Journal of Rural Community Psychology, Vol. E3(1), 20000
Rural Management Concerns:
Management Concerns in Rural Community Mental Health
Dale V. Wayman, Ph.D.
Thompkins Child and Adolescent Services
Rural community mental health offers some special concerns for managers. The mental health manager who is aware of the community and professional concerns for rural areas will be more sensitive to the needs of the personnel of the rural Community Mental Health Center and therefore more successful in his or her managerial role.
Management Concerns in Rural Community Mental Health
A thorough search of the literature reveals little information regarding management in rural community mental health. One particularly good article about mental health consultation that considers multicultural issues is evident (Jackson & Hayes, 1993) and some concepts could be applied to rural community mental health settings.
Some information is available regarding rural issues in mental health, particularly in the area of the rural Community Mental Health Center (Celenza, 1988; Solomon & Bernstein, 1985). A realization that personnel issues in rural mental health are dissimilar from those in urban mental health is becoming more apparent (Adams & Benjamin, 1988; Blank, Fox, Hargrove, & Turner, 1995; Center for Mental Health Services, 1997; Hill & Fraser, 1995; Wayman, 1998). As these issues are being realized, the rural CMHC manager needs to be attentive to these differences.
The term "rural" is associated with areas of small and sparsely settled population and remote location (Shelton & Frank, 1995; Wayman, 1998). The Office of Technology Assessment has a rather complicated definition of "rural" that considers settlement size and density and economic integration factors. They report that 15% of the US population lives in rural areas (Hewitt, 1989).
The implementation of the Medicare and Medicaid programs, just two years after the Community Mental Health Centers (CMHC) act of 1963, contained few considerations for psychiatric health care. Often, funds that were intended for the attraction of CMHC personnel were diverted to inpatient general hospitals (Werner & Tyler, 1993). Werner & Tyler (1993) maintain that if the funds for inpatient services (the least effective and most costly form of treatment) were directed toward CMHC personnel retention, with a focus on the development of community-based interventions, a much greater percentage of people requiring services would have access to community-based programs. This concept of community-based treatment is consistent with the thinking of individuals within the rural community as they expect a high level of support from "kin" (Powers & Kivett, 1992).
Rural Community Concerns
It is important to remember that mental health management is guided by the norms and values of the environment (Brack, Brack, Beaton, Edwards, Hill, Smith, & White, 1996). Elaborate employee manuals and written contracts may not always be as accepted by rural individuals as they would be in other environments. Rural individuals are often described as being encompassed by a "high context" culture which places high value on a person's word and makes verbal contracts binding (Jackson & Hayes, 1993).
The mental health manager is aware that the rural CMHC may function best when existing social structures and institutions are utilized (Blank et al., 1995). For example, rural residents believe that problems should be faced privately, through the resources of the church and family (Hill & Fraser, 1995). Researchers note that rural individuals are more likely to first approach their minister with personal and family problems (Merwin, Goldsmith, & Manderscheid, 1995). It appears that the rural CMHC manager may do well to understand this strong connection to the church. Churches provide an opportunity for mental health professionals to collaborate with a naturally occurring and mutually helpful institution. The rural CMHC manager can establish professional liaisons to area churches so that suspicion, fear, and stigma can be reduced. Also ownership and participation of programs that improve the mental health of individuals in rural communities can be enhanced with this intermediary to the church communities (Blank et al., 1995).
The astute manager also makes use of other established professionals in the rural community. Many rural residents rely on livestock to support themselves so the veterinarian could provide valuable information regarding the mental health of rural individuals. In times of financial troubles (e.g.: farming crisis), bankers could provide helpful information as well. One rural CMHC in Minnesota provided early intervention to their rural clientele through training these two groups of professionals about services provided by the center, what to look for as precursors to mental health concerns, and how to make referrals (Adams & Benjamin, 1988). The authors provided no information about the effectiveness of this novel concept, yet it does appear to have merit for the mental health manager of the rural CMHC.
