Journal of Rural Community Psychology Volume E6 Number 2 Fall 2003
Rural Mental Health: A Qualitative Inquiry
Jill M. Thorngren
Defining characteristics of “ruralness,” definitions of mental health from a rural perspective, and strengths of rural people were explored in this pilot study. Twelve women and men, all residents of a rural community in Idaho, were interviewed via a focus group format. Data was collected from transcribed audiotapes and qualitatively analyzed for themes and patterns.
Participants indicated that they did, indeed, experience mental health issues such as depression and anxiety. They also agreed that the experiences inherent in rural life both contribute to and help ameliorate symptoms of these disorders.
It is widely known that mental illness is pervasive in the United States. Depressive disorders, schizophrenia, anxiety disorders, eating disorders, suicide, attention deficit hyperactivity disorder (ADHD), autism, Alzheimer’s disease and other diagnosable mental disorders affect approximately 22.1% of the American population age 18 or older (NIMH, 1994). The prevalence of these clinically defined mental disorders is roughly the same among rural and urban populations. However, Rural Mental Health Research at the NIMH indicates that the 60 million Americans who live in rural America have an equal or even greater likelihood of suffering from mental illness and substance abuse as their urban counterparts.
Providing much needed mental health services in rural populations can be challenging for a plethora of reasons. Lack of qualified providers, complex ethical dilemmas, and stigma have all been cited as deterrents of providing effective mental health services to rural residents (Roberts, Battaglia, & Epstein, 1999, Spoth, 1997, & Roberts, Battaglia, Smithpeter, & Epstein, 1999).
Known Barriers that Prevent Access to Mental Health
The barriers preventing access to mental health care in rural populations have been exhaustively identified in the literature. Innovative research in this area has been conducted by the Center for Mental Health Services (CMHS), the Frontier Mental Health Services Resource Network (FMHSRN), the National Rural Health Association (NRHA), National Association for Rural Mental Health (NARMH), and others, i.e., Roberts, et al. (1999), and Spoth (1997). A review of this data indicates that there are several challenges and ethical dilemmas to consider if effective mental health services are to be provided and accessed in rural areas. These include the following: 1) limited access to qualified providers and services; 2) increased stress on care-providers; 3) co-morbidity of substance abuse with mental illness; 4) geographical isolation; 5) dual relationships and conflicting roles among care-providers, patients, and families; 6) protection of patient confidentiality; and 7) cultural philosophy regarding mental health care.
Starr, Campbell, and Herrick (2002) reported that physical and social isolation as well as conservatism and independence, all of which are prevalent in rural communities, have been cited as factors that may limit acceptance of mental health treatment.
Cultural Perceptions of Mental Health Care
The field of mental health is often permeated with a certain negative connotation in rural areas. Stereotypical perceptions of mental health patients as “crazy” still abound. A recent study (Sirey, 2001) indicated stigma not only dissuades people from seeking mental health services, but may also impede progress once people are engaged in the treatment process. Esters, Cooker, and Ittenbach (1998) argued that the effects of this stigma are magnified among rural Americans. They hypothesize that this may be due not only to the stigma attached to mental health services, but to the stigma attached to help-seeking in general.
An additional concern is described by Roberts et al. (1999), “Rural communities have been likened to fish bowls. Comings and goings at the mental health clinic are observed and people listen carefully to comments of clinic staff members” (p.500). The close scrutiny common in rural communities combined with the pervasive tendency to stereotype mental health services creates a barrier for those who are in need of such services.
In examining the perceptions that rural parents have regarding attaining mental health services for their children, Starr et al. (2002) found the following:
60% of parents/guardians in their study expressed concern about what others
might think if they accessed the mental health system;
60% expressed concern that their family and others would not approve if they
accessed the mental health system;
73% reported they would be concerned if someone found out they were taking
their child/adolescent to see a mental health professions;
37% thought their child/adolescent would not want to see a mental health
63% were concerned that the mental health professional would not care for their
70% were concerned that the mental health professional would not respect their
43% wondered if they could trust the mental health professional.
