Mental Health Care Issues in a Predominantly Rural and Frontier State:

Results and Implications from a Comprehensive Survey

 

Theodore W. McDonald1, Stephanie M. Harris & Elizabeth A. LeMesurier

 

 

ABSTRACT

 

Some research suggests that life in rural and frontier areas, although often portrayed as idyllic, may in some respects be problematic.  One area of concern regards mental health, as it has been repeatedly reported that access to mental health care is poor in rural and frontier areas, that barriers to mental health treatment exist, and that some mental health problems may be particularly prevalent in these areas.  In the present study, surveys asking questions about mental health care access, barriers to mental health care, and prevalent mental health care problems were sent to all licensed and registered mental health providers in each rural and frontier county of an Intermountain West state.  The results suggested that mental health care access is indeed poor, with the primary reported barriers being cost, lack of trained staff, travel distance and time, and the stigma associated with mental health problems.  Prevalent problems included depression, substance abuse, and marital/relationship problems.  The results are discussed in terms of policy implications and strategies for preventative interventions.

 

 

INTRODUCTION

 

According to several researchers (e.g., Campbell, Gordon, & Chandler, 2002; McCabe & Macnee, 2002), there are two perspectives of rural life held by many people.  The first, which is held by many people in the lay public, is quite idyllic.  This image of rural life is likely to include communities characterized by isolated farms with barns, horses, and rows of crops; these communities are commonly perceived as having a tranquil environment, with strong family and social ties, little or no pollution and crime, and a high quality of life.  Community residents are seen as being strong, resilient, and traditional (Campbell et al., 2002; McCabe & Macnee, 2002).  There is a different perspective on rural life, however; this perspective is held primarily by mental health workers, economists, and sociologists, and is not always so idealized.  This perspective maintains that although rural and frontier life may be highly desirable in some respects, it is potentially problematic in others.  This perspective holds that rural and frontier communities are frequently economically depressed (e.g., Murray & Keller, 1991; New Freedom Commission on Mental Health, 2003; Stamm, 2003), isolated (e.g., Campbell et al., 2002), with relatively poor educational systems (e.g., Campbell et al., 2002), and poor access to medical and mental health services (e.g., Amundson, 2001; Hester, 2004; Human & Wasem, 1991; Letvak, 2002; McCabe & Macnee, 2002; Merwin, Goldsmith, & Mandersheid, 1995; Merwin, Hinton, Dembling, & Stern, 2003; Murray & Keller, 1991; Rathbone-McCuan & Bane, 2003; Smith, Peck, & McGovern, 2002; Stamm, 2003).  In other words, many practitioners believe residents of rural communities face numerous challenges (in addition to reaping benefits) as a result of living in sparsely populated areas.

 

Problems associated with access to mental health services in rural and frontier areas have been particularly highlighted by community psychologists and other community mental health researchers.  One of the primary problems with mental health access in rural and frontier areas is that, quite simply, there are very few mental health practitioners who work in these areas (Amundson, 2001; Letvak, 2002; McCabe & Macnee, 2002; New Freedom Commission on Mental Health, 2003).  According to the United States Census Bureau (2001), 62 million Americans (approximately one-fourth of the U.S. population) live in rural areas, and nine million of these persons live in areas so geographically isolated that their communities are classified as frontier (Frontier Education Center, 2004)2,3.  Unfortunately, only 10% of physicians practice in rural and frontier areas to serve residents of these areas (National Rural Health Association, 2004).  The vast majority of all federally designated Mental Health Professional Shortage Areas are in rural and frontier counties, and the professional shortage problems are reported to be even worse for providers trained to treat special populations such as children and seniors (Bird, Dempsey, & Hartley, 2001; Keys, 2005; National Advisory Committee on Rural Health, 2002; New Freedom Commission on Mental Health, 2003).  That mental health services are difficult to access in rural and frontier areas is distressing, particularly in light of recent research that suggests that rural and frontier residents seem to suffer from high rates of depression and substance abuse (e.g. Bischoff, Hollist, Smith, & Flack, 2004; Roberts, Battaglia, & Epstein, 1999), as well as suicide (Institute of Medicine, 1994; Roberts et al., 1999; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994).