The rural CMHC manager also needs to understand the central role of the "country doctor" (Hill & Fraser, 1995) in the rural community. Flaskerud & Kviz (1982) found, with the exception of suicidal behavior, that the general practitioner was the preferred professional for most mental health problems in rural communities. Shelton & Frank (1995) substantiate this claim with the statement, "rural residents prefer to use their primary [health] care givers for mental health problems, except in the case of serious mental illnesses" (p. 545). Almost one-half of the mental health treatment is provided by nonpsychiatric physicians (Mechanic, 1993) and referral of mental health problems by general practitioners is rare, especially in rural areas (Shelton & Frank, 1995). The knowledgeable rural CMHC manager can establish a liaison to the area doctors as a point of referral contact. This connection could help to ensure that rural residents receive proper, specialized mental health treatment and can coordinate care with the physician.
The prudent rural CMHC manager would seek to establish peer helper programs and other informal support networks to provide care of the community's mental health needs. One such program established in rural Iowa involved 370 volunteers. These volunteers received 15 hours of training in identification of feelings, signs of depression and suicide, listening skills, resource identification, and strategies to encourage people to use resources. This peer helper program reduced suicide completions, increased communication within families and the community, increased referrals to the CMHC, and encouraged individuals to obtain governmental financial assistance (Adams & Benjamin, 1988). The effectiveness of the use of this peer helper program has been firmly established.
A very serious concern of the rural CMHC manager is the availability of mental health professionals. Seventy-three percent of mental health personnel shortages are in rural areas (DeLeon, Wakefield, Shultz, Williams & VandanBos, 1989) and 1682 rural counties have no core mental health professional (Blank et al., 1995). The rural CMHC manager is concerned with the recruitment and retention of needed mental health professionals. Creativity is an important skill for the rural CMHC manager. Creativity is needed so that the recruitment and retention of rural mental health personnel can be augmented. The rural CMHC could help in paying back student loans and providing scholarships as well as economical financing for housing and vehicles for rural mental health professionals.
Another concern for the rural CMHC manager is the many stressors a rural mental health professional faces. Rural counselors are often overworked, underpaid, and must play conflictual roles in the lives of their caseload (Sovine, 1988). These conflictual roles often strain the boundaries of a therapeutic relationship when counselors and counselees must live in the same small community (Merwin et al., 1995). These stressors for the rural mental health professional can lead to early burnout and feelings of isolation, depression, demoralization, frustration and inadequacy (Merwin et al., 1995; Sovine, 1988). The perceptive rural CMHC manager will attempt to establish ways of decreasing these stressors for rural mental health professionals. One ingenious way the rural CMHC manager can decrease stress for mental health personnel is through the use of a 24-hour hotline for rural residents (Adams & Benjamin, 1988). Rural residents rely more heavily on crisis services than their urban counterparts (Flaskerud & Kviz, 1982; Shelton & Frank, 1995). This hotline could serve to decrease stress among mental health professionals by helping them to resolve many of their clients' mental health issues before they become too acute. The rural mental health professional then is helped to feel more in control of potentially problematic situations and develops a sense of mastery over his/her own stress. Another consideration is for the rural CMHC manager to establish computer networks to maintain contact with other counselors to reduce isolation (Merwin et al., 1995). The rural CMHC manager can begin to address these stressors common to the rural mental health professional with the establishment of the above-stated suggestions.
Literature on rural mental health issues suggests that rural residents are not homogeneous, the characteristics of rural Americans are changing (Merwin et al., 1995) and there is starting to be a loss of communality (Blank et al., 1995) in rural areas. The rural CMHC manager needs to be informed and sensitized to issues allowing the rural CMHC to provide the best service possible. The manager who is aware of the community and professional concerns for rural areas may be the more successful rural CMHC manager. The rural CMHC manager would remember the considerations offered in this paper and apply them appropriately.
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Dr. Wayman is a Clinical Director for Thompkins Child and Adolescent Services in rural, southeast Ohio. He can be reached at firstname.lastname@example.org or 610 Walnut St., Coshocton, OH 43812.