Jackson Rainer, PhD, ABPP
A depressed teenager made a suicide attempt that was unexpectedly interrupted by his brother. After an eleven hour stay in the county hospital’s emergency room, the local police transported him, on an involuntary status, to his state’s regional mental health institute – a three hour ride, locked in the back of a patrol car. Following a brief stay to stabilize the young fellow, practitioners met with the family for discharge planning. The psychologist suggested individual and conjoint family therapy in addition to regular medication management. The closest community mental health center had a two month wait list, even on referral of a patient discharged directly from a state hospital. The psychologist inquired about other resources available to the boy and his family. His father replied, “We live a long way from here. I’ve lost my job and money is tight. The hospital applied for Medicaid just so my son could be admitted here. There aren’t any shrinks in our town that I know of, but I guess our family doctor can take care of the medicine.” When the psychologist suggested they return to the hospital’s out-patient clinic for psychotherapy, the father said, “You’ve got to get us somewhere closer. His mother and I are working now in the cash economy, and if we’re not working, we’re not being paid.”
Isolation, culture, and small size are essential characteristics of rural life and are the descriptors of rural experience requiring special attention. Health and heath care are linked closely to economy and demography and many limits are magnified in rural communities. For mental health care, psychologists are often the most highly trained mental health providers in rural areas, though their numbers are small. Treating rural and isolated clients presents a distinct set of problems with quality, access, and understanding of mental illness and mental health care. These unique challenges faced by those living in rural communities are recognized by the profession, and an organized movement toward improving rural mental health continues to gain social and political momentum as a public health concern.
Empirical work particular to rural mental health uncovers multiple health disparities, revealing rural residents as more likely than their urban counterparts to live in poverty, lack health insurance, report poor health, have a chronic health condition, and be under or unemployed. Almost one in three adults living in rural America is in “poor to fair health.” Nearly half have at least one major chronic illness. However, rural residents average fewer physician contacts per year than those in urban communities. Low population density in rural areas makes it inherently difficult to deliver services to targeted persons with special needs. This is especially true regarding the provision of mental health care and also true for people with HIV or AIDS, the homeless, mothers, children, and adolescents, racial or ethnic minorities, and persons with disability. As a general rule, rural populations lack the social and health services necessary to accommodate their residents, which include a high percentage of the elderly.
Sixteen percent of the United States’ population lives in rural communities. Congressional reports find that these rural areas have less than one-half as many physicians per capita as urban areas. Related to this demographic, the US Department of Health and Human Services (HHS) and its Health Resources and Services Administration (HRSA) state that ninety million residents live in designated Mental Health Professional Shortage Areas (MHPSAs). In 2011, more than 61% of these shortage areas are “non-metropolitan.” It is estimated that between 4000 - 6000 new mental health professionals would be required just to meet this identified need. Examples of the acute shortage overflow: In rural Appalachia, for example, 75% of non-metropolitan counties are considered mental health shortage areas. In Georgia, 52% of counties have no licensed psychologists. Only ten percent of the state’s psychologists live and practice in rural counties. In 2001, little more than a decade ago, The American Psychological Association sounded a national alarm, stating that more than one half of all the counties in the United States lacked a psychologist, psychiatrist, or social worker practicing in their communities. This deficiency of access is one of numerous barriers to the receipt of effective services. Other relevant problems include the crucial need, but lack of emergency mental health services in rural areas. Transportation availability and confidentiality concerns are noted as continuing problems. Policies and programs designed for urban mental health service are often inappropriate for rural mental health clients, yet the urban model seems to be the only lens of practice.
Clinically, there are important differences in the treatment of rural clients. In this contemporary era of specialized services, rural mental health relies heavily on primary medical care, social services, and generalist practices. Stigma is particularly intense in rural communities, where anonymity and privacy are difficult to maintain. The ethics of confidentiality and multiple relationships are often stretched to breaking points. Rural mental health services remain predominantly publically funded, that is to say, largely underfunded. Consumer and family involvement in advocacy, characteristic of urban and suburban areas, is rare in the rural community. The supply of services and professionals is limited, so choice is constrained.There are few self-help groups and resources. Informal supports and indigenous healers assume more importance in rural mental health care. Counseling is something that one receives from the local preacher; psychotherapy is a little-known term. Attending any self-help group, other than an anonymous twelve-step group, is unheard of.