Of these same respondents, however,
67% said they would feel good taking their child to see a mental health
80% thought that mental health professionals were needed for their children
77% thought a mental health professional would find out what was wrong with
60% perceived that taking their child to a mental health professional would help
her/him grow up healthy. (p.297)
In this particular study, it appeared that while the outcome expectations for mental health treatment were fairly positive, respondents had negative biases regarding the stigma of accessing treatment and were unsure about ways in which positive therapeutic relationships could be built. This points to the need for educating potential clients regarding the therapeutic process and alleviating the negative viewpoints that often accompany the realization that mental health services may be necessary or beneficial.
Lawrence and McCulloch (2001) reviewed the barriers that older adults, specifically those in rural areas face when in need of mental health care. They note that stigmatization, migration, economic conditions, and informal social support inhibit elders in rural communities from seeking mental health services. Stigma seems to have a bi-directional pattern of influence. Rural people may be more likely to be considered mentally ill because of their avoidance of services, and this discriminatory attitude may contribute to additional avoidance. Migration patterns indicate that younger people are leaving rural areas to seek professional type careers. This leaves rural communities depleted of the resources that younger people may contribute. Younger people, who may be more open minded to mental health care, are thus leaving rural areas. This tends to propagate the stigma that mental health issues are not important to address.
Recent studies (e.g. Goetz & Freshwater, 1997) indicate that the incidence of poverty is higher among rural families and for women and children residing in rural, female-headed household than for those living in America’s inner cities. Rural elders have 12% to 19% fewer financial resources than their urban counterparts (McLauglin, 1998; Miller & Montalto, 1998). This results in fewer resources being available in rural areas and fewer individuals being able to afford what services are available. When a choice has to be made between mental health care or medical care, few choose mental health. Even if services are available, rural folks, who live at or below the poverty level, cannot feasibly access them.
A strength and weakness typically inherent in rural communities is that of community support. While rural peoples may enjoy an informal support network among their families and community members, this may also weaken their view of the importance of facility-based services. In other words, too much emphasis may be placed on utilizing friendships and neighborhood relationships as opposed to seeking professional help. As noted in the description of migration patterns, younger family members are leaving rural areas. This depletes part of the social network on which elderly community members may rely. It also reduces revenue due to shrinking tax bases. If elderly rural residents rely on community support and part of that support system is diminishing, they are at greater risk for mental health crises. At the same time that this is occurring, there are less financial resources to support professional treatment facilities and less sources to counteract negative viewpoints of such services.
It has thus been documented on a general level that stigma exists and impedes access to and progress in mental health treatment. It is still unclear, however, what exactly creates said stigma in particular rural areas. Preliminary hypotheses include that small populations and a “fishbowl” atmosphere contribute to stigma. Fears about the unknown relationships between mental health professionals and clients may also create stigma. As noted, participants who were surveyed believed that professional mental health care would probably be useful, but they were unsure of how relationships would be built between their children and the professional. This uneasiness contributed to an avoidance of seeking out care. It also appeared that older people in rural areas may hold onto outdated notions regarding what mental health and illness actually are. As younger people migrate out of rural areas, the older residents are left with little to replace these ways of thinking.
Garfinkel and Goldbloom (2000) depicted stigma surrounding mental health as originating in fear, lack of knowledge, and ingrained moralistic views that have persisted since antiquity. Rural cultural philosophy tends to exacerbate this stigma. Kelleher, Taylor, and Rickert (1992) postulate that certain characteristics of rural residents such as a high regard for autonomy and self-help propagate this stigma even more.
Weinert and Long (1987) conducted a qualitative/quantitative study regarding health care needs of rural Montanans. Contradictory to current data that suggests equivalent rates of mental illness in rural and urban populations, the Weinert and Long study indicated fewer indices of depression in rural Montana than in urban counterparts. Suggested rationales for this outcome, however, were the possibilities of rural peoples not recognizing symptoms of depression as such, or not seeking help for this symptomology. This study also illuminated the importance of self -help as described by the rural participants.
Though helpful starting points, these studies primarily point out the need for more in-depth purview of the origins of mental health stigma. Whether it emanates from fear or a high regard for autonomy, there is still a paucity of understanding about stigma in rural areas. It would appear that perceptions people harbor regarding their understanding of mental health, mental illness, and treatment may contribute to whether or not they seek services.
What is Rural?
