Mental Health Scare in Rural Areas - How does this affect Homelessness

H. C. Covington (
Sat, 13 Dec 1997 13:15:03 -0600

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H. C. Sonny Covington @ I CAN! America
Lafayette -  New Iberia, LA  70563-1722
(318) 364-6239  Fax 318-367-9141
December 12, 1997



            Mental Health Care Scarce in Rural Areas
            Traveling Social Workers and Psychologists, New Technology
Bring Services to Far-Flung Clients

            By Kate Darby Rauch
            Special to The Washington Post
            Tuesday, December 9, 1997; Page Z07

            When Margie Whichard looks out the windows of her central
Virginia trailer just beyond the Appalachians she sees miles of trees and
fields. The loudest sound she hears is the clucking of chickens from her
barn. The nearest town, Dillwyn, is 15 miles away down a narrow, windy

            Months ago, events in Whichard's life triggered a depression
that made her feel her world was collapsing. She sought counseling, but the
nearest mental health professional was more than an hour's drive from her
home. The time and expense of traveling made regular therapy impossible,
and Whichard struggled on her own.

            "They were wanting me to come [for counseling] every week, but
we didn't have the money for the gas to get there. It was also quite a bit
of time out," said Whichard, 31. "I just kind of had accepted that I was
just going to be depressed. Myself and my family were dealing with it the
best way we could."

            She eventually found help, however, from a University of
Virginia research project that is studying depressed rural women. Trained
mental health professionals provided Whichard, who has no health insurance,
with extensive home-based counseling. After 12 weeks of weekly sessions,
she says she feels on much more solid footing now. Others in rural areas
aren't so lucky.

            Emotional or mental health difficulties can affect anyone,
regardless of where a person lives. But for people living in rural areas,
whether in the tobacco fields of the Southeast, the blackberry brambles of
Maine or the rain forests of the Northwest, finding treatment for mental
health problems can be difficult. Social workers, psychologists and
psychiatrists tend to be far away and expensive to reach. Regular or weekly
visits, a common treatment pattern, are often out of the question. Even
when care is available, experts say, the lack of privacy of small-town life
deters many people from seeking help. Some turn to other sources of care --
churches, self-help books, folk medicine, friends.

            "I think ministers are probably the number one marriage
counselors in this state," said Jim Clardy, a psychiatrist and assistant
professor at the University of Arkansas for Medical Sciences. "Some of them
are very well trained and some don't have training at all."

            A variety of efforts are being made to improve rural mental
health care. They range from traveling social workers to "teletherapy," in
which computers with video capacity are used. Still, experts say, mountain
ranges and miles of desert and fields are stubborn barriers to providing

            "The issue for people in rural areas is one of both not
understanding the services that are available, but more particularly that
there aren't services available," said Jeanne Fox, director of the
Southeastern Rural Mental Health Center at the University of Virginia. "A
major issue is there simply aren't providers out there."

            Choices Are Few

            For urban dwellers -- and most people in the United States live
in metropolitan areas -- some form of mental health care is fairly
accessible. A car trip to the therapist's office. A bus ride to the clinic.
A taxi to the pharmacy. A walk to the community center for a support group.
It may be a hassle to find the best kind of help, and paying for it may not
be easy, but options for treatment are usually available.

            People living in rural regions, specialists say, often have
little, if any, choice. Most states have a system of public mental health
clinics serving beyond city limits. But as with many public health clinics,
budgets are tight and services limited. Also, these clinics may still be
miles from where a patient lives. Counselors who travel to or are based in
remote areas are rare.

            It's impossible, experts say, to define statistically how many
rural residents nationally have mental health care problems, or, what they
do when faced with a problem. And while studies generate some statistics,
experts say, measuring mental heath care is limited by unknowns. Some
people never seek help or talk to anyone about their problems.

            Counting care providers is easier. The federal government,
under the Department of Health and Human Services, recognizes areas with a
paucity of mental health care, designating them "mental health care
professional shortage areas." In 1997, of the 536 designated mental health
care professional shortage areas in the country, 408, or 76 percent, were
in non-metropolitan or rural areas, according to federal data.

            In many ways, experts say, the difficulties of delivering rural
mental health care mirror those of delivering primary care or basic
medicine in rural areas. Doctor shortages in remote or isolated nooks are
much publicized. Still, there tend to be more physicians in rural regions
than mental health care practitioners. And often when rural people are
having mental health problems, they turn first to the local doctor.

            In many ways, experts say, the difficulties of delivering rural
mental health care mirror those of delivering primary care or basic
medicine in rural areas.

            "Most mental health in rural areas is done through primary care
practitioners, if you look nationally," said Michael Blank, a psychologist
and assistant professor at the School of Nursing at the University of

            But even if a doctor is within reach, said Blank and others,
most "country docs" are general practitioners without special training in
the diagnosis and treatment of mental illness. "And they don't recognize it
well or treat it particularly effectively," he said. In addition, experts
said, unlike doctors in urban settings, these physicians do not have an
array of specialists they can consult with and refer patients to.

            Also, there are few self-help groups in rural areas (such as
chapters of Alcoholics Anonymous), classes in stress reduction or support
groups for people who are grieving.

            When rural residents have mental health problems requiring
hospitalization, said Peter Beeson, a medical sociologist and administrator
for the Nebraska Health and Human Services System, they can end up in limbo
after being discharged and may be forced to stay nearby for post-discharge
services. "At state hospitals you get psychiatric ghettos. People are
admitted from rural areas, but because of the lack of services, they're
discharged to the town where the hospital is," Beeson said. "And so, in
fact, they are isolated from their family and community."

