When Fonda Bryant called her aunt to ask if she wanted her shoes, her aunt knew something wasn’t right.

“She said, ‘Are you gonna kill yourself?'” Bryant remembers. “And I said, ‘Yes.’ And she went into action, like a superhero. And she saved my life.”

Unknown to herself or her family, Bryant was suffering from depression that took her to the brink of suicide. Her experience echoes a growing suicide crisis across the nation.

September marks National Suicide Prevention Month, spotlighting the pressing need for continued awareness of the signs of suicide and methods to prevent it. But even as conversations about mental health have become more common in public spaces, statistics show the continued challenges of speaking up for help.

How to help someone who is suicidal?

Although 47% of American adults receive mental health care in a given year, the average delay between the onset of symptoms and the receiving treatment is a staggering 11 years, according to the National Alliance on Mental Illness. An American Psychiatric Association study found that over a quarter of American workers are unsure of how to access mental health care through their employer.

The rate of suicide rose 2.6% from 2022 and 5% the year before, after declining in 2019 and 2020, according to CDC data.

“Things are not good. We have not been able to put a persistent, visible dent in suicide rates in the U.S.,” Dr. J. John Mann, a professor of translational neuroscience at Columbia University in New York and the director of the Conte Center for Suicide Prevention, told USA TODAY.

Suicide is rarely an isolated condition, and often accompanies a mental illness or other condition.

For Bryant, that diagnosis was depression, one with a close correlation to suicidality.

Bryant said her suicide attempt was the culmination of a lengthy struggle with depression. As a single mother working full time and facing a tight financial situation, Bryant began to feel that her daily stress was becoming unmanageable.

“It was like every move that I made took great energy, took great effort, even talking, washing yourself, just getting through today,” she said. “It felt like I was walking in molasses.”

At least 90% of those who attempt suicide have a psychiatric diagnosis, Mann said. “It’s very rare to see a suicide, death or even an attempt outside the context of a psychiatric illness, half the time that illness is a depression.”

Mental health woes can carry social sigma

As a suicide survivor, Bryant says the enduring stigma surrounding depression and mental illness remains one of the largest barriers for those suffering to receive help.

“We get blamed for mass killings,” Bryant said. “Who wants to go and put that out there, that you have a mental health condition, when we can lose our jobs? So that’s why we don’t say anything.”

That stigma often takes effect in the form of comments that those suffering from depression encounter when they share their symptoms. Those could include suggestions to get out more, increase exercise, or socialize, or other advice that glosses over the severity of a psychiatric diagnosis.

“If you’ve got a broken leg, You need to see somebody to get the cast, get some orthopedic surgery, rest, and let it heal, then walk around,” Mann said. “Depression is the same thing. Get it treated, and then start socializing, then start improving your academic performance again, and all of those other things. It’s not the other way around.”

Statistics show that stigma may dissipate as more Americans learn about suicide prevention techniques.

About “94% of people believe that you can prevent suicide, and over 80% want to do something to help someone,” Jill Harkavy-Friedman, senior vice president of research at the American Federation for Suicide Prevention, told USA TODAY. “So I think those are signs that the stigma is being reduced. The problem is that only 30% of people have any idea how to know when someone is at risk and what to do.”

What does depression look like?

What’s the most effective way to spot the signs of depression? Mann said it all comes down to noticing changes in behavior. “That person isn’t their normal self. They’ve gone quiet. They’re struggling. The mornings are particularly difficult. Work performance goes down. Educational performance goes down,” Mann said.

When it comes to heading off a suicide attempt, the best course of action can be a simple, direct check-in, like Bryant’s life-saving conversation with her aunt.

“If you’re worried about someone, the first step is to trust them, and have a conversation with them, and it can start off with simply, ‘How are you doing?'” Harkavy-Friedman said. “You don’t have to become a therapist. You just want to open the door to say, ‘I care about you. I wonder if you’re feeling so bad that you’ve thought about taking your life.'”

Mann stressed the importance of a face-to-face conversation. “When you see somebody and you ask them how they’re doing, look at them when they’re giving you the answer. Think about what the answer means in relation to what you already know about them and how they’re doing.”

More:New Mexico governor’s temporary gun ban sparks court battle, law enforcement outcry

‘You’re not alone. Need help?’

Bryant decided to turn her experience into action after another brush with suicide in 2014. One night after she was laid off from a job, she walked out of her gym and drove to a parking deck in uptown Charlotte with the intention of jumping over the side.