As noted by Spoth (1997), when exploring issues and designing services for rural populations answering the question “what is rural” is primary. While Hewitt (1989) lays out a classification scheme that incorporates multiple components of rural populations, the primary characteristics are population density, urbanization, and principle economic activities. Certainly, these are dimensions of “ruralness,” but they overlook, to a large extent, the complexity and richness of rural culture as well as differences between rural communities. It is therefore proposed that an examination of personal and interpersonal characteristics that differentiate rural people from people in non-rural populations will contribute to a better understanding of what mental health methods may be most effective.
Beeson (1992) queries… “whether there is something specific to rural that contributes to problems…or whether the structural effects of rapid social change, economic distress, and the decay of social institutions (regardless of geographic setting) give rise to stress-induced mental disorders” (p.3) (as cited in Spoth, 1997). The current study sought to illuminate information regarding this question as well as initiate query into the strengths that may contribute to rural peoples overcoming mental health problems.
To begin addressing the aforementioned issues, this pilot project undertook three broad areas of study. First, the definition of rural was explored. This included examination of personal and interpersonal characteristics of people who live in geographically defined rural areas. Secondly, perceptions and definitions of mental health and illness as characterized by those in rural areas are described. Finally, potential strengths that are engendered by rural life are discussed.
Description of Participants
Six men and six women ranging in age from 25 to 71 were interviewed in a focus group format. All participants were contacted via telephone prior to the interview. Informed consent was provided, including limits of confidentiality. All were given the option to withdraw from participation at any time.
Participants were residents of a small, unincorporated community in rural Idaho.
They had lived in the target community from 12.5 to 71 years. While the community is primarily agricultural, five of the participants were engaged in non-farm related careers. All group members were Caucasian and considered themselves to be in the lower middle to low socio-economic status range. Three of the female participants had spent their formative years in non-rural communities, moving to the rural area upon marrying their husbands. All of the males had spent the majority of their lives in the aforementioned or a similar rural area.
Participants were asked to 1) define the concept of “rural” from their perspectives; 2) discuss their perceptions of mental health/illness and whether or not they would seek professional help for treatment of mental health issues; and, 3) discuss ways in which living in a rural community affected their mental health.
Description of Analysis
The focus group session was audio-taped and transcribed. Using grounded theory methodology (Lincoln & Guba, 1985; Strauss & Corbin, 1990), the resulting data was subsequently coded and overarching themes were extrapolated. The initial procedure used was that of open coding, or breaking the data down to name and categorize the phenomena that it represented. Next, axial coding was utilized. This involves “putting the data back together” in new ways that depict relationships (Thorngren, 1999). Selective coding drew out the themes that were most pervasive and inclusive of the data that was generated.
As this was a preliminary study, it is anticipated that further data will be gathered and used to either substantiate these findings or add additional components to the study. An overarching theory has not yet been developed and is dependent on further research.
How Is Rural Defined
A variety of responses was given to this question. Participants started by laughingly stating that “there are no sky-scrapers,” and “grain silos are the tallest buildings.” Further discussion elicited the following themes.
Relationships with Others
Participants described their perceptions that while there were far fewer people in rural, versus urban, communities, rural peoples share a closer bond. Discussion ensued around knowing one another’s children and even being able to recognize one another’s vehicles. Several members described neighbors helping each other. Some also felt that they and their children were safer in a rural community. There was a consensus that “strangers” would immediately be recognized and therefore potential criminals were less likely to perpetrate crimes in a rural community. No mention was made of community members committing crimes or endangering one another.
Connection to the Land and Animals
All participants, even those not engaged in full-time farming operations, cited a connection to “the land” as a unique characteristic of rural life. One group member discussed “having a sense of giving back to the world….” through working the land and producing food. Several talked about the sense of completion that comes from tilling the soil, planting seeds, irrigating and caring for the crops, and finally harvesting them.
Group members also discussed the importance of animals. Many said that they insisted their children have calves, chickens, etc. to care for so that the children learn responsibility and the value of caring for another life.
Rural community members noted that the absence of grocery, department, and convenience stores, as well as medical facilities, and other amenities defined, in part, their lifestyle. They discussed the fact that extra time had to be allotted for traveling into town, even for basic services. An additional component of rural lifestyle was characterized as the idea that “you are never done.” In other words, group members viewed their lives as revolving around chores, crops, and other work that need to be attended to constantly. One woman described her childhood experiences of living in town and having the house cleaned by noon on Saturday so that she and her siblings could play. She contrasted this with her present life on the farm where she experiences, in her perception, a never ending array of house and farm chores that are never quite completed. Some participants described a feeling of “being tied down” to their farms and animals. Time away from the farms is minimal due to irrigation schedules, milking cows, etc.
