Editor's note: This story has been revised to clarify per-capita mental health spending in Idaho.
The voice started when Shawna Ervin was 16 years old, and it hounded her for two years.
It told her to hurt herself.
"It was relentless and wouldn't stop laughing at me until I burned myself on my face," she said.
When she finally did burn her face, the laughter turned maniacal. Then it stopped.
Ervin's mental illness is not rare. She is one of thousands of Idahoans whose disorders can be severe enough to warrant hospitalization.
Ervin has schizoaffective disorder - which is like a mix of bipolar disorder and schizophrenia - along with generalized anxiety disorder and post-traumatic stress disorder, or PTSD.
About one in five Idahoans has a mental illness of some kind, according to federal data. About one in 20 has a serious mental illness like Ervin's. Tens of thousands of Idahoans consider suicide each year. Idaho's rate of mental illness is among the highest in the country.
But many Idahoans aren't getting help.
Some don't seek psychiatric care. Or they can't find a treatment center or psychologist to help them. Many Idahoans simply can't afford help. More than 20 percent of Idaho adults who lack health insurance are in serious psychological distress, according to federal data. Idaho mental health centers often take Medicaid, but the state-run program won't cover most adults.
As a result, a growing number of Idahoans get help only when they reach a crisis point - attempting suicide, getting arrested, having a dangerous psychotic episode or ending up homeless.
For Ervin, the crisis point has been a refrain: She becomes suicidal and ends up in the hospital.
The past year has been life-changing for her. She just emerged from a new program, paid for by cobbling together health-insurance plans.
NOT ACCEPTING STATUS QUO
Ervin's parents thought her self-harm was just a phase, that she was doing it for attention, she says. So there was no medication or psychotherapy or counseling when she first became ill.
After she moved out of her parents' house at 18, the hallucinations that told her to burn herself went dormant.
Over the next decade, Ervin met her husband and welcomed her first baby to the world. It was a happy time, a break in the clouds that gave Ervin the time to grow into the type of person whose voice sounds confident even when it's cracking under a sudden wave of emotion.
But her depression eventually came roaring back, bringing with it the hallucinations, anxiety and suicidal thoughts of old.
Ervin, now 40 and living in Nampa, is one of the first patients and a recent graduate of a new partial hospitalization program at West Valley Medical Center in Caldwell.
She hopes the program - a year old this month - will break the revolving-door cycle she shares with many Idahoans: sitting in a psychiatric hospital room several times a year, getting stable and leaving, only to end up back in the emergency room after a crisis or suicide attempt.
"I think a lot of people figure that that was probably status quo for her - that she would always be in and out of the hospital, and that was all that we could expect," Amy Hicks, program manager, said as Ervin graduated from the program on a late-September afternoon.
THE ILLNESS COMES BACK
It was during Ervin's second pregnancy, at age 27, that she remembers the illness creeping back into her life. It was a rough pregnancy, and Ervin spent six weeks in the hospital trying to keep the baby inside. But her son arrived nine weeks early.
"While he was in the NICU and I was home, I remember going to my closet and seeing the maternity clothes with tags still on them, and crying because I never got to wear them," she said.
Ervin's postpartum depression made it hard for her to bond with her new child. When the boy started talking, he called Ervin's husband "moddy" - mommy and daddy.
It took about a year for the depression to lift.
Ervin finished her 20s in a good place mentally, and had a third baby without any postpartum depression.
But the illness came back, worse than ever, in her 30s. That's around the time that Ervin and her husband packed up the family to move to Idaho from San Diego, eager to live in a place where they could afford to buy a home.
It went all right at first. Then, a cousin killed himself, and Ervin "really took on his feelings. ... A lot of my suicidal feelings came from thinking about him," she said.
She didn't just internalize her cousin's feelings; she also couldn't leave work at work. Ervin has a bachelor's degree in social science and decided to put her degree to work as a psychosocial rehabilitation worker. She still has copies of glowing reviews of her work, and she loved what she did. But she began dwelling on her clients' problems.
"That's when my full-on depression (returned with) voices, suicidal thoughts, suicide attempts, everything - just, it was full-blown depression," she said.