What is rural?
There is great debate about what “rural” is. As late as 2005, no single, consistent definition of rurality has been established. Among researchers, the USDA provides the most approachable method for defining the term, based on population density and proximity to urban areas. The popularity of this rubric is understandable since inferences can be made regarding the extent of urban influence on the rural area. However, there are problems with the rubric, and ultimately, no easy way to capture those demographic, cultural, and economic factors that must be considered in any intelligent discussion around models of rural mental health care delivery. In greater perspective, the concept of “rural” embraces a wide-ranging set of variables that includes geography, topography, population distribution, economic systems, and cultural factors.
There are, however, two relatively consistent variables found across rural populations: poverty and inability to pay urban fees for services. In rural communities, the availability of employment is limited and younger people frequently leave to find work. Upward of 15 percent of adult rural residents live below the federal poverty line, with rates significantly higher for minority rural residents. Because of economic changes, the tax base required for maintaining public services decreases as the population shifts from those who have a higher earning power to those who are on relatively stable incomes or those who, because of under or unemployment, descend into the cash economy. Fees-for-services slide with great variation. Rural residents live for longer periods of time without health insurance coverage when compared to urban peers and are less likely to seek needed medical and physician services because of pride, stigma, and the lack of access to reduced priced/free clinical care.
Mental Health in Rural Areas
Living and working in rural communities presents distinct stresses and strains as varied as rural America itself. Mental health is one of the top ten leading health indictors targeted by Healthy People 2010, the nation’s blueprint for improving health. The need for rural mental health care has not been met with widely available and accessible mental health services. Other factors under discussion include the scarcity of providers, stigma, and the general lack of anonymity. As noted, the problem of inadequate mental health care is strongly tied to the lack of affordable, meaningful health insurance coverage. Mental health care is expensive and largely unaffordable as an out-of-pocket expense. With many families already struggling to pay health insurance premiums or existing medical debt, accessing mental health treatment is not a choice easily made.
Mental health and mental illness exist on a continuum, with no clear cut line differentiating health from illness. Symptoms vary with age, gender, race, and culture. Mental health is commonly defined as successful mental functioning resulting in productive activities, fulfilling relationships with other people, and the resilient ability to adapt, change, and cope with challenging situations. Sound mental health is characterized by clear thinking, effective communication skills, continued learning, emotional growth, adaptability, and a sense of self-worth. Mental health is important for individual mastery, family and community health, general well-being, and productivity. Mental illnesses are health conditions characterized by alterations in thinking, dysfunctional mood or behavior, or any combination of these associated with distress and/or impaired functioning. Psychosocial influences affecting mental health include stressful life events, childhood abuse or domestic violence, poverty, cultural factors, social isolation, racism, prejudice, and interpersonal relationships.
Rural residents have higher levels of depression, substance abuse, domestic violence, incest, and child maltreatment than residents of urban areas. Up to 40% of mentally ill individuals in rural areas have a comorbid substance use disorder. Rural residents have higher rates of completed suicide than their urban peers. Rural women face particular pressures impacting their mental health, including increased risk for abuse, heightened isolation, economic instability, and a lack of childcare support – all of which are linked to mood disorders.
The prevalence of depression is significantly higher among rural residents. Rather than being attributed to geography itself, the rural population contains a higher proportion of individuals whose characteristics, such as poor health, place them at higher risk for depressive disorders. Rural youth have higher rates of depression and substance use than are found in the urban community. The school system has become the community mental health center, and the teacher is likely to be the de facto mental health counselor. School police are prone to become the informal and only available family therapist for children and teens with behavior and adjustment problems, and crisis management becomes the norm of the “clinical” encounter.