 

Unfortunately, not only does there seem to be a profound shortage of mental health professionals in rural and frontier areas, there seem to be a number of barriers in place to decrease the likelihood that rural and frontier residents seek care even when it is available.  These barriers include an inability to afford appropriate care (Fox, Blank, Rovnyak, & Barnett, 2001; Mueller, Patil, & Ullrich, 1997; New Freedom Commission on Mental Health, 2003; Rathbone-McCuan & Bane, 2003), a greater social stigma (relative to more populated areas) associated with seeking mental health treatment (Rost, Fortney, Fischer, & Smith, 2002; Stamm, 2003), belief systems incongruent with care-seeking behavior (Letvak, 2002; Sheffler, 1999; Weinert & Long, 1987), and poor roads and distance from providers (Fox et al., 2001; Sussman, Robins, & Earls, 1987).  Furthermore, the relatively few trained professionals who are available to provide mental health services in rural and frontier areas may be trained primarily in models developed from the treatment of people living in urban areas, which may not be effective or appropriate for the treatment of rural residents (Mohatt, 2005; New Freedom Commission on Mental Health, 2003).

 

Examples of these barriers abound in the community psychology and community mental health literatures.  For example, information from a variety of sources (e.g., McLaughlin & Jensen, 1993; U.S. Department of Agriculture Economic Research Service, 2004) shows that people living in rural and frontier areas are more likely than people living in urban areas to live in poverty, regardless of their race and ethnicity.  In short, many rural and frontier residents simply cannot afford mental health care (Elliot & Larson, 2004).  Rural and frontier residents have also been repeatedly found to be less likely than urban residents to have health insurance coverage, and when they do have coverage, it is more likely to be coverage provided by Medicaid or other public programs designed to assist the poor (Brown & Herrick, 2002; Ormond, Zuckerman, & Lhila, 2000).  With an inability to pay for mental health care and the lack of insurance to help defray the costs of such care, rural and frontier residents may simply forego needed care and thus remain living with symptoms of psychological distress that could usually be treated (Elliot & Larson, 2004; McCabe & Macnee, 2002).

 

Although the stigma associated with “mental illness” and seeking assistance for mental health problems has been well documented in many populations (e.g., Cooper, Corrigan, & Watson, 2003; Fink & Tasman, 1992), this stigma may be even worse in rural and frontier areas than in more populated locations (Fox et al., 2001; Van Hook, 1996; Wrigley, Jackson, Judd, & Komiti, 2005).  This heightened stigma, or the fear of being stigmatized, may be due in part to the perceived lack of confidentiality (Brown & Herrick, 2002) that exists in rural and frontier areas where residents may feel that “everyone knows what everyone else does.”  In other words, although both urban and rural residents may be aware of social stigmas about mental health problems, rural residents may be more often deterred from seeking mental health care because they worry that their neighbors will observe or hear of them seeking care, and stigmatize them as a result.  Furthermore, the unique culture of rural and frontier areas may serve to inhibit assistance seeking.  Sheffler (1999) noted that rural culture tends to value privacy, independence, and self-reliance; although these may be praiseworthy values in many respects, they do not seem likely to facilitate the seeking of help from mental health professionals by people who may need it.  Rural and frontier residents who have been socialized to seek support from known, trusted, and local sources (Weinert & Long, 1987) may also be socialized to view mental health professionals serving in their areas as “outsiders” that they cannot trust, further decreasing the likelihood that they would seek care from such individuals.

 

Finally, it should be noted that even when care can be accessed, it may be so inadequate or inappropriate that it itself becomes a barrier to quality care.  McCabe and Macnee (2002), as well as Merwin and her colleagues (1995), argue that many rural residents may receive mental health services from non-professionals or non-specialty providers with little or no training or even desire to provide these services.  Those mental health providers who do have professional credentials may also be trained in methods that are efficacious in the treatment of mental health problems in urban residents, but which are not effective for use with rural or frontier residents (Bjorklund & Pippard, 1999; Merwin et al., 1995; Murray & Keller, 1991).  In short, it seems that poor quality or inappropriate treatment efforts may hamper the ability of rural and frontier residents to receive the effective mental health care they need.

