President Bush's New Freedom Commission on Mental Health called for
improving access to care and increasing the presence of service providers in
rural and geographically remote areas of the United States, but little has
changed there since the commission pointed out the mental health disparities
in rural America six years ago, said speakers at the annual meeting of the
National Association for Rural Mental Health in Albuquerque in June.
Rural areas need more support to overcome stigma about mental health
treatment, said Wilma Townsend, M.S.W., at the National Association for Rural
Mental Health annual meeting.
Credit: Aaron Levin
Creating the systems and settings to make such changes possible is never
easy anywhere but is often more difficult in rural areas, thanks to questions
about accessibility, availability, and acceptability of mental health
services, said Wilma Townsend, M.S.W., president of WLT Consulting of
Jonesboro, Ga. The firm specializes in consumer involvement and cultural
competence in mental health recovery. She previously served for more than 15
years as the chief of the Office of Consumer Services for the Ohio Department
of Mental Health.
Accessibility problems range from simple distance to the passability of
roads in winter to the ability to pay for services. Those problems increase in
states west of the Mississippi River as the population becomes sparser, said
In some places, mental health services simply aren't available, she said.
Half of rural counties do not have any mental health providers. Often,
clinicians who do work in rural areas do so without the professional backup or
the ancillary patient support found in metropolitan areas, making it hard to
plan treatment and leading to a greater potential for patient self-harm or
Finally, the sense of self-reliance that rural culture values so highly can
have contradictory effects on residents' willingness to accept illness and
treatment, said Townsend.
"Because they value doing for themselves, they take longer to
acknowledge the scale of mental health problems," she said. "They
seek and enter treatment later than urban residents, and they have access to
fewer care providers."
Stigma has a heightened effect, too, in small communities where everyone
knows everyone else. Combined with poverty, that means that rural people are
skeptical about care, she said. "They think, 'Why pay for something that
can't be guaranteed to work?'"
Rural people are often undereducated about mental health, mental illness,
treatment, and recovery, but they should not be blamed for that, she said.
"We have done a very bad job of making people understand that mental
illness is an illness that people can recover from," she said."
Our culture and the media have done a good job of scaring people
regarding mental illness and leading them to believe that people can never get
well and can become a danger. We have some re-education to do."
In addition, clinicians and administrators must adapt procedures developed
elsewhere to fit the settings and values of rural America, she said. Many
evidence-based treatments have not been tested among rural populations. Some
policies may need to be adjusted for use in rural areas.
Some policies and practices may get in the way of recovery, said Townsend."
For instance, [clinic administrators] hire a peer-support specialist
from the community and then try to enforce a no-fraternization
Encouraging more professionals to work or stay in rural areas means
providing them with more support and more resources to encourage recovery, she
said. Another underexplored source of help may be rural people themselves,
particularly older individuals, who might be encouraged to volunteer in the
community once they received some initial training.
Rural mental health problems aren't restricted to the clinical, said
Townsend. These regions face heightened rates of poverty that are both caused
by and produce a continued outward migration of young people. Although
children in rural areas graduate from high school at about the same rate as
their urban counterparts, many leave for college, jobs, or military service
and never return.
The recent economic downturn has hit rural areas hard. Often the failure of
a single small manufacturing plant can put a significant percentage of a
town's population out of work.
Several federal economic and health care initiatives may soon bear fruit,
said Larke Nahme Huang, Ph.D., senior advisor on children, youth, and families
at the Substance Abuse and Mental Health Services Administration.
Nationally, $1 billion has been directed to prevention and wellness
efforts, addressing social determinants of health, including strategies for
rural communities, Huang told the conferees. Programs like Project LAUNCH,
which began in 2008, provide funds to link mental health consultation with
primary care, child-care settings, early childhood education, and home
Six grants under the program were assigned last year to state health
departments in Rhode Island, New Mexico, Washington, Arizona, and Maine and to
the Red Cliff Band of Lake Superior Chippewa in Wisconsin.
Information about the National Association for Rural Mental Health
is posted at<www.narmh.org/>.▪