In a manic episode, Ervin insisted on walking across the country to a friend's house in North Carolina. It was the middle of summer. She'd packed a bag and had $120 in her pocket. Her husband realized how severe her illness had become and took her to the hospital.
'WAIT AND SEE'
Ervin has lost track of how many times she's been hospitalized since moving to Idaho.
Three times at Saint Alphonsus Regional Medical Center's psychiatric inpatient unit.
Four times at State Hospital North, the state-run psychiatric hospital in Orofino.
Twice at Intermountain Hospital, which also has a partial hospitalization program.
She's not sure how many times she's been at West Valley Medical Center for 24-hour psychiatric care. It's around 30.
She always took medications as prescribed, but they didn't always work.
"My kids would come home and ask me if they could go to a birthday party next week. And I would say, 'We have to wait and see,' " she said. "They didn't know why ... but I used to say that because I didn't know if I was going to be in the hospital."
The day after Christmas last year, Ervin joined the new West Valley partial hospitalization program, which she calls "the PHP."
Listen to Ervin and others talk about mental illness:
NOT ENOUGH HELP
People on the frontlines of Idaho's mental health system have a plethora of theories about the rising need for hospitalization. Here are four of the biggest:
Inadequate state funds. Idaho spent $37 per capita on mental health services in fiscal year 2010, according to the National Association of State Mental Health Program Directors Research Institute. The only place in the U.S. with lower per-capita spending was Puerto Rico. The national average? $120.
Idaho also spent the least in the country - in sheer dollars - on mental health care. Montana outspent Idaho by almost 300 percent; Wyoming outspent Idaho by about 30 percent.
However, the Idaho Department of Health and Welfare says the institute's report is flawed, because it does not include Idaho Medicaid's mental-health spending. It is unclear whether the report excludes Medicaid for other states as well.
"The main shortage right now is care for poor people - for Medicaid," said Dr. Charles Novak, medical director at Intermountain Hospital, Allumbaugh House and Sage Health Care in Boise and a psychiatrist leader at Saint Alphonsus. "It's just gotten busier and busier as progressively, slowly, more people who can't access outpatient care get ill and end up in the ER. ... If they don't end up in jail."
Too few places to get treatment. Idaho has an anemic supply of care for patients who need round-the-clock attention from mental health providers.
"Saint Al's inpatient (behavioral health) unit runs full all the time," Novak said.
For juveniles in crisis, there are almost no options. Intermountain Hospital recently cut back its inpatient services for teens, which "obviously has set up a shortage of psych beds for teens," Novak said. Asked where local parents can send young children who need intensive 24-hour psychiatric care, Novak said, "There is no such thing" in this area.
A shortage of psychiatrists. It's twice as easy for an Idahoan to find a radiologist to read an X-ray as it is to find a psychiatrist to craft the perfect cocktail of medications to get someone back to being functional.
A shortage of psychologists. Dr. Ninon Germain, a Boise psychiatrist, says psychologists are best equipped to deliver therapy for depression and anxiety.
"I will discharge teenagers from Intermountain Hospital with depression/anxiety - they've cut themselves, they want to die," Germain said. "The medication is the easy part. The hard part is trying to find a therapist who will get them well quickly and effectively ... and then get them on their way."
Between 1 percent and 3 percent of Idaho teens have tried to kill themselves and needed medical attention for their suicide attempts, according to federal data.
It's not just that psychologists are in short supply. It's also that Medicaid - which covers thousands of Idaho children, including those with severe psychiatric problems - doesn't pay enough.
"What frequently happens is (adolescents) go to therapy, they vent, family may be pulled in for some of it," Germain said. "But when I ask if there's actual family therapy going on, usually the answer is no - because that's difficult, and it requires a level of training (beyond) what Medicaid's willing to pay for. So, young people typically have a revolving door. They get discharged from the hospital, they come back, they get discharged from the hospital, they come back."
THE REVOLVING DOOR
Optum Idaho has said it's trying to change that. Optum, a contractor paid by the Idaho Health and Welfare Department, says family therapy has increased since it took over part of Idaho's mental health Medicaid system last year.