 

The purpose of the present study was to assess, through a survey of all licensed and registered mental health care providers in rural and frontier counties of an Intermountain West state, perceptions of issues associated with access to mental health care, barriers to seeking or receiving such care, and prevalent mental health problems among rural and frontier residents.  Although this study was exploratory in nature, several findings or patterns of findings were expected.  First, we expected to find that the mental health providers perceived access to mental health care in their regions to be quite poor.  We expected that mental health providers in counties classified as frontier would report that their clients have to travel longer distances to visit them and other mental health professionals (i.e., psychiatrists) than providers in counties classified as rural, and that providers in frontier counties would also report that access to mental health services is poorer than providers in rural counties.  Second, we expected the rural and frontier mental health providers to report common access barriers documented by past researchers in other parts of the country (e.g., Fox et al., 2001; Hester, 2004; Rost et al., 2002; Sussman et al., 1987), including cost, lack of insurance, stigma, and travel distance and time.  Finally, we expected that the rural and frontier mental health providers would report, similar to past researchers (e.g., Bischoff et al., 2004; Roberts et al., 1999), that certain health problems are particularly prevalent in their areas, and that depression and substance abuse would be among the most prevalent.

 

 

METHOD

 

Participants

 

The participants in this study were 128 persons who responded to a mailed survey; all of these persons were licensed to perform work in a mental health field, whose primary work location was in one of the 36 Idaho counties classified as “rural” or “frontier.”  The most commonly reported professional titles among the survey respondents were Licensed Professional Counselor (Private Practice) (reported by 34 respondents, or 26.6% of the sample), Licensed Clinical Social Worker (28; 21.9%), Licensed Social Worker (13; 10.2%), Marriage and Family Therapist (13; 10.2%), and Social Worker (10; 7.9%).  The most commonly reported highest degree among the respondents was a Master’s degree (reported by 85 respondents, or 67.5% of the sample), followed by a Bachelor’s degree (23; 18.5%) and a Doctorate (17; 13.5%).  Only one respondent (.8% of the total sample) reported having a M.D.

           

When the respondents were asked to report their primary office location, the most common response was a leased office (reported by 47 respondents, or 37.3% of the sample).  Slightly over one-fifth of the respondents (26; 20.3%) reported working in a mental health clinic, and smaller numbers reported working out of their homes (15; 11.7%), in hospitals (11; 8.6%) medical clinics (9; 7.0%), and schools (6; 4.7%).

 

 

Materials

 

A three-page survey, along a cover letter describing the project and stressing the voluntary nature of participation, was developed by a group of community researchers at a large university in the Intermountain West.  The 15 survey items were developed jointly by the research team and the program manager of the adult mental health program operated by the state’s department of health and welfare.  The survey items asked questions related to the training and expertise of the respondents, the types of individuals they served and the payment options they accepted, the distances traveled by their clients for various types of mental health services, perceived accessibility of mental health services in their respective geographic areas, barriers to mental health care access, stigma associated with seeking mental health treatment, and the prevalence of mental health care problems in rural areas.

 

 

Procedure

 

A listing of all licensed mental health care workers was procured from the Bureau of Occupational Licenses in the target state.  This listing was extremely comprehensive, and included workers who were licensed as psychiatrists and clinical psychologists, as well as counselors, clinical social workers, school psychologists, child protection workers, and pastoral counselors, as well as others.  The listing was sorted by county, and then the research team sorted the listing into groups of mental health professions registered in urban, rural, and frontier counties.  Urban counties were classified, in accordance with the target state’s categorization scheme, as counties home to a city with at least 20,000 residents; eight counties were classified as urban.  Frontier counties were classified according to the guidelines developed by the Frontier Education Center, which take into account residential distance and travel distance in time and miles to a market and service area; 26 counties were classified as frontier.  Rural counties were classified as counties that were not home to a city of at least 20,000 residents but which did not fit the criteria of a frontier county; 10 counties were classified as rural.