Bryant said a voice told her to get back into the car. She kept her eyes on the moon for the drive back home, collapsing in tears the moment she parked.

The experience kickstarted her campaign to put up signs reading “You’re Not Alone. Need Help?” along with the suicide prevention hotline around the perimeters of every parking garage in North Carolina.

Her efforts led to a bill introduced by Massachusetts Sen. Paul Feeney (R-MA) to mandate parking garages across the state to install the signs. The bill was introduced as the Fonda Bryant Suicide Prevention Signage Act in the North Carolina General Assembly by North Carolina State Rep. Carla Cunningham in April. Bryant is hoping it will be passed this month.

“When you’re struggling, a lot of times you feel like you’re by yourself, even though you know there’s other people out here,” Bryant says. “I don’t want a lot of stuff on them. I just want you’re not alone.”

Cybele Mayes-Osterman is a breaking news reporter for USA Today. Reach her on email at cmayesosterman@USAToday.com. Follow her on X at @CybeleMO

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Fabio Azeredo earned a Ph.D. in psychology and practiced as a licensed supervising psychologist in Brazil for 29 years. Since moving to Minnesota two years ago, he has had to work as a pre-licensed psychotherapist under supervision. 

Suzana Duarte Santos Mallard also has a Ph.D. in psycho-sociology and a master’s in clinical psychology and has worked in private practice in Brazil since 2005. Since moving to Minnesota five years ago, she has been unable to earn a license to practice psychology. She now works as a pre-licensed therapist at a Twin Cities mental health clinic. 

In her native Guatemala, Ileana Ortiz de Leon was a psychologist in private practice for many years. To continue her mental health career after moving to Minnesota, she has chosen to reconfigure her professional credentials, becoming a licensed professional clinical counselor, or LPCC, and taking her goal of a private psychology practice off the table. 

Because of Minnesota’s complex licensing requirements, these three internationally trained mental health professionals say they haven’t been able to practice at a level equal to their education and experience since moving to the state. Other internationally trained mental health professionals face similar struggles in Minnesota. At the same time, Minnesota is struggling with a significant mental health workforce shortage, particularly among practitioners of color. 

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“I work under supervision,” Azeredo said. “I cannot have a private practice. I would like to have my license and not to be supervised because I am older. I appreciate and enjoy the process of supervision, but the truth is I’ve been licensed for 29 years.”

In Brazil, he added, “I was an established professional. I was regarded as an expert who had a voice in the mental health field.”

MinnPost photo by Andy Steiner

Azeredo shown looking over the many documents he has had to assemble to argue his case for licensure with the Minnesota Board of Psychology.

Ollie Schiefelbein, internationally trained professionals navigator at the International Institute of Minnesota, has heard stories similar to Azeredo’s plenty of times. 

“I have a client who has one bachelor’s degree and two master’s degrees,” Schiefelbein said. “She basically has to start over if she wants to work as a therapist here. She’s been told she has to go back to school to get licensure.” This client, Schiefelbein said, worked as a psychologist and a therapist in her home country, and even though she has been in communication with the Minnesota Board of Behavioral Health and Therapy for a couple of years, Schiefelbein explained, “She has not been able to identify a path forward.” 

Brooke Anttila-Escoto, International Institute medical careers pathway manager, said that her organization has been working with new Americans interested in health careers since 1990. In 2022, the nonprofit was one of seven Minnesota organizations awarded grants as part of the Internationally Trained Professionals Program administered by the Minnesota Department of Employment and Economic Development  (DEED), a grant designed to help more internationally trained health care workers gain licensure in the state.  

The grant, Schiefelbein explained, allows International Institute staff to serve “a very wide variety of clients falling under the category of physical and mental health care. We have clients who are doctors, pharmacists, nurses and psychologists.” 

In Minnesota, licensure for medical professionals is handled by a number of professional boards that set standards and make final decisions about allowing individuals to practice in the state. These boards, established by legislative statute, all have different methods of granting licensure. Mental health professionals are regulated by four boards: psychology, behavioral health and therapy, social work, and marriage and family therapy. 

Leah McNamee, senior program manager at the employment assistance nonprofit Hired, another Internationally Trained Professionals Program grant recipient, explained that the DEED grant money helps fund expenses involved in the licensure process. She said earning a license to practice as a mental health professional in Minnesota costs money, something that many new immigrants lack.   

