Updated: Aug 27, 2021
First, let me congratulate and thank you Diana for putting your name forward for the president-elect position. It makes our association stronger when membership is engaged in this process.
Also thank you for your interest in the endorsement of the Rural Health Interest Group and Caucus. Our caucus would be delighted to learn more about your thoughts and experiences related to rural mental health.
Would you please respond to these questions, so we can learn more about your interest in this area?
1. What experiences do you have that inform your views of rural mental health care?
I grew up on a farm. There was no mental health care in my community. Perhaps this could be called a “therapy desert.” While living in rural Indiana, I taught Spanish grammar in summer migrant school as a teen and young adult. It was through this experience I became concerned about unfair educational evaluation of migrant farm children and decided to become a psychologist. I trained at the University of Nebraska-Lincoln (UNL) with a rural specialty (funding provided by NIMH, coordinated by Dr. Scotty Hargrove). While I was there, we experienced the farm crisis of the 80’s. As rural doctoral students, we went out to rural Nebraska communities to help provide intervention, encouraging people to draw together at potluck dinners and avoid isolating due to financial difficulties.
I went to the high school in which I grew up in Indiana to explore with the teens their understanding of growing up in a rural area and their “sense of place.” This intervention was both education and intervention, developed with the guidance of a community psychologist. I traveled with the rural UNL students to Wisconsin and Mississippi to better understand their rural programs. This was the first time I had been on an airplane. I was also placed at a small rural Nebraska school for practicum one year. My dissertation involved driving to the schools within 100-mile radius of Lincoln, Nebraska, observing children with behavioral and mental health difficulties, so I became very familiar with the rural educational system in Nebraska, as well as the problems the children were demonstrating. I also presented in North Carolina with the National Association of Rural Mental Health (NARMH) and was a member of this association.
My first full-time job after graduation was in Evansville, Indiana, in a medical center which draws patients from surrounding rural areas in Kentucky and Indiana. There was significant depression there, stigma, and a dearth of mental health services. I then moved to Bangor, Maine, where I have served people from the rural surrounding communities in a medical center and its companion non-profit psychiatric hospital. My current consulting practice is in Hampden, Maine, a rural town of about 5,000. I have appreciated learning about rural mental health care in Maine (New England state), which is surprisingly like the Midwest and the Plains. There is not a lot of it, and there is stigma regarding accessing it.
In Maine, I have also been centrally involved in the development of integrated primary care in rural areas, through chairing the Maine Migrant (now Maine Mobile) Health Program board and serving on the Maine Primary Care Association Board of Directors. I also have worked in pediatric obesity through the medical center, developing their integrated care component. Prior to the pandemic, we began using telehealth to provide integrated behavioral health services to rural children via iPad.
I would be remiss if I did not mention I also learned about rural mental health care through chairing both the Rural Health Interest Group and Caucus and the APA Committee on Rural Health. Both were wonderful experiences for me, and I remain close to those psychologists. In Maine now, I have been working for three years with an interdisciplinary group called the Maine Rural Health Action Network (RHAN). https://www.newenglandrha.org/me-rhan This group has certainly shaped how I think of rural mental health care. For example, I have learned about the importance of emergency services in rural areas and considered how to embed psychological services in the provision of emergency services.
2. In addition to the general paucity of services, what do you see as the most important mental health need(s) in rural areas?
This is a fascinating question. I am glad you allowed more than one response here! Lack of transportation was the first barrier that came to mind (along with the stigma previously mentioned, that prevents folks from seeking mental health care). With the dramatic increase in the availability of telehealth resources for provision of mental health care, I would say adequate funding is probably the most important need. Of course, lack of providers has always been a big problem (workforce shortage). This importance has only been underscored by the dearth of mental health providers with openings during the pandemic (despite our best efforts).
3. How do you think APA should work to address it/them?
I know from my service on the APA Board of Directors, Dr. Arthur Evans and the Board of Directors are moving to address some of these needs through population health interventions. I believe APA is in a great place to develop the models to help deepen the bench, so to speak, and intervene in some of these problems “upstream.” APA can also partner with the national and state organizations in positions to assist us in improving the mental health of our rural citizens. This may mean helping individual psychologists consider how to provide a role in this population health intervention in whatever state they might reside. With telehealth, these psychologists no longer need to live in the rural community in which they are practicing. Of course, it is important that these psychologists – the team leaders – are culturally competent about treating rural residents, understanding the incredible diversity of our rural residents. If elected APA president, I intend to represent rural people and places and extend the previous presidential initiatives of Deep Poverty and Health Equity to rural and underserved populations.
4. The COVID-19 pandemic created a significant increase in the use of virtual therapy platforms. Subsequently, many organizations (e.g., health organizations, insurance companies) are now seeing the potential to serve rural and remote areas through this virtual modality without considering efficacy, digital literacy of the client, broadband capability of the rural area, and rural competency of the provider, What role do you see APA playing under your leadership as we move into this new digital era.
This is another excellent question. I personally do not feel we can obstruct the part of this movement that represents progress and opportunity for rural residents. However, we know some rural residents simply are not digitally literate and do not have adequate broadband capability. Some providers simply are not culturally competent. Many of these organizations are moving into this digital space, because of high demand and opportunities for increased revenue generation. APA could partner with these organizations as a consultant to assure the services the organizations are providing are appropriate and accessible, and the providers culturally competent. It would be important for APA to make the case for establishing that psychologists provide evidence-based high-quality care that the insured need to be able to access, to be healthy (and therefore, save the organization money). Psychologists may not need to be providing the care; however, they would be the logical team leader and supervisor to create, implement, and drive improved population health for rural residents.
5. Rural populations have shown to have lower vaccination rates than urban areas. Beyond access, vaccine hesitancy also plays a part in this lower vaccination rate. What role can APA play to reach this rural population?
APA has been working to partner with the CDC to provide science-based information about COVID vaccination to patients/clients. In Maine, our rural residents have been more reluctant or unable to access vaccination. I recently saw a story in the news about Ms. Dorothy Oliver https://www.msnbc.com/the-last-word/watch/how-dorothy-oliver-got-94-of-her-alabama-town-vaccinated-against-covid-19-118917701774. This story highlights for me the importance of “street cred,” the cultural competence needed in rural areas to be effective in increasing the rate of vaccination. Psychologists understand the importance of relationship, of developing relationships with people like Ms. Dorothy Oliver or being that trusted person to encourage people to get vaccinated. As our own Dr. Robin McLeod explained to the White House, motivational interviewing is a tool that can be utilized successfully to join with people, using their own motivations to help them change their behavior. APA can help distribute this information to rural providers who are able to extend this to their clients/patients. If we are using a population-based approach, these interventions would involve more than just the psychologist. Certainly, in rural America, the trusted leaders include many other types of people other than mental health providers (such as pastors, coaches, teachers, police officers, etc.). APA and psychologists will need to partner with other organizations and community leaders like Ms. Oliver to assure success in increasing vaccination rates.