Because of its co-morbidity with other mental disorders, the research community and mainstream media describe a remarkable rise and recognition of substance use in rural areas. Alcohol (particularly binge drinking), opioids, and methamphetamine abuse is higher for rural youth than their urban counterparts. Marijuana is the most commonly used illicit substance in rural communities. Nonmedical use of prescription drugs is a growing national problem and one heavily impacting those living in rural areas. Statistically, adjusting for race, health, and other drug and alcohol use, rural youth are significantly more likely that their urban peers to have used prescription drugs non-medically. For rural adolescents in particular, factors associated with prescription drug abuse include poor health, presence of a major depressive episode, and other drug (marijuana, cocaine, hallucinogens, and inhalants) and alcohol use.
Substance abuse in rural areas varies by social and economic characteristics. Lower education is strongly related to illicit drug use for young adults. Teenagers from low income rural families are more likely to abuse illicit drugs than youth from high income families. Unemployment is positively related to high rates of illicit drug use. While gender is not related to substance abuse among youth, substance abuse is higher among adult men than adult women.
Domestic violence is a primary care issue in rural America, one that is easily hidden and forgotten. More than one third of women living in a rural community will be victimized by an intimate partner. Circumstances of rural living exacerbate the danger for those families experiencing abuse. Geographic and social isolation, concerns about confidentiality, and limited access to services trap families, particularly women, in violent relationships. Firearms in the household are a fact of life in much of the rural community. Law enforcement response times vary in rural settings where domestic violence is not always considered a priority. Accessing shelters and protection programs is difficult.
Women who experience domestic violence are more likely to experience a wide variety of chronic health problems than urban women. They suffer disproportionately from arthritis, irritable bowel syndrome, stomach ulcers, chronic pain syndrome, migraines, and eating disorders. They have higher incidence of common physical and mental symptoms, including chest pain, low back pain, breathing disorders, and anxiety. These types of long term health problems limit options for mental health treatment, especially during later years of life. Chronic illnesses and physical disabilities are major barriers to leaving an abusive relationship. The mental health consequences of living in such a relationship worsen this entrapment, particularly when combined with the social and geographic isolation of communities with few resources. Domestic violence increases a woman’s risk of insomnia, depression, post-traumatic stress disorder, panic disorder, and substance abuse. The symptoms can persist for years after the abuse ends. Numerous studies have demonstrated a connection between a history of abuse and an elevated risk of suicide.
Child maltreatment in rural families tends to mirror that of urban families. However, rural families involved with Child Protective Services (CPS) are more likely than those in urban areas to be experiencing financial difficulties and live with high family stress, i.e., abandonment, moral/legal maltreatment, educational maltreatment, and exploitation. Nearly one in three rural families reported to CPS have trouble meeting basic financial needs compared to just over one in five urban families in the same demographic. Child neglect, defined as the failure by the caregiver to provide needed age-appropriate care, is the most common type of reported child maltreatment in the rural community. Approximately one half of reports to CPS are for neglect. In contrast, about one-fourth of the reports are for physical abuse. The remaining fourth are reported for more than one type of child maltreatment.
It would appear that working in a rural community holds a bleak perspective. Great truths are found in the complex challenges awaiting the psychologist who ventures into a rural practice. However, there are exciting opportunities unfolding in the unlimited scope of practice at several levels, including direct clinical services, consultation, teaching, and collaborative multi-disciplinary research. Opportunities to work with other professional, paraprofessional, and lay persons abound. Many of the potential problems associated with work in smaller, rural communities can be easily translated into creative practice opportunities.
Practice in rural areas, by definition, is more general than specific, with the character of psychological practice heavily influenced by the culture and context of the community. As stated by Lisa Curtin and David Hargrove (2010), “Multigenerational families, multiple relationships, porous boundaries, smaller populations, limited resources, and widespread knowledge of personal lives are important factors in psychological service delivery and influence choices of whether to or how to practice in a given community” (p.550). Ultimately, the joy of a rural psychology practice is found in how it thrives by becoming embedded in the context of the community and region. Contextually sensitive practices consider the impact of problems and potential change on the systems in which individuals function. Awareness of the consequences of change and decisions based on them are integral to the therapeutic process and are figural and evident in rural practices.