           

Survey packets were mailed to the 630 mental health professionals who were registered in the 36 rural and frontier counties.  Each survey packet included a cover letter, survey, and a self-addressed, postage-paid envelope for the respondents to return the surveys to the researchers.  Thirty-three surveys were returned to the researchers because the mental health professionals were no longer registered at the listed address.  Of the 597 surveys that did reach the correct address, 159 were completed and returned to the researchers, for a response rate of 26.6%.  Thirty-one of these surveys were not considered usable, for one of three reasons.  First, some of the respondents listed their office as being in one of the eight urban counties (even though their mailing address had been in a rural or frontier county) or even in another state.  Second, several respondents provided such little information (for example, only demographic information) that they offered no real data to analyze, and third, several respondents wrote on their returned surveys that they were no longer practicing in a mental health field (e.g., they had changed occupations or retired).  Thus, 128 usable surveys remained. Sixty-seven of these surveys (or 52.3% of the usable surveys) were from respondents practicing in rural counties, and 61 (47.7%) were from respondents practicing in frontier counties.

 

 

RESULTS

 

Populations Served

 

To assess the populations that the responding mental health professionals served, the respondents were asked to indicate which three of nine listed populations (children 0-11 years of age; adolescents 12-17 years of age; adults 18-64 years of age; seniors 65 years of age and older; couples; people with severe mental illnesses such as schizophrenia; people with substance abuse problems; people with developmental disabilities; and people with dual diagnoses) they most frequently served.  Among the respondents who completed this item (eight, or 6.3% of the sample did not), the most commonly reported populations served included adults (reported by 81 respondents, or 67.5%), adolescents (64; 53.3%), children (42; 35.0%), people with severe mental illnesses (37; 30.8%), and couples (30; 25.0%).

 

Client Payment Options

 

The respondents were asked to indicate what forms of payments they accepted from their clients by selecting among four options:  1) Medicaid; 2) third-party insurance; 3) sliding scale fees based on income; and 4) pro bono or free services.  Perhaps not surprisingly, among the respondents who completed this item (16, or 12.5% of the sample did not), the largest number and percentage of respondents (83; 74.1%) reported accepting third-party insurance.  Over half of the respondents (66; 58.9%) reported accepting Medicaid, and over half (62; 55.4%) also reported accepting sliding scale fees based on client incomes.  Interestingly, nearly half of the respondents (55; 49.1%) also reported providing pro bono or free services for clients who could not pay for these services.

 

Client Travel Distances

           

The respondents were asked to estimate approximately how far their average client had to travel in order to visit them in their office and how far their most distant client had to travel in order to visit them in their office.  The mean length, in miles, reported by the respondents for their average client was 14.17 miles (sd = 28.24, with a median of 10 miles and a range of 0-300 miles), and the mean length of travel for their most distant client was 54.93 miles (sd = 61.55, with a median of 43.5 miles and a range of 0-500 miles4).  Contrary to prediction, no statistically significant differences in miles traveled for average or most distant clients were found between respondents working in rural and frontier counties (both ps > .05).

           

The respondents were also asked to estimate approximately how far from their office location a client would have to travel if he or she was referred to an in-patient mental health facility or a psychiatrist.  The mean distance, in miles, that a client would have to travel to reach an in-patient facility was 45.32 miles (sd = 31.61, with a median of 45 miles and a range of 0-160 miles), and the mean distance that a client would have to travel to visit a psychiatrist was 36.87 miles (sd = 33.57, with a median of 30 miles and a range of 0-160 miles).  As hypothesized, significant differences in mean responses to these two questions were found between respondents in rural and frontier counties.  With regard to travel distances to in-patient facilities, respondents in rural counties (M = 30.74, sd = 16.99) reported significantly shorter travel distances than did respondents in frontier counties (M = 59.91, sd = 35.97), [t (118) = -5.68, p < .001].  With regard to travel distances to visit a psychiatrist, respondents in rural counties (M = 23.75, sd = 21.27) also reported significantly shorter travel distances than did respondents in frontier counties (M = 50.70, sd = 38.49), [t (109) = -4.60, p < .001].

