Almost every American will, at some point or another, face a mental health challenge. It may be related to depression, anxiety, suicidal thoughts, substance abuse or maybe something more circumstantial like grief over a loss or trouble adjusting to a life change. The CDC reports 43.4 million adults suffered from some sort of behavioral health issue in 2015 alone.
Now, imagine there wasn’t a psychiatrist or psychologist for miles around, let alone another specialist who these millions of people could trust with their specific needs. This is what life is like for many Americans in rural communities.
A new study in the American Journal of Preventive Medicine finds that a majority of non-metropolitan counties (65%) do not have a psychiatrist and almost half of non-metropolitan counties (47%) do not have a psychologist.
This is troubling because poor access to mental health care, according to experts, is a serious issue that overlaps with other public health crises like drug abuse and suicide.
Limited access means care is a last resort
Jackson Rainer is a clinical psychologist who has practiced in rural communities in western North Carolina and South Georgia. He says the problem is obvious: There’s just not enough options; in some areas, no options at all.
"People in rural communities have limited access to the diversity of care they may need. There are very few services offered and people have to travel to reach them," he says. "Typically, the first closest providers are generalists, and there is very little specialized care. There is no community (public) mental health care, and often there are no relevant hospital services within a reasonable distance. So, people are just left on their own."
Because of this, mental health care is often seen as a last resort instead of a preventative measure or an ongoing program of therapy. That can have devastating consequences, because the problem is only treated when it becomes a full-blown crisis.
"The services that are available become much more restricted," Rainer says. "It becomes oriented towards crisis intervention, not prevention. It’s, let’s get rid of your crisis as it’s happening.’ And if you don’t have good insurance or enough money, that’s the best you can hope for."
Practitioners are overwhelmed
Rainer says the frustrations for small-town care providers are endless. The web of mental health resources doesn’t just include psychiatrists and psychologists, but also external resources like shelters, hospitals and community support groups.
In small communities, those types of resources just aren’t there, and that leaves professionals shouldering a Herculean obligation.
"As a practitioner, I am asked to be the end of the road," Rainer says. "For mental health, I would hope that I would be one piece of a larger puzzle to get people to an improved quality of life, not to be the last resource that they have available."
Jennifer Christman, the president of the National Association for Rural Mental Health, says even when there is available care, providers are often limited by rigid regulations.
"The frustration is, if you are a provider who wants to be able to provide services more globally, there are restrictions you face," she says.
For instance, she says, even if someone practices just miles from the state line, their license may not allow them to practice across state borders, which further limits their already small scope of care.
Adding to the stress, health care funding cuts can rip away what little medical resources may be available. Across the country, about 80 rural hospitals closed between 2010 and 2017, according to the Chartis Center for Rural Health. Hundreds more are at risk for closure.
Rainer says he has seen firsthand how limited funding — both for general medical care and specifically behavioral health care — affects people in small, isolated towns.
"What services are still available have taken on a much narrower focus, and there are fewer tax dollars to support the broader community. That includes the rural community," he says. "Our country is in very, very deep trouble when it comes to mental health care, and that’s across all areas; urban and rural."
It causes a vicious, dangerous cycle of health problems
A lack of care doesn’t just result in the neglect of whatever problem is at hand; it can actually perpetuate or worsen a cycle of poor mental health because those seeking treatment can feel isolated — both by their surroundings and by a lack of resources .
"Isolation is a cultural, social and interpersonal response," Rainer says. "When someone feels isolated, they feel diminished and apathetic and are unable to pull resources from their own selves. When it comes to rural mental health, isolation is a particularly dangerous problem."
Christman says the whole thing can create a downward spiral for sufferers, and that can lead to even more serious problems.
"There’s this continual spiral, which can lead to overdoses, can lead to suicide and depression," she says.
Suicide, drug abuse and addiction are certainly problems that affect all populations and all parts of the country, but both drug deaths and suicide deaths disproportionately affect rural America. The CDC reports that rural areas have a higher suicide rate than non-rural areas, a disparity that has been widening since 2001.
The problem goes beyond access to care
On top of it all, access to mental health care is just one of many factors that may put small, isolated communities at higher risk.
"Due to higher poverty rates, higher likelihood of hourly pay and productivity-based labor, and lack of transportation infrastructure, mental health services are often not accessible even if they are available in a rural community," K. Bryant Smalley, a professor of community medicine and psychiatry at the Mercer University School of Medicine, told CNN in June. "That is, even though it is there, many people either cannot get to it or cannot afford (either directly or indirectly) to go."
The close-knit nature of small communities could also heighten stigma around seeking treatment. There is sometimes a fear, Smalley says, of "someone seeing your car parked at the only psychologist’s office."
Rainer says, when people are experiencing a mental health issue, they often reach out to the first available point of guidance or community they have. This could be a family unit, neighbor, or as is often the case, a church group or religious leader. That’s fine, but without further help, they usually aren’t enough.
"Ministers are good as initial resources," Rainer says. "But they are not any more trained to practice mental health than a mental health practitioner is trained to preach."
Alternative treatments aren’t a good substitute, but they’re a start
The interwoven challenges of rural mental health care can feel like a Gordian knot — impossible to untie and tightening with every tug. Of course, the ideal solution is more practices, professionals and programs to alleviate both the need for and stigma surrounding mental health care. But those solutions don’t grow on trees, and neither does the funding to support them, so more and more mental health practitioners are turning to other methods.
"There’s a lot of work that’s being done right now to use technology and license portability [the ability to practice in multiple areas]," Christman says. Patients and professionals can now connect via virtual sessions and online portals, a practice called telebehavioral health. For instance, a patient in Wyoming may see a psychologist in Pennsylvania.
"[We] are trying to bridge that divide," Christman says. "Telebehavioral health has really come a long way."
It’s an imperfect solution — issues of internet accessibility, computer savvy and financial wherewithal still apply. Plus, Rainer says, people who pursue this type of care should be cautious.
"The task is to find a professional who is licensed as a mental health professional, and not just take advice from the wild wild west of the internet," he says.
The bottom line is, small communities need more tangible resources, and until they do, even the best efforts are just a temporary dressing on a much larger wound.
"We need as a country to come together and really recognize that for individuals that have mental health concerns, making it easier for them to access care, and then the providers being able to be reimbursed for that care, that’s something that we need to address," says Christman.
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