Given that much of a rural practice is contextually bound, there are several general, emerging trends worthy of consideration, including the development of prevention and education programs, use of technology, and integration of mental health and primary care. Prevention and education programs are designed to create community safety, respond to crises, and promote the development of individual good character and social interest. Information technologies, particularly telehealth, hold the potential to create new paradigms of care by leveraging the strength of its ability to connect individuals in immediate, cost-effective ways. Such possibilities bring new definition to the notion of integrated practices. There is widespread support for the idea of integration – that people’s physical and mental health problems should be coordinated and not treated separately or in isolation.
Rather than treating, preventing mental disorders is not only cost-effective, but supports quality of life, healthy families, and productivity throughout life. Prevention and education practices have emerged in a variety of settings and are designed to address a broad array of mental health needs and groups. Particularly among children, youth, and young adults, mental health and substance use disorders are major threats to health and well-being that continue into adulthood. The costs of treatment for mental health and addictive disorders, which create an enormous burden on the affected individuals, their families, and society, have stimulated increasing interest in prevention practices that can impede the onset or reduce the severity of the disorders.
It has been noted that mental health practitioners can be the most effective in rural communities when contextual cues are taken into account. Heightened awareness acknowledges the distinct need for strong community outreach, coordination, case management, and education. For the majority of residents living in the community mainstream, the stigma of mental health/illness continues to rear its ugly head. Stereotypes, prejudice, and discrimination may be darkly effective ways of organizing the complex world, but they do little to encourage the self-efficacy and esteem needs of individuals and families needing help. Such issues are amplified by the interconnectedness of people in rural communities. Social contact and high-speed communication make it hard for individuals to maintain privacy.
Prevention and education serve to involve community members in collaborative, non-threatening ventures by addressing change efforts on a macro level. Working collaboratively, the community identifies its problems and needs,energizing the desire to work toward viable solutions. The psychologist brings skills of program design and development to the table, marshalling resources needed to implement the solutions chosen by the community. Essentially, prevention and education reframe mental illness into mental health and encourages utilization of psychological services, which then generalize into notions of individual and systemic self-sufficiency and nourishment. As an added benefit, the psychologist involved in prevention and education is further integrated into the community as trust in mental health services grows and is found to be acceptable.
The use of technology in clinical services is a natural fit for rural practices as it serves to bridge the access gap for quality mental health services. Telephone and video conferencing, online counseling, email correspondence, and virtual reality increase the viability of rural service. Professional associations report an upward trend by psychologists indicating successful use of technology for mental health intervention. Primarily, real-time videoconferencing allows the client and psychologist to interact with immediacy, approximating the relationship developed in face-to-face traditional psychotherapy. Technological advances with personal computer systems have made inexpensive, user-friendly, and reliable videoconferencing easily available for use in clinical settings. There is some evidence that individuals are more likely to disclose highly charged personal and private information about themselves to a computer rather than in face-to-face situations. Preliminary research speaks to the ability to form authentic, positive therapeutic alliances in videoconferencing relationships.
Across research reviews, diagnostic efficacy shows good reliability between televideo and face-to-face diagnoses with both children and adults. The varieties of tele-mental health are shown to be a reliable means of conducting clinical interviews with high levels of clinician and client satisfaction. Technology-based services are cost effective for clients when factoring in reduced travel requirements, time away from work, and childcare needs. Beyond the financial savings, telehealth also increases access to specialty services and self-help resources without compromising client satisfaction or treatment adherence.