 

 

Mental Health Care Accessibility

           

The respondents were asked to select one of five options to reflect how accessible they perceived mental health care to be in their areas.  The five options were: 1) very easy to access; 2) somewhat easy to access; 3) somewhat difficult to access; 4) very difficult to access; and 5) do not know/not sure.  The most common response, which was selected by 48 respondents, or 39.0% of the respondents who completed this item (five respondents did not) was that mental health care was somewhat difficult to access, followed by such care being very difficult to access (30; 23.4%).  Smaller numbers and percentages of the respondents reported that mental health care was somewhat easy to access in their areas (28; 22.8%) and very easy to access (16; 13.0%).  Only one respondent (.8%) reported not knowing how accessible mental health care was in his or her area.  Contrary to prediction, there was no statistically significant difference in patterns of responding to this item as a function of whether the respondents were practicing in a rural or frontier county [c2 (df = 4) = 5.85, p > .05].

 

Those respondents who indicated that they perceived mental health care in their areas to be somewhat or very difficult to access were asked to write, in their own words, what they felt the primary barriers to accessing such care were.  A content analysis procedure was used to identify the major themes among the responses.  As seen in Table 1, the most commonly perceived barrier, selected by over half of those who identified at least one barrier, was related to cost of care.  A second commonly perceived barrier was the lack of psychiatrists and other trained staff in the respondents’ areas.  Smaller but substantial numbers of respondents also identified as barriers travel distance and time, the stigma associated with seeking mental health care, a lack of education or knowledge about mental health care services, and lack of transportation for clients.

 

Table 1

Primary Barriers to Mental Health Care

Barriers

Percentage of Respondents

N

Cost/Lack of insurance

53

53.0

Lack of psychiatrists/trained staff

33

33.0

Travel distance and time

17

17.0

Stigma associated with seeking mental health care

14

14.0

Lack of education/knowledge of available mental health services

 

13

 

13.0

Lack of transportation

12

12.0

Note.  The percentages reported are “valid” percentages, meaning they are calculated out of the total number of

respondents (100) that completed this item.  Multiple responses were allowed to this item, so the cumulative percentage

may exceed zero.

 

The respondents who indicated that they perceived that barriers to health care existed in their areas were asked to list strategies that they believed could reduce or eliminate those barriers.  A content analysis procedure was again used to identify the major themes among the responses.  As seen in Table 2, the most common response was again related to cost; nearly half of the respondents who completed this item indicated that more funding or payment options would be helpful in reducing or eliminating mental health access barriers.  A substantial number of respondents also indicated that more psychiatrists or other staff in rural and frontier areas and enhanced community awareness/education about mental health issues would reduce or eliminate barriers to mental health care access (see Table 2).  Smaller numbers of respondents indicated that better transportation and more mental health facilities in general would be helpful in reducing or eliminating these barriers (see Table 2).

 

Table 2

Strategies to Reduce or Eliminate Barriers to Mental Health Care

Strategies

Percentage of Respondents

N

More funding/insurance/payment options

42.5

42

More psychiatrists/trained staff available or nearby

23.4

23

Enhance community awareness/education of mental health difficulties and services

 

20.4

 

20

Better transportation

9.2

9

More mental health treatment facilities

8.1

8

Note.  The percentages reported are “valid” percentages, meaning they are calculated out of the total number of

respondents (98) that completed this item.  Multiple responses were allowed to this item, so the cumulative percentage

may exceed zero.

 

Stigma Associated with Seeking Mental Health Care

 

The respondents were asked to indicate whether they felt that the stigma associated with seeking mental health care was greater, about the same, or lower in rural areas relative to more populated areas.  The majority of the respondents (76, or 59.4%) who completed this item (two did not) indicated that the stigma associated with seeking such care was greater in rural areas.  A relatively large number of the respondents (48; 37.5%) reported that the stigma was about the same in both areas, and only two (3.3%) reported that the stigma was lower in rural areas relative to more populated areas.

 

Prevalence of Mental Health Difficulties

 

To assess perceptions of whether mental health difficulties are more prevalent in rural areas compared to more populated areas, the respondents were asked to indicate whether they felt this to be to the case, or whether they felt the prevalence of mental health difficulties was about the same in both areas, or lower in rural areas.  A slight majority (67, or 54.9%) of the respondents who completed this item (six did not) reported that the prevalence of mental health difficulties was about the same in rural and more populated areas, however a large minority (51; 41.8%) reported that mental health problems were more prevalent in rural areas compared to more populated areas.  Only four respondents (3.3%) reported that the prevalence of mental health problems was lower in rural areas.