            Riding the Circuit

            To address these problems, some rural counties have
"circuit-riding" psychiatrists who visit small-town clinics to consult with
local care providers. They may help diagnose a problem or check on a
patient trying a new medication. But finding psychiatrists willing to take
a "circuit-riding" post is tough.

            "We haven't been able to find one," said Gary McConahay, who
runs a county mental health clinic in Grants Pass, a town of 17,000 in the
forested mountains of Josephine County in southern Oregon. McConahay, a
psychologist, has been trying for years to find a child psychiatrist to
work in his and neighboring counties. "Just a little thing like this you
don't think about in a big city, where psychiatrists are a dime a dozen."

            Across the continent in the wilds of rural Maine, Kathy Bubar
is having the same problem.

            "There is no psychiatrist at all in Washington County," said
Bubar, a lawyer who runs a mental health care project in Bangor for at-risk
rural children. "If you need a psychiatrist, you have no choice but to come
to Bangor, which is 90 miles away. Access is a huge problem."

            Nonetheless, McConahay found a reliable way to reach rural
children needing regular counseling by placing mental health workers at
schools. Josephine County is zigzagged with mountain roads and tiny logging
towns. Rather than expecting families to make the extra drive to town for
an appointment, McConahay arranged for counselors to set up shop at

            "Because of our spread-out nature, we take our therapists to
the clients," he said.

            An essential component of Bubar's Maine program is training
health workers to assist participants at home.

            Taking help to clients is also the framework of the University
of Virginia project that helped Whichard with her depression. The project,
referred to as the "depressed women study," offers home-based counseling to
rural women in central Virginia who have been diagnosed with depression. At
the same time it is studying the effectiveness of the services provided.

            Based in New Canton, Va., and serving a five-county area in the
Piedmont region of the state, the project serves about 72 women. Funded by
the Federal Office of Rural Mental Health Research at the National
Institute of Mental Health, it is four years old.

            Whichard and other women in the study receive weekly visits by
a social worker trained to educate clients about depression and teach
self-help skills. The focus is on giving clients support and practical
tools they can use to help themselves. Weekly sessions last for 12 weeks
and are replaced by less frequent maintenance visits.

            The effectiveness of the program is yet to be fully analyzed,
said Emily J. Hauenstein, a psychologist, nurse and associate professor at
the University of Virginia School of Nursing. Interviews with women who
have been enrolled in the program show that depression symptoms for a
significant number of them have decreased, she said.

            Possibilities of Telemedicine

            Home-based care makes great therapeutic sense in rural areas,
experts say, but in financial and practical terms it is hard to pull off.
It requires a contingent of specialists willing to travel frequently to
remote places and the money to support such a system.

            "This is extremely hard to do in rural areas," said Clardy in
Arkansas. "That one mental health care worker that might be able to visit
10 people a day in the city might be able to visit two people a day in a
rural area."

            Some groups have turned to telemedicine or using video systems
or computers to link rural residents with professional help in the city.

            With available technology, a general practitioner in a small
town can arrange for a patient to meet via a video screen with a
psychiatrist hundreds of miles away. A farmer on a Midwest wheat farm who
suffers from panic attacks can be hooked up via computer at his home or at
the local clinic with a support group. A network of caregivers can
participate in a video teleconference, outlining the follow-up care plans
for a small-town child about to be discharged from a city hospital.

            Telemedicine for mental health care has exciting potential,
many experts say, but it too is costly. "It's a steadily growing field, but
telemedicine isn't going to burgeon until it becomes cost-effective," said
Catherine Britain, psychologist and program manager of Rodeo Net, a mental
health telemedicine system in eastern Oregon run by a consortium of

            Sometimes a good old-fashioned 800 number makes a difference
for people far from the nearest specialist. In Redfield, Ark., population
about 2,000, Jackie Weser helps staff a toll-free number for people with
anxiety disorders, called the Anti-Anxiety Network. An anxiety patient
herself, Weser is trained to provide simple counseling over the phone and
to make referrals. Many of the people who call live in remote areas, as she
does, Weser said. "I have found that healing comes from helping others,"
she said. The service is run by the Arkansas Alliance for the Mentally Ill
with help from a state grant.

            While not a substitute for professional care, Weser said, a
toll-free telephone number includes a feature many rural people deeply
appreciate -- anonymity. Mental health problems are associated with stigma
in communities of all sizes. But stigma can be more troublesome in rural
areas, experts say, because privacy is tough to maintain.

            "If there's one psychologist in your town and you're parked out
front, that's going to come back to you," said John Fortney, a medical
geographer and assistant professor in the department of psychiatry at the
University of Arkansas for Medical Sciences. "People in the grocery store
will talk about you."

            Since rural communities tend to be more close-knit than in
urban neighborhoods, there is a greater likelihood that rural residents
will learn personal details about each other's lives, including emotional
or mental problems, experts say. "And this makes people less likely to go
seek help," said Nebraska sociologist Beeson.

            The key to mental health care in rural areas is the same as in
urban settings: to help people before their problems deteriorate. "When
treatment is not really available, people delay it," said Arkansas
psychiatrist Clardy, "and oftentimes it's worse [by the time] people are

            Kate Darby Rauch is a writer in Berkeley, Calif.

             Copyright 1997 The Washington Post Company


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