Technology services are well received by providers and patients across the lifespan with varied diagnoses. Research reviews find the majority of evidence for the successful use of technology in the areas of depression, dementia, schizophrenia, post-traumatic stress disorder, and cessation of smoking, with less compelling evidence for obsessive compulsive disorder. There are studies noting clinical improvements in depression and anxiety with the use of cognitive behavioral therapy for rural clients. Favorable evidence is shown for psychotherapy with children and adolescents, adherence to treatment, and regimens for individuals with chronic mental illness. In general, IT interventions demonstrate positive effects in the current literature, with benefit especially for those without access to traditional care.
Providers report worries about proficiency with technology. There is certainly a need to receive ongoing training to increase confidence, so that the technology becomes a tool rather than a barrier. Electronic interventions guide psychologists to think creatively and adapt the session needs to the IT setting, e.g., faxing handouts ahead of the session. For the provider, the major advantage of IT is found in the expansion of services to high need rural populations without having to be away from competing clinical responsibilities. As one psychologist said, “When I began considering inclusion of technology in my practice, I had two questions to answer. The first was, ‘Is this going to augment my therapeutic strategies or will it replace them?’ The second was similar: ‘Will this be a direct clinical service approach or a support strategy?’ I need to outline the risk and benefits of the particular technology with each client. I’m transparent and acknowledge the use of IT in a psychological practice is on the razor’s edge.”
The research base, as well as national consensus guidelines, continues to move the telehealth field forward with rural mental health practices and processes. There is great potential for new paradigms of care that leverage the unique strengths offered by telecommunication technologies. Working collaboratively, practitioners and clients can find comfortable ways to deliver and receive safe, high quality care.
Integrating primary care with mental health care
In this political year, there are visible, often contentious discussions surrounding healthcare, particularly regarding the Patient Protection and Affordable Care Act (PPACA). The enactment of this healthcare reform could have an extraordinarily positive impact in the rural United States. The law focuses on improving access to primary care services and preventive and public healthcare, all of which address many of the acute needs of rural citizens. By 2014, this legislation ensures that all Americans will have access to high quality, affordable, and comprehensive health insurance plans that cannot include lifetime or annual dollar limits on benefits. The law provides a number of rural provisions, including expanding rural demonstration initiatives, modifying problematic Medicare reimbursement levels, and calling for a comprehensive study of the adequacy of Medicare payments for health care providers serving in rural areas. A clear statement is made for integrating primary and specialty care, based on the impetus that traditional separation of general health and mental health services hinders a holistic approach necessary to effectively treat co-morbid health problems. The chronic health care needs of the residents of the rural US should be well served by the Administration’s emphasis on integrated, holistic, and coordinated care provided by teams of interdisciplinary health care providers.
For many individuals in the rural community, primary care is the point of entry for a mental health concern. Epidemiological estimates suggest that as many as 40% of those with mental health needs seek treatment in primary care settings. Mental health and substance-use problems are the leading cause of combined disability and death in women, second highest in men, and by 2020 will be in the top five leading causes of morbidity, mortality, and disability among children in the US. This high overlap led the President’s 2003 New Freedom Commission on Mental Health which underlines the need to increase access and quality of mental health care in rural areas, primarily through integrated care.
Currently, federal support is available for integrated care to develop and implement behavioral health initiatives that increase access and utilization of mental health services. The contemporary view of integrated care is to provide a flexible locus of service. Scholarly investigation continues, examining the benefit of locating primary and specialty care in community based mental health settings, under which those with mental illness and co-occurring primary care conditions and chronic diseases would be served. Conversations discussing integration diverge along two dimensions: integration of providers and integration of processes of care. Where care is provided and how care is provided become the primary, relevant concerns. This question moves the conversation beyond the structure and into the function of integration.
In the present heath care system, using the naturally close proximity found in rural communities, psychologists can quickly establish collegial and collaborative relationships with medical practitioners who become more familiar with screening and triage of mental health complaints. Rural psychologists anecdotally report on many physicians’ profound relief with the cross-discipline involvement. The professional correspondence becomes creative, energetic, and adaptive in response to otherwise limited resources.