 

 

Most Common Mental Health Difficulties

 

A final item asked the respondents to list, based on their own experiences and in their own words, what they felt were the most common types of psychological difficulties in rural areas.  As seen in Table 3, the most commonly reported mental health problem was clearly depression.  Substance abuse, marital or relationship problems, and anxiety were also reported by a substantial number of the respondents.  Domestic violence, family discord, and abuse (broadly defined) were also reported with some frequency.

 

Table 3

Most Commonly Reported Mental Health Difficulties

Mental Health Difficulty

Percentage of Respondents

N

Depression

79.5

97

Substance abuse

40.2

49

Marital/Relationship problems

29.5

36

Anxiety

23.8

29

Domestic violence

16.4

20

Family discord

12.3

15

Abuse

10.7

13

Note.  The percentages reported are “valid” percentages, meaning they are calculated out of the total number of

respondents (122) that completed this item.  Multiple responses were allowed to this item, so the cumulative percentage

may exceed zero.

 

DISCUSSION

 

In the present study, a comprehensive glimpse of mental health care issues in a predominantly rural and frontier state in the Intermountain West was developed through the survey responses of a large number of mental health professionals.  As researchers, we attempted to achieve excellent external validity by soliciting responses from a broad range of individuals involved in the mental health care delivery sector in rural and frontier counties, and by sending surveys to every licensed professional working in such counties, we believe we were successful in this regard.  As a result, we feel that we can make some strong generalizations about a number of important mental health care issues, at least within the target state.  However, to the extent that the target state shares some similar characteristics (demographically, economically, and in other respects) with other predominantly rural and frontier states, the results may be of value to researchers and mental health care professionals in those states as well.

           

Several results from this study seem to deserve additional discussion, because they appear to have important implications in terms of mental health care generally and on policy decisions that affect mental health care accessibility and delivery.  First, it seems important that, although no differences in estimated travel distances to mental health professionals were found between rural and frontier counties, significantly different estimated travel distances to both psychiatrists and inpatient mental health treatment facilities were found between these two types of counties.  Thus, it seems that residents of rural and frontier counties, at least in the target state, may be similarly close to (or distant from) offices housing certain mental health professionals.  In our sample, most of these professionals had Master’s degrees and many of them were licensed to provide psychological counseling.  Therefore, it seems that residents of frontier counties (again, at least in the target state) may have access similar to residents of rural counties to basic mental health care.  However, residents of frontier counties may be less able to access mental health care professionals (i.e., psychiatrists and inpatient facility clinical staff) who are trained to treat serious mental health problems or to address crisis-level episodes.  It seems to us that efforts to make such professionals more accessible in frontier areas (either by encouraging psychiatrists to practice in frontier areas or by developing a better infrastructure to support inpatient facilities in these areas) are warranted, as travel greater distances may discourage frontier residents from seeking emergency mental health care when they truly need it.

           

Accessibility to mental health care in general seems to be a key issue.  As noted earlier in this article, numerous researchers have reported that mental health care is generally less accessible in rural areas than in urban areas.  The results from our survey seem to support this notion:  Over 60% of the mental health care professionals who responded to our survey reported that mental health care options were somewhat or very difficult to access in their rural and frontier counties, and only slightly more than one-third reported that access to such care was somewhat or very easy to access.  Worse yet, most of the respondents felt that marked barriers to mental health care access existed.  As discussed earlier in this article, many of the respondents reported that residents of rural and frontier areas simply could not afford to pay for the mental health services that they might need.  Many of the respondents also reported that many residents of rural and frontier areas might be unaware of what treatment options are available, and that even if they were aware of the options, they might be deterred from seeking care due to the stigma associated with doing so (which 60% of the respondents perceived being even higher in rural and frontier areas than in urban areas).  Furthermore, these respondents reported that there is not enough trained staff in these areas to treat mental health problems, even if the residents-in-need were aware of the services, could pay for them, and were willing to brave the stigma to seek help.  These results paint a rather bleak picture.