Characteristics of Rural People
Members of the focus group described specific characteristics that they believed people who live in rural communities possess in order to be successful in their surroundings. Ambition, or the ability to work hard, was cited most frequently. Participants noted that the farming, mechanics, and other “hands on” occupations in which they were involved demanded long hours of work as well as physical strength. Additional characteristics included the ability to problem solve, figuring things out for one’s self, and working together. Lengthy discussion ensued pertaining to the notion that when one lives in a rural community, one has to learn how to do plumbing, mechanical work, preserve food, etc. because those services are not readily available. Because of the importance of sharing resources, such as irrigation water, rural folks must also learn how to cooperate and solve problems together. Willingness to “give,” in terms of sharing water, equipment, and labor, as well as patience were additional traits that group members believed rural people possess. An overarching trait that was described was that of responsibility. All group members believed that learning to take care of crops and animals as well as the necessity of self sufficiency contribute to a strong work ethic and an ability to take responsibility for one’s self and one’s duties.
It appeared that definitions of “rural” were broken down into categories that described relationships with others, a connection to land and animals, lifestyle influences, and personality traits or characteristics. These definitions substantiated Kelleher, Taylor and Rickert’s (1992) description of rural residents as having a high regard for autonomy and self-help (cited in Ittenbach, 1998). This type of definition diverged, however, from those cited by Spoth (1997). He specifically recommended the need to develop definitions and descriptions of “rural” that did not rely on dichotomies such as rural versus non-rural. Spoth also noted the need for definitions that encapsulated more than a description of population density. The preliminary data gathered via focus group methodology elucidated personal perceptions of what delineates rural life. It is hypothesized that gathering data through qualitative means such as interviewing adds a new and important personal/interpersonal dimension to the body of literature pertaining to rural life and treatment of rural mental health issues specifically.
How Mental Health is Defined
In response to the query “how do you define mental health?” one focus group member offered the following: “it is feeling good about yourself and being at peace…with life and yourself.” Other members verbally and non-verbally agreed then went on to discuss what they think contributes to depression. It appeared that all were familiar with the concept of depression and equated it quite closely with their definitions of mental problems or issues.
Causes of Depression
Several group members cited the selling off and development of their land as a primary cause of stress and depression. One member shared that a neighbor was pursuing the option of developing his farm land. All other members expressed dismay and concern. Several described feeling “sick” and “betrayed” at the thought of having farm land encroached upon by those who would develop versus work the land. This led into a discussion of financial issues that frequently necessitate selling land. Every person in the group cited financial problems as a primary source of worry. Intertwined with finances was worry about the weather which determines, to a large extent, the success or failure of crops. Excessive worry about something that is out of one’s immediate control is closely related to decline in mental health. As noted by Kunzmann, Little, and Smith (2002), perceived control over desirable outcomes is associated with high emotional well-being, whereas perceived others' (or lack of) control is an emotional risk factor in old age. Following discussion of factors that contribute to depression, these participants shifted into what ameliorates these factors.
“Cures” for Depression
An overall consensus from the group participants was the idea that lack of work contributes to depression, and therefore, engaging in work alleviates depression. One member declared a belief that television and video games underlie the increase in diagnoses of depression. Other members agreed and went on to explain that children who are allowed to “sit” for too long in front of television or video games became more easily bored and restless, which subsequently could lead to feelings of depression. Another member described a belief that all people need to “blow off steam” and that living an active lifestyle i.e. engaging in farm work or other chores was an appropriate way to blow off steam and avoid a build up of negative feelings that contribute to depression. One member described the inability to see one’s accomplishment as a root of depression. Others substantiated this comment by discussing their beliefs that planting and watching crops grow, engaging in lawn and yard work, etc. contributed to a sense of accomplishment. There was a consensus that people living in rural areas had more opportunity for these kinds of experiences than those in urban areas.
Lastly, service to others was named as a detractor from depression. Three members stated that when they were helping others, they forgot their own worries or that “helping someone else let’s you feel good about yourself.” Overall, the 12 focus group members seemed to agree that active lifestyles and focusing on others versus self were key factors in preventing depression. When queried about the prevalence of depression that was experienced among them or people with whom they associated, the following responses were given.