One psychologist and physician refer to their collaboration as “warm handoffs.” The friendly pair report. “As doctor to doctor, we can introduce patients to each other. It happens through conference phone calls, group emails, and on several occasions, skype consults. These types of handoffs seem particularly useful in enhancing the trust and rapport that patients have in us. When we are seen as being in sync with each other and their treatment, our patients are more likely to follow-through with mental health care. This makes everyone feel better about the work we do. We also feel like our camaraderie helps reduce the demands on the primary care staff. It allows us to see more patients with better quality and more time to listen.” As collaborative bridges are built, the problems in coordinating primary, mental health, and substance-use issues are more adequately addressed. This type of integration is a fundamental change from the view of mental health/illness and substance abuse as separate and unrelated to overall health and general health care. Incorporation of these concerns into the general health care system is rapidly becoming a standard for primary care.
Evidence regarding the effectiveness of integrated care is prevalent in the scholarly literature. Integrated care programs tend to have positive outcomes for symptom severity, treatment response, and remission compared to usual primary care. However, the results vary widely on many levels because of the varieties of emerging notions with provider integration and integrated processes of care. The data cannot be over interpreted, but may be seen through an optimistic lens.
Making the Case for a Rural Practice
A study conducted by Kramen-Kahn and Hansen (1998) identified six categories of occupational rewards for psychotherapists: “feelings of effectiveness (e.g., helping clients improve); ongoing self-development; professional autonomy-independence; opportunities for emotional intimacy; professional-financial recognition and success; and flexible, diverse work” (p. 130). All are easily within the reach of the rural psychologist. While there is rightfully a great deal of focus on the problems associated with small community practices, the picture painted by rural practitioners is generally quite positive. The lifestyle, opportunities, and sense of personal control allow the rural psychologist to be a valued member of the fabric and weave of community life.
Rural communities offer a different and desirable quality of life than what typically is found in urbania. Opportunities for genuine connections and friendships, lower costs of living, the institutional value of the community spirit, and the pace of life are satisfying on deeply felt levels.
Psychologists in rural practices endorse the lifestyle and thrive as generalists. The obligation to stay current on new information, trends, research, and practice issues is immediate and engaging in response to the variety of clients coming to the door. As one practitioner said, “I am forced to use everything that I have ever learned.” Such variety overlaps in the community context and allows for intervention that extends beyond the typical 50-minute hour. Therapeutic alliances are strengthened when clients acknowledge and know the psychologist as a part of the same community, recognizing and sharing values and beliefs. Rural psychology promotes comprehensive practice and engenders loyalty that develops between the provider and community. Once accepted in the community, psychologists are seen as experts and imbued with the special power of their professional role. They are able to see the results of their work, take on leadership roles in a variety of special issues, and feel acknowledged and appreciated. They are known as more than just their jobs.
The mental health of rural communities remains a vital concern and holds increasing promise for a high quality of professional and personal life for psychologists. Rural areas vary significantly in demographics, economics, industry, and degree of isolation. The major barriers to providing mental health care in rural America are similar: low population density, long distances from metropolitan areas, large geographical areas with poor transportation, and limited workforce power and financial resources. National conversations have brought light to promising practices in rural areas to continuing problems and challenges that plague underserved populations. Positive movement is afoot to enhance the mental health of rural Americans.
Rural psychologists speak of organic strategies that emerge in practice. There is a sense of diversification. A generalist practice involves different tasks, activities, levels of involvement, and multi-disciplinary relationships. Rural practices also require linkages and referrals to diminish the sense of professional loneliness and to address the problems of client isolation. Finally, practitioners find ways to enhance their standing in the community in intensely personal and satisfying ways. One client laughed as she told the author during her course of psychotherapy, “I used to tell my problems to Jack Daniels. Now I tell them to Jack Rainer.”
Jackson Rainer, PhD, ABPP, is a board certified clinical psychologist. Dr. Rainer has practiced for the last fifteen years in rural communities in the mountains of Western North Carolina and the Coastal Plains of South Georgia. He is currently the head of the Psychology and Counseling department of Valdosta State University in Valdosta, Georgia. He may be contacted at firstname.lastname@example.org.
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