           

Our training in community psychology encourages us to avoid becoming unnecessarily dismayed by bleak pictures; rather, this training encourages us to see not only problems, but solutions to problems as well.  Certainly, the problems associated with mental health care issues in rural and frontier regions of the target state—and in sparsely populated regions in other states—are not insurmountable.  However, they do seem to require dedicated, multilevel efforts to address them.  Some suggestions for these efforts seem warranted here.

           

It seems clear to us that there was some consensus among our responding mental health professionals that access to mental health care in the rural and frontier regions of the target state is relatively poor.  Other researchers have reached similar conclusions in rural and frontier regions of other states.  So the question arises:  What can community psychologists do to improve such access?  It seems that we must first consider what the primary barriers to access are.  The results of our survey indicated that, at least according to mental health professionals practicing in rural and frontier counties of the target state, the primary barriers include the cost of receiving treatment, lack of available trained staff (especially highly trained staff such as psychiatrists), travel distance and time, the stigma associated with seeking mental health care, lack of resident knowledge about available mental health services, and lack of transportation for potential clients.  These seem to be the key problems, at least in terms of access.  What are the solutions?  The respondents to our survey certainly suggested some ways to reduce these barriers, and these suggestions included: developing more funding, insurance, or payment options for clients, having more trained staff (including psychiatrists) available nearby, enhancing awareness of and education about mental health problems and available services, better transportation options, and more mental health treatment facilities.

           

On the surface, these strategies may seem difficult to implement for community psychologists and other community mental health professions.  For example, one might ask:  What can I do to provide more funding, insurance, or payment options for clients in rural and frontier areas?  Changing funding, insurance, and payment options may seem beyond our control.  However, this is not necessarily true.  Many community psychologists have the skills and experience to present their research to local, state, and federal officials whose decision affect policies.  Indeed, some community psychologists (e.g., Jason, 1991; Wolff, 1987) have argued that working for positive change is an integral part of community psychology.  By conducting relevant research on topics such as this one, and presenting this research to decision-makers, we can attempt to change the formulas through which mental health care is funded.  For example, by showing that residents of rural and frontier areas may be forced to forego needed mental health care because they cannot afford it, we might be able to persuade more states to pass mental health parity laws, which require insurance companies to cover the costs of mental health care similarly to physical health care (rather than only allowing a small number of visits per year, or not covering mental health care at all).

           

Using the results of soundly conducted research, community psychologists and other community mental health professionals can also address several other strategies to reduce access barriers that were suggested by our respondents.  By demonstrating that there are too few mental health treatment facilities and trained staff available in rural and frontier areas, we may be able to persuade state legislators to consider building and maintaining new community mental health centers, and attempting to have several of them located in rural and frontier areas (certainly, this would be a sound strategy in the target state, where seven community mental health centers—all but one of which is in an urban county—are meant to serve approximately 1.4 million people scattered across nearly 83,000 square miles).  Engaging in greater efforts to train, in a culturally-competent fashion, new mental health providers to work in rural and frontier areas can also be accomplished; some organizations, such as the Western Interstate Commission for Higher Education, have been pioneers in working to shape rural mental health workforce development (Mohatt, 2005).  We can also demonstrate the need for an effective advertising campaign to help make residents of rural and frontier areas become more aware of what constitutes a mental health problem, and where help might be sought before the problem becomes particularly pathological.  Lastly, we can demonstrate the need for collective efforts (in the media, schools, and elsewhere) to reduce the stigma associated with seeking mental health treatment.  All of these strategies seem viable, and by employing them, we can reduce the “bleakness” of the picture painted earlier, and turn problems into solutions.

           

A final set of results revealed that certain types of mental health problems are particularly prevalent in rural and frontier counties of the target state, and that these mental health problems include depression, substance abuse problems, marital/relationship/family problems, domestic violence and other types of abuse, and anxiety.  It should be noted that some of these problems have been reported by other researchers (e.g., Bischoff et al., 2004; Roberts et al., 1999) to be among the most prevalent in other rural and frontier regions in the United States, which suggests that there may be some generality in the mental health problems faced by rural and frontier residents across the nation.  In other words, it is highly likely that certain mental health problems may be incurred more frequently by rural and frontier residents, regardless of the state that they live in.  Knowing this at least enables us to define our problem; it also enables us to begin searching for potential solutions.