Do Rural People Experience Depression or Anxiety?
When asked this question, there were resounding answers of “yes” followed by several people
echoing one another that worry about finances was the major source of depression in rural people.
“Weather” was cited as a close second to financial worries. When queried about how these worries
or bouts of depression were handled these responses were given:
Member 1 stated that “you just turn off the worry switch.”
Member 2 said “…sometimes you can’t turn it off. Some people need medicine; I’ve taken
medicine for my nerves for 20 years…I might as well admit it.” This disclosure was met with
empathy and “good for you” comments from other members. Member 2 then went on to say,
“….I tried to go off it once, but I got sick to my stomach and I felt worse. It helps me keep a
pretty level stream of water running….when you get to a point you can’t hardly do your thing,
then there’s something you better be doing.”
Member 3 noted “…I really don’t have anything to be depressed over, but I get…I feel this
anxiety inside till sometimes I can’t stand it. I told my doctor about it and he said it was alright
and nothing to be ashamed of. He said there were things to help me. It doesn’t always cut
it to just go out and work” [sic]
Member 4 said “…I think we tend to look at mental health as a failure on our part. I’ve had some
problems in the past…but they used to lock up people who had those problems. I’m into nutrition.
I think a lot can be done with proper nutrition and diet….my daughter is also teaching me about
positive affirmations….you know, replacing negative thoughts with more positive ones.”
Member 5 denied experiencing depression but stated “…our kids have experienced depression and
I tell them ‘hey go for a walk...watch the trees and grass and watch things in your neighborhood
grow and change’…you have more opportunity for that in rural areas though.”
Member 6 noted “…I think we carry a lot of our mental health issues the same as people in urban areas.
Women have had to go to work. We all face financial issues; that happens in rural and urban families.
Member 7 stated “…at least in the past, I think mental illness has been looked at as ‘it’s your own fault'
to some degree. If you have a heart disorder, everybody says ‘well, it’s not your fault’ and it may be.
Maybe it was your diet or something. But your mental health, everybody says ‘well crazy bugger, that’s
his own dang fault’ which is not necessarily true. I guess it’s being more understood as time goes by” [sic].
Member 8 noted “…it’s because you can’t see it [mental illness] and you don’t understand unless you’ve
gone through it and so you’re saying ‘okay, come on, just get over it.”
Member 9 said “…there’s a difference between feeling sorry for yourself and being depressed, which is
a real problem. Sometimes it is a physical problem.
Other group members listened or non-verbally affirmed the aforementioned responses. This discussion was followed up with the question “Would you take advantage of mental health services if they were available in your community?” Responses ranged from “no – heck no!” to “if you need some help, it’s smart to get it done.” Additional themes emerging from that discussion included a belief on the part of both men and women that women were more likely to seek help than men, and that everyone present would encourage someone who they perceived as needing mental health help to seek it. The person who declared “heck no” to seeking services for himself stated that he had encouraged his daughters to seek counseling and was in the process of persuading a man with whom he was acquainted to “get some help.” He laughingly admitted that he supposed he would “get help” if his neighbors thought he was “crazy enough to be hauled in.”
It appeared that all members of the group could see possible benefits of mental health services, but that they still experienced a sense of stigma in terms of seeking counseling or treatment for themselves.
Strengths of Rural People
In general, members of the focus group agreed that living in a rural community engendered certain stressors that could lead to depression or anxiety. They, however, concurred that the same living conditions also provided opportunity to prevent or overcome mental health problems. Those strengths fell into the following categories.
Connection to Land. A large part of the discussion between focus group members highlighted a reverence each felt for the land on which they lived and worked. Questions about “what defines rural” to “how do you deal with mental health issues” were met with responses that indicated a connection to the soil and the crops that are a large part of the participants’ lives. Even those in the group who did not rely on farming for income stated their need for gardening and producing plants or crops or animals. The physical aspects of actually planting and caring for crops appeared to be important as did the less tangible components of being part of producing plant and animal life. This was described as “giving back to the world,” and “seeing your accomplishments growing before your eyes.”
Strong interpersonal ties
Participants in this group each cited strong ties with neighbors as important to their way of life and their mental health. Part of the definition of rural included references to knowing everybody who lived in the community and having close relationships with one another. Service to others was defined as an important way to alleviate stress and worry. The mental health literature is abundant with references regarding the importance of interpersonal relationships.
