Mental health disorders cause more disability and suffering in rural areas of our country. The presence of high rates of depression, domestic violence and child abuse creates increased risk for behavioral health issues. In addition, rural areas have higher rates of abuse of alcohol, tobacco, opiates, meth, inhalants, marijuana and cocaine. Suicide attempts and deaths by suicide occur more often in rural settings, with the rate of deaths by suicide running as much as 300% higher than an equivalent urban sample in some areas. Reasons for these disparities are certainly complex, but can be summarized under three primary categories: accessibility of mental health treatment, availability of services, and the acceptability of receiving services in rural culture.
Accessibility to services is a complex problem that rural health providers are attempting to address. Rural residents are likely to live further apart from one another, further away from services, and have less access to transportation. Telehealth is one recent technique being used to address some of these issues but it must be considered that due to the higher poverty levels in rural areas, some people may not have access to the technology required to receive telehealth in their home. The prevalent rates of domestic violence could provide a significant barrier for the use of telehealth in such situations. Many community mental health agencies provide i- school services in order to overcome some accessibility problems. Additionally, some rural mental health centers are creating “hubs” for telehealth services, but continue to struggle with transportation to get patients in need to these hubs for sessions.
The availability of services is limited in rural areas. A major problem in service provision is a relatively low number of doctoral level psychologists, coupled with high turn-over rates for any degreed professional attempting to practice in rural areas. Structured treatment locations are even more limited. Treatment centers for substance abuse or inpatient mental health can frequently be 1-4 hour commutes each way, and the lack of the availability of services closer to home may create an unbearable financial hardship due to time away from work, transportation costs, and childcare. Additionally, rural residents may have been aware of their behavioral health difficulties but unable or unwilling to access far away services until a crisis has occurred. This same pattern exists in accessing medical services as well, but less stigma is present in seeking medical versus psychological help. As such, treatment facilities that have a rural catchment area tend to have higher levels of acuity than urban centers, and thus face working with more urgent and challenging patients and conditions with minimal resources.
Finally, as mentioned, there is a lower rate of acceptability of mental health services by many rural people. While there have been recent gains made in decreasing mental health stigma, rural areas lag behind urban environments in understanding and accepting mental health issues.
A potential solution to some of these troubling difficulties may be integrated health clinics. Since medical services are more socially acceptable to rural residents, why not address accessibility and stigma by providing medical and mental health services under one roof? This lessens the patient’s anxiety about being identified by others within their community as receiving mental health services. Also, since medical and mental health issues interact and tend to exacerbate one another, approaching patients more holistically may serve to decrease both mental health and medical crises, and reduce overall acuity levels.
An additional hurdle is that many clinicians lack training in rural cultural competencies. Creative ways of working in rural communities are needed at graduate, practicum, and internship levels—and solutions may vary from community to community, needing specific approaches. Community mental health models that work well in urban environments may not be feasible in rural areas, so clinicians need to take a “troubleshooting” approach in the rural area they wish to serve.
Solutions to the barriers to mental health care in rural areas can be identified and developed. Most importantly, all mental health services need to be tailored to the culture and way of life of the rural area being served.
Smalley, K. B., Rainer, J., & Warren, J. (2012). Rural Mental Health : Issues, Policies, and Best Practices. New York: Springer Publishing Company
Rain Blohm, MS
WKPIC Doctoral Intern