“We help our clients get their credentials translated into English,” McNamee said. “We can also get them evaluated by whatever accrediting body would do that, to determine what they might need in order to become licensed here in the U.S.”  

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And it’s not just licensing fees that add up, Schiefelbein added. Many internationally trained mental health professionals have been told by their governing boards that they need to go back to school to earn further degrees if they’d like to practice in the state. 

“Money is the big issue,” Schiefelbein said. “Education in the U.S. is not cheap. Most of our clients already have families. They are in their 40s and 50s and may not be able to return to school. Going back to school just isn’t an option for everyone.” 

These roadblocks mean that some of Schiefelbein and Anttila-Escoto’s clients have given up on their dreams of picking up their mental health careers in Minnesota. “Many of the individuals I’ve spoken with who have backgrounds in psychology or mental health say there has not been a way to identify a path forward,” Schiefelbein said. “They’ve struggled with communication times, lack of information and misinformation barriers.” 

For their part, executive directors of state licensing boards say that their role is to ensure that mental health professionals practicing in Minnesota meet standards of care set by the state Legislature. This means that credentials earned in other countries may not be enough to meet those standards and that international applicants will need to have their credentials evaluated and might have to earn additional degrees or credits to gain licensure. 

“We evaluate all applicants, both applicants from another state but also applicants who have degrees granted in other countries,” said Sam Sands, executive director of the Minnesota Board of Psychology. “We evaluate each based on the degree they completed and the education they completed as is laid out in statute and rule.”

The application process is complicated, Sands explained. “It’s a case-by-case basis. Applicants have to get a transcript evaluation. Each situation is different. The way higher education is structured is different in different countries. In order for our board to evaluate whether an applicant has met the standards laid out, we ask that applicants get a transcript evaluation from a group of organizations.”

The reality is that there is not a worldwide standard for education and degrees, explained Samantha Strehlo, executive director of the Minnesota Board of Behavioral Health and Therapy, the state board that licenses and regulates licensed professional counselors (LPCs), licensed professional clinical counselors (LPCCs) and licensed alcohol and drug counselors (LADCs). 

When you are working with people who were trained internationally, she said, “It’s not like everybody neatly sits in the box. Usually they are going to have to complete some additional coursework, and they have to take the national exam that is required for licensure.”  

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‘It makes me want to give up’

When Azeredo decided that he and his family were going to move to Minnesota, he thought he had done his homework. He’d put time into researching states that accepted degrees from institutions credentialed by the National Association of Credential Evaluation Services, or NACES. He learned that Minnesota was a NACES-friendly state, which he believed meant that he should be able to practice as a licensed psychologist here. 

But when he settled in the state and began researching the process of gaining licensure through the Minnesota Board of Psychology, Azeredo said he realized that his degrees and long work history in Brazil carried much less weight than he anticipated they would. He said a staff member from the Board of Psychology told him that he would need to take a number of additional complicated steps to prove the validity of his degrees.  

“In Brazil I’m a licensed psychologist,” Azeredo said. “Here it is much more complicated.” He  took a job as a pre-licensed psychotherapist at Canopy Mental Health and Consulting, a Richfield-based mental health clinic that provides culturally informed care for underserved and marginalized populations.  While he appreciates his colleagues and enjoys his work at Canopy, Azeredo said the limitations placed on his practice by the Minnesota Board of Psychology feel frustrating, like his years of experience in Brazil count for nothing. 

“I have a Ph.D. in clinical psychology with a concentration in psychoanalysis,” Azeredo said. “Same thing for my master’s. I shouldn’t have to prove that, because NACES did it for me.”

He believes that staff at the Board of Psychology don’t have a strong working understanding of international mental health training and licensing. 

“It makes me want to give up,” Azeredo said. Board of Psychology staff, he said, “could improve their understanding of the different ways of being a licensed psychologist.” This lack of understanding about international training and licensure feels short-sighted, he continued. Though there is a great need for psychologists of color like himself, “There is no accumulated knowledge [among board staff]. It’s almost like, ‘Has anyone in the entire history of the board gone through this process?’” 

Suzana Duarte Santos Mallard

Mallard said she believes the licensing process for psychologists in Minnesota is biased against mental health professionals who’ve completed their training outside of the United States. She completed her Ph.D. in 2021 through the Federal University of Rio de Janeiro, because she thought it would meet the state’s education requirements for licensure. When she presented her credentials to the Minnesota Board of Psychology, Mallard said she was told they did not meet state requirements. 