Optum Idaho says the changes it is making to Medicaid have kept patients from being repeatedly hospitalized.
Local mental health workers interviewed by the Statesman disagree.
Dr. Lawrence Banta, who runs the behavioral health program at West Valley, said the switchover last year to a privately run system for Medicaid patients with mental illness is not helping to ease the crisis. Instead, more people are showing up with psychiatric emergencies.
"Quite a few of the ones we had to send out (to get care in the new system) have become frequent fliers that weren't before," he said.
AN UNMET NEED
Patients in "partial hospitalization" stay in the hospital all day for two weeks to two months - busy with group therapy from 10 a.m. to 3 p.m., plus individual therapy, art therapy and medication. They go home at night, where they do the homework of navigating their lives with a new compass.
West Valley launched the program in October 2013, saying it was responding to the gap in services between "make an appointment to see a doctor or therapist" and "be hospitalized."
"The need is simply there," said Glenda Nelson, a registered nurse and director of behavioral health services.
Nelson has worked in the inpatient psychiatric unit since 1994. She says patients with mental illnesses usually spend five to seven days in the hospital. The bill typically goes to some taxpayer-funded program.
At the end of their stays, patients leave with referrals in hand. West Valley calls within a day to check on how a patient is doing, she said. (Fewer than half of Idaho's mental health treatment centers check in with patients after discharging them back to the outside world.)
But there are patients, such as Ervin, who end up back in the ER, sometimes after attempting suicide.
While Ervin was a willing patient, Idaho is in the midst of a spike in emergency, involuntary hospitalizations - court-ordered commitments of people deemed to be a danger to themselves or others, or "gravely disabled" by their mental illnesses.
According to the Idaho Supreme Court, Idaho courts oversaw more than 4,500 cases of involuntary mental commitments in fiscal year 2013, up 82 percent since 2008.
Hospitals also have been flooded with patients in crisis, and the number of people held temporarily during psychotic breaks, extreme depression or other mental health crises rose from about 3,600 in 2008 to more than 5,000 last year.
'IT GETS LONELY'
The day she graduated from partial hospitalization, Ervin said she was "anxious but happy."
It had been a longer journey for her, compared with most of the program's graduates so far. Ervin was hospitalized twice, which interrupted her progress and prompted her private health insurance to cut her off.
Another of Ervin's insurance plans picked up the rest of the program. Hicks notes that Ervin is fortunate to have good health insurance coverage, which is not the case for many Idahoans with mental illness.
The week after Ervin's graduation from the partial hospitalization program, she was adjusting to daily life again.
"I really miss the PHP," she said. "The PHP is still there for me. I've called them a few times, and I've stopped by and got my hugs."
A public health team now drops by Ervin's house twice a week to check on her, make sure she's "not thinking bad thoughts" and remind her about doctor appointments, she said.
For the first time in years, Ervin is hopeful.
"She's married, the mother of three and is not the stereotype of mental health issues - but she really is. She's who we normally see," Hicks said. "It's everybody. Mental illness affects everyone."
Like almost every person interviewed by the Idaho Statesman and Boise State Public Radio for this series, Ervin has felt alone and harshly judged as a person with a serious mental illness.
Just spending hours in group therapy with other patients - where nobody blamed or doubted her - made a difference in her life, she said.
"For nine years, I have lived in my house and have not reached out to anybody," she said on her graduation day. "Being alone was a big thing. And there's only so many people you can call. And it gets lonely."
Ervin's and her husband's children are teenagers now, and as summer vacation drew to a close and the kids returned to school, Ervin decided to make a change: She would reach out.
"So I went to my neighbors who were 'hello and goodbye' neighbors," she said. "I invited them to coffee, and we went to the movies. And this Saturday, I went to the train station with one of my neighbors. I started socializing, which is very unusual for me. And I learned those skills here at the partial hospitalization program. I never would have done it without it."
She also has been applying for jobs - not as a mental health worker this time - and looks forward to working again.
This year, Ervin began to envision a future where she won't have to tell her kids, "We'll wait and see."
"In Crisis" is a collaboration between the Idaho Statesman and Boise State Public Radio.