Problem solving abilities. A common pattern among responses in this group was a characterization of problem solving skills. It was noted that people in rural areas have to take on multiple roles and rely on themselves for meeting many of their needs. While this is sometimes considered a barrier to rural people seeking treatment for mental health issues (Weinert & Long, 1987), it can also be utilized as a strength. Clients who are willing to work hard and who can view mental health as a goal to be achieved can work in collaboration with therapists to define steps in solving the problems of depression, anxiety, etc.
The work completed in this pilot study began illuminating a multi-dimensional definition of rural. Conducted from a naturalistic stance of inquiry, this research began elucidating intrapersonal and interpersonal dynamics that characterize rural life. These components are crucial to understand when developing effective prevention and treatment strategies for mental health issues in rural populations. Ways in which mental health is perceived and/or misperceived were also brought to the forefront. Given that stigma has been cited as a barrier to seeking mental health services, it is important to understand what perceptions guide the avoidance of seeking treatment. These participants noted that a belief that mental illness is “one’s own fault” may prevent them, or other rural people from seeking necessary services.
Lastly, strengths that are either engendered by or developed because of rural living were highlighted. Much research has focused somewhat on the deleterious affects of rural life on mental health problems and treatment (e.g. Lawrence & McCulloch, 2001; Starr et al., 2002;). The issues in these and other studies are of extreme importance to the understanding of rural mental health and the development of appropriate resources. It is further proposed, however, that more effort be made to utilize the characteristics of rural people and their environments in the promotion of mental health. Members of this study were in consensus that while they experience a similar quantity of mental health stressors as their urban counterparts, they, the rural residents, had better opportunities and coping skills with which to deal with such detractors.
Implications for Therapists
Utilizing a strengths based approach to mental health treatment with rural people would include incorporating the sense of connection that this population feels with their environment, capitalizing on the importance of strong interpersonal ties, and accessing the seemingly natural problem solving abilities that appear to be characteristic of rural people. For example, therapists may use metaphors describing connection with land and the environment to help clients make connections between their thoughts and feelings. Building a strong therapeutic relationship is of utmost importance with all clients, but should be especially recognized when working with rural clients. A relationship based on collaboration and sharing of ideas seems best suited for members of this population. Rural clients may have a tendency to want to help or give as much as they receive. If therapists can demonstrate that they, too, are being influenced by their rural clients, they may experience more success. As noted by Thorngren (1999), reciprocal influence between clients and counselors is predominant in a majority of therapeutic relationships. In her study, it was noted that clients and counselors tend to have a fairly equal impact on one another and that awareness of mutual impact deepens the therapeutic alliance and leads to greater growth and change. This does not equate to equal disclosures by counselors and clients, but results indicated that counselors who share their perceptions and expectations with clients foster a more productive relationship.
Lastly, it is recommended that therapists involve their rural clients in mutual problem solving endeavors. Harnessing the tendency toward self sufficiency and creativity that appears prevalent in rural people will enable clients to feel empowered and less stigmatized by mental health issues. Therapists are encouraged to ask these clients their thoughts and perceptions on what may work best for them and utilize these suggestions. With this population, therapists may take more of an educative role in terms of explaining connections between the mind and body, and helping clients determine the best courses of action.
It is further recommended that professionals work jointly with rural community members in developing larger scale programs such as parenting classes, children and adult groups, etc. While these endeavors were not specifically discussed, there was a strong sense of community and a desire for helping one another apparent throughout the discussion. It is speculated that if professionals approached rural people with the goal of helping them to strengthen their community they could capitalize on the stated desire of these participants to serve others and lessen the stress and depression that some experience.
Limitations of Study
This study was conducted with a small sample size of Caucasian participants indigenous to one community in rural Idaho. While the sample size was conducive to an efficient naturalistic inquiry, readers are cautioned to not generalize to the overall rural population. This pilot study was intended to gather information in order to formulate questions and hypotheses to examine with a larger group.
While data was gathered regarding definitions of rural and perceptions of mental health in rural areas, specific information regarding the extension of services into rural populations was not explicitly gained. It was inferred that a collaborative/educative approach to prevention/ remediation of mental health issues would be better received than an approach that presumed outside expertise or that was put into practice without joint effort between professionals and rural people. More information is needed, however, in terms of specific procedures.
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