“I was dismayed by the ethnocentric process of licensing implemented by the Board of Psychology in Minnesota,” Mallard said. “I aspire to practice and be acknowledged for my work because working without a proper license also means that insurance reimbursement rates for my work are lower than what I believe I am qualified for.” 

Though she’d found work as a pre-licensed therapist at the St. Paul-based Roots Wellness Center, a culturally specific mental health organization focused on healing intergenerational trauma in marginalized communities, Mallard was determined to practice as a psychologist. It was what she’d done for her whole career. She didn’t feel like she should  have to give that up. 

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She said she spoke with a staff member at the Board of Psychology, who told her one way she could continue to practice was to call herself a mental health “coach.” “I was able to tell her,” Mallard recalled, “‘I think this measure is very ethnocentric, very disrespectful toward my career by even implying I could call myself ‘coach.’ She said, ‘The only way you can apply here is to do another Ph.D.’ It is insulting.” 

Despite these roadblocks, Mallard said she’s not ready to give up. “I will keep fighting for this and I will keep telling my story,” she said. “I have a lot of support from my peers, my friends.”  

Rather than fight to have her Guatemalan psychology license recognized, Ortiz de Leon said she instead chose to work as an LPCC. 

Ileana Ortiz de Leon

“I already had licensure in my country,  but then once I came here I didn’t have it anymore,” she said. The complex and burdensome licensing process in Minnesota was, she said, a “cultural shock. Even though I’ve been practicing for 13 years outside of the country and seven years inside the country and I passed my boards as well, they still want all of that information.” Though she knew she could make more money as a psychologist, Ortiz de Leon explained, it didn’t seem worth the hassle and the expense: “I decided to go that other direction instead.” 

Sands said that he and his Board of Psychology colleagues acknowledge the great need for psychologists of color in the state. He added that during his time at the board, he estimated that four internationally trained psychologists have sought licensure and that three had been approved. Minnesota’s requirements for licensure — a PhD in  psychology — is the same as the rest of the country, Sands said. 

At the Minnesota Board of Behavioral Health and Therapy, applicants are sometimes required to take additional coursework, Strehlo said. “Maybe in the country they came from there isn’t an internship that is required. It might be little things here and there, but it hasn’t been a big issue over the years.”  

Azeredo said he wondered if the boards’ “American-centric” processes deter more internationally trained mental health professionals from even trying to get licensed in Minnesota. 

Katy Armendariz MSW, LICSW, Roots Wellness Center CEO, said that state requirements for licensure tend to discount academic and professional standards met in other countries, which can make it difficult for applicants like Azeredo, Mallard and Ortiz. “The boards don’t recognize international academic frameworks,” she said. “There is a condescending viewpoint. They don’t honor or validate or accept degrees — even if they are from the most respected universities in their countries.” 

Why international licensure matters

If the mental health profession wants to survive into the future, things need to change, Armendariz said. Increasingly, clients tell her they want to see providers who have a personal understanding of their own life experiences. In many cases, internationally trained mental health providers fill that need. 

“Black and brown communities are tired of white psychologists,” she said. Too often, she said, psychology and other mental health professions operate under a “Westernized, white, pathologizing lens. It is not a field that is welcoming or accepting of BIPOC providers. The BIPOC community wants that experience and background in their providers. We’re tired of the same old profession that has always been. We want to see more people like us.” 

Ollie Schiefelbein

Schiefelbein supports this perspective, adding: “People are best served in mental health by someone who has similar experience as they do, who speaks the same language, someone who understands the culture, who understands the refugee experience.” 

This issue feels particularly distressing for Armendariz, who would like Roots staffers like Mallard and Ortiz to be able to work at their full license.  Just having a therapist like Mallard, a Black woman who speaks multiple languages and who “understands and looks like the people who need her, changes everything. When clients have heard her talking, their demeanor just changes.” 

The same goes for Azeredo, who said he understands that his personal background is seen as a plus for many of his clients, many of whom are young people who have been adopted internationally. “The adoptive parent comes up to me and says, ‘He needs to talk to someone like you. He’s Latino. You’re Latino. You understand in ways I can’t.’ It is a thing. This is a place I know I can help. I hope I can keep it going.”

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