           

Solutions for mental health problems are often conceptualized in two categories:  treatment and prevention.  As most community psychologists have learned (to our eternal disgust), much more emphasis seems to have been traditionally focused on treatment efforts—often at the expense of prevention efforts.  Still, we all recognize that treatment of existing mental health problems is very important, and the results of this study suggest some avenues for treatment efforts.  It seems that any efforts to expand mental health care options in rural and frontier areas (which we have advocated for here) should be tailored to provide quality care for the prevalent mental health problems that we have identified above.  It seems that it would be particularly desirable for efforts to be made to encourage mental health providers who specialize in the diagnosis and treatment of depression and anxiety, substance abuse problems, family and relationship difficulties, and abuse issues to provide services in rural and frontier areas.  It also seems that it would be helpful to focus greater educational efforts in such areas, to help rural and frontier residents recognize whether they or a loved one may suffer from a prevalent mental health problem, and to know where to access treatment for it.  In other words, knowing what the most prevalent mental health problems are in rural and frontier areas should help us to create and provide appropriate treatment options tailored to these problems.

           

Many community psychologists truly believe the old adage “that an ounce of prevention is worth a pound of cure,” and therefore tend to be (as we are) more interested in determining how to prevent, rather than treat, the mental health problems that we have identified to be particularly prevalent in rural and frontier areas.  This may be a challenging task, as many of the problems that researchers have identified as contributors to the development of mental health problems in rural and frontier residents may be structural or systemic in nature, and therefore somewhat outside of the normal realm of experience for mental health professionals.  For example, economic issues including the decline of resource industries such as mining and forestry, as well as agricultural work on family farms have been associated with both stress and the incidence of psychopathology (Hargrove, 1986).  Social isolation, which is common in rural and frontier areas, may also influence rates of mental health problems (Quevillon & Trenerry, 1983).  It is recognizably difficult for community psychologists to prevent or even affect economic issues in any region, or to influence the lack of residential density that may in some cases lead to social isolation.  However, community psychologists can do much to prevent the mental health problems, or at attenuate the magnitude of these problems, for residents of rural and frontier areas by targeting for mental health educational campaigns and outreach towns and regions facing impending economic crises (e.g., the proposed closing of a mill, mine, or agricultural industry) or currently experiencing such crises.  We can also make efforts to weave ourselves into the local fabric of rural and frontier communities to engender trust and understanding, so that we can more easily provide services in these communities if and when economic concerns develop.  Lastly, we can work to facilitate natural support and helping systems in rural and frontier communities to reduce the social isolation that may cause or exacerbate mental health problems.

           

In this article, we have attempted to demonstrate that there may be serious problems related to mental health care access in rural and frontier counties of one sparsely populated state, and have speculated that these access problems may also be characteristic of other predominantly rural and frontier states.  We have also attempted to demonstrate that certain types of mental health problems may be particularly common in rural and frontier areas.  Although we recognize these as daunting challenges, we have attempted to offer solutions to these problems, and we believe that they can be solved, if community psychologists muster the true strengths of our discipline: A unflagging sense of optimism and an enthusiasm for working for positive change.

 

 

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Notes

1 Address correspondence and reprint requests to the first author at:  Department of Psychology MS-1715, Boise State University, 1910 University Drive, Boise, ID 83725-1715.

2 A rural area is defined by the U.S. Census Bureau as a county with fewer than 2,500 people per town boundary.  For the purposes of this study, a definition of “rural” provided by the Idaho Department of Commerce (1998) was used.  This definition is that a county is considered rural if it has no town or city of at least 20,000 persons.

3 “Frontier” areas are defined differently by different sources.  Some definitions (e.g., the one used by the Idaho Department of Commerce, 1998) focus solely on residential density (the IDC defines a frontier county as one with six or fewer people per square mile).  The definition of frontier used in this study was developed by the Frontier Education Center, and takes into account a combination of residential density and travel distance in miles and travel time from a market and service area.

4 An outlying value of 3,000 miles was removed from the calculation of the farthest distance traveled by a client.  The rationale for the removal of this value was that there are no distances between towns in the target state that are remotely close to 3,000 miles.