end of the line didn’t give a name. But Armas knew it was a student. They asked if she was busy with someone else.
“I am not,” Armas answered, concerned.
The student couldn’t suppress the urgency in their voice. They asked if they could come see her.
“Yeah, for sure,” Armas said, shuffling her papers. That call would remake her plan for the entire morning.
Armas is a frontline worker fighting to rein in a crisis. Her job, as an in-school therapist was created by a community-wide effort in Eagle County to change the bleak narrative of rural childhood mental health in the region by putting therapists in the schools. Today there are 17 therapists who see students at every school in the district. In 2017 there were none.
At Homestake Peak, the room is an oasis. Kids who come to see Armas can opt for the modern bench sofa, or the bean bag by the window. There are pillows piled up on both. But the most important thing about the space is its location, just a few feet away from the school counselors’ office, and around the corner from the classrooms where Armas’ adolescent clients spend their days.
“They come into my office, and we have a whole session here at school and then they're able to go back to class or go on about their day without having to miss much of school,” Armas said.
Proximity is everything when a student is experiencing a crisis. The call Armas answered came from the school nurse’s office. It was one of her middle school clients, in the throes of an anxiety attack. Instead of acting out in class, or calling it quits and leaving school for the day, the student called Armas.
“That tends to happen,” Armas said, hanging up the phone. “I recognize [the] voice.”
Less than 90 seconds later, the student was in her office, getting treatment.
A mental health crisis: too much demand, not enough supply
That student is not alone. Kids all over Colorado are living with mental health struggles. According to state data from 2017, more than 15% of Colorado children require mental health care, and not all of them get it. Seventeen percent of high schoolers have considered suicide. And that was before the pandemic exacerbated the problem.
Many communities lack the resources to help those who need it. In fact, most counties in Colorado are classified as Mental Health Professional Shortage Areas, a federal designation meaning there aren’t enough therapists, psychiatrists, social workers, case workers and other mental health providers to begin to chip away at the demand.
The problem is especially acute in rural areas. More than two-thirds of the designated shortage areas are in rural communities. Rural children are more likely than their urban and suburban counterparts to have mental and behavioral health disorders. And yet, mental health care providers who specialize in youth and adolescent care are in particularly short supply in these communities.
Challenges unique to a rural mountain resort town
Armas grew up in Eagle County. But attitudes towards mental health look very different now than when she was a schoolgirl. Back then, there were no therapists down the hall from homeroom.
Armas recalls two of her friends attempting suicide in the 8th grade. They both ended up leaving the community to get in-patient care in a city hours away because local resources didn’t exist at the time.
“It would have been very beneficial for them to see a clinician [here],” Armas said. “They had trauma that they could have unpacked.”
She says there was a lot of stigma surrounding mental health issues when she was growing up. “It was not until recently that our community really started placing a big emphasis on mental health,” she said.
That change came about in 2017. That year, the county experienced a spike in suicide deaths, forcing the community to take a hard look at their growing mental health crisis. The county passed a new tax to fund a complete community-wide mental health overhaul.
As the community dug into the problem, one thing that stood out immediately was the lack of local mental health resources.
“The biggest challenge to behavioral health in Eagle County is recruiting and retaining qualified licensed providers,” said Dana Erpelding, Senior Operations Director with Eagle Valley Behavioral Health, the organization that coordinated the overhaul.
But there were other challenges, too. Structural and economic forces in the region placed a lot of stress on families, and that stress trickled down to the kids
Eagle County is a rural area but luxury ski resorts like Vail and Beaver Creek cast a long shadow over the community. Expensive vacation homes dot the mountains surrounding Homestake Peak School. The cost of housing is high. And yet, the area also has high rates of poverty. Close to 40% of students in the Eagle County School District qualify for free and reduced lunch. Many are immigrants.
Homestake Peak School Principal Stephanie Gallegos says that combination creates enormous stress and anxiety for families. “Parents often will have second and third jobs,” she said.
As for Armas, most of her clients come to her with trauma. “The biggest two [issues] that I have here at this specific school is a lot of sexual abuse and immigration trauma,” she said.
At the same time, barriers to care remain high. In an area where towns – and the resources – are separated by long stretches of highway, Erpelding says a simple lack of transportation can be one of the biggest hurdles.
“Parents have issues getting time off of work to take their kids to a clinician,” she said. “That's why we started exploring school-based services and having licensed clinicians placed in our elementary, middle and high schools in the public school system.”
Proximity as a solution
Placing therapists inside the schools makes sense in this region because it dissolves those barriers.
Armas currently juggles a caseload of 30 kids, most of whom she sees on a weekly basis at her office in Homestake Peak School. On a typical day, she does individual therapy sessions with a handful of students, whom she pulls out of class with a discreet phone call to the teacher.
But Armas says oftentimes her clients will come to her, asking for a session when they need one, like the student who had the anxiety attack that morning.
When that happens, Armas is able to jump in and help students get regulated. That morning, she guided the student who called her through breathing exercises. She grabbed an icepack from the teachers’ lounge — the cold sensation on the skin helping to ground them in their body.
“Once I get them to a calm, collected place, then we talk about the triggers,” she said.
That’s where the in-school therapist model excels. “We're able to help in the moment rather than waiting until the next appointment and have the student forget the reason why they had an anxiety attack,” Armas said. “I think it's pretty cool that we're able to intervene right there and then.”
The Your Hope Center runs the in-school therapy program. It started in 2018, with two clinicians serving just two of the schools in the district. They’ve since expanded to 17 clinicians serving all 18 district schools.
Their services are in high demand. During the 2021-22 school year, the school-based therapists worked with 803 kids in the district. This year, they anticipate that number will be over 1,000. Armas has maxed out her caseload – and then some – since her first day on the job.
More work ahead
When the COVID-19 pandemic hit in 2020, the efforts to address community-wide mental health in Eagle County got its first major stress test. As childhood mental health across the country deteriorated over video-conferenced classrooms, Eagle County seemed to have a head start.
“Having these clinicians’ already established relationships with the students, I think our community came out of the pandemic over the last few years in a better place because we already had those services in place,” Dana Erpelding, of Eagle Valley Behavioral Health, explained.
Still, Eagle County remains a designated Mental Health Provider Shortage Area, and clinician recruitment is difficult — particularly for clinicians like Armas, who have the language skills and cultural competencies to connect with the kids here.
“It's difficult to find pediatric behavioral providers, let alone behavioral health providers that work with kids and speak Spanish,” Erpelding explained.
Nearly one third of students in Eagle County are English language learners. Ideally, there would be enough therapists for them who “speak Spanish, who are bicultural, bilingual, who understand the unique challenges of our immigrant population,” Erpelding said.
But Armas remains one of only three Spanish-speaking clinicians in the entire school district. Your Hope Center is actively trying to recruit more. Lack of affordable housing makes that difficult.
The district was recently awarded a federal grant to help. They’ll receive nearly $800,000 each year, for the next five years, including money to fund signing bonuses for bilingual practitioners.
Building a connection
Armas says the language skills are important, but it’s also life experiences in common that help her build connection with the kids.
“Growing up in this community is a unique experience,” she said. “It's a resort town, but you see a lot of different challenges. It would be hard to pick up on those challenges and really understand the kids and what they go through if you weren't in the area growing up.”
The connection she has with the kids — that trust earned over time — is what makes her an effective clinician in moments of crisis.
“My quote is ‘be the person that you needed when you were younger,’” she said. “I really try to show up for these students every single day.”
If you or someone you know is in crisis, help is available. Call 988, Colorado's Suicide & Crisis Lifeline, 24 hours a day.
