When Haley DelPlato returned home to Long Valley, NJ from Colgate University during winter break of 2012, she knew she needed help. She was suffering from anorexia, depression, and anxiety, and was determined to get well again. Her parents made appointments with a local therapist who claimed to specialise in a wide array of mental health issues, but DelPlato said she quickly determined the provider wasn't equipped to treat all of her symptoms or conditions.
"I thought it was strange that she was recommending eating behaviours that were essentially disordered," DelPlato told POPSUGAR. "But I thought she was just trying to connect with me because I definitely wasn't a fan of being there, in general. In hindsight, it was clear she wasn't qualified to be considered 'specialised' in eating disorders."
"Thank God I had my family as a support system because the treatment that I received was not as tailored to what I was going through as it could've been."
DelPlato struggled to find adequate, specialised treatment in her region until she located an outpatient facility in Ridgewood, NJ. The only problem? It was roughly an hour and a half away per trip. Regardless of the distance, DelPlato's parents woke up early to make the trip five days per week for eight months. "My dad would pick me up and drop me off and that obviously puts a lot of strain on my parents," explained Haley. "It was a long commute — and similar to a 9 to 5 job — which meant it was a huge adjustment for my family."
Although DelPlato felt well enough to return to college in the fall of 2012, finding mental health specialists who suited her needs was extremely challenging. Eventually, she returned to New Jersey to seek additional treatment at Robert Wood Johnson University Hospital, and has been better ever since. "In hindsight, it's sad to me now," she said, looking back on her initial experience seeking therapy in her hometown. "Thank god I had my family as a support system because the treatment that I received was not as tailored to what I was going through as it could've been."
DelPlato's experience is just one example of how individuals living outside of metropolitan areas need access to mental health specialists and care — access that's often difficult to come by.
Why are people in rural communities at a disadvantage?
For folks living in rural communities, the vast amount of space combined with smaller concentrations of people can make finding a mental health specialist challenging. "The smaller population in rural areas — and often the stigma against seeking help — does not produce a demand for mental health specialists, placing these communities at a disadvantage," Danielle Steelesmith, a post-doctoral scholar in the Department of Psychiatry and Behavioural Health at The Ohio State University Wexner Medical Centre, told POPSUGAR. "They do not have easy access to mental health care, must travel further, and often wait longer periods of time because services are often not readily available in their community."
Lauren Paulson is an assistant professor of psychology at Allegheny College who's done significant research on this topic. Experts in her field have broken down the "unique concerns of rural residents" into three distinct categories:
- Accessibility: Rural residents typically need to travel long distances to receive services and are less likely to have mental health services or recognise an illness and seek care.
- Availability: It has been well-documented that chronic shortages of mental health professionals exist in rural areas.
- Acceptability: Because of the negative stigmas associated with mental health issues, individuals are less likely to ask for help. "The close-knit nature of small communities can heighten public and self-stigma around seeking treatment," explained Paulson. "There is decreased privacy and anonymity in places where 'everyone knows everyone.'"
According to the Rural Health Information Hub, the fact that suicide rates are higher in rural areas is definitely cause for concern. In fact, there are nearly twice as many suicides in the most rural counties compared to the most urban counties, which experts say is in part due to the lack of access mental health care.
Why can going to a primary care physician for mental health concerns be problematic?
Although primary care physicians in rural areas are doing their best to cater to every resident, they often have a lot on their plates. "Due to the shortage of mental health professionals, sometimes you are the only provider in town," said Paulson. "Therefore, most rural mental health practitioners have to work from a generalist perspective. In other words, you have to be prepared for everything. You need to be able to work with a wide range of populations and diverse issues and mental health concerns."
Jackson Rainer, PhD, a clinical psychologist and author of Rural Mental Health Issues, Policies, and Best Practices who practiced in rural communities in western North Carolina and South Georgia, said that general practitioners have typically been eager to work with him given his expertise. "I was welcomed with open arms," he told POPSUGAR. "The medical practitioners had worked to try to clean up problems that they were insufficiently adept at. So they would call on me and we'd collaborate very, very well."
"Sometimes rural practitioners question if they are working outside of the scope of training and practice."
Addressing all types of conditions and diseases can be particularly hard if physicians do not have specific training, expertise, or the necessary support system — yet still need to care for patients with diverse needs. "[Treating patients without the proper expertise] can be a challenge, as sometimes rural practitioners question if they are working outside of the scope of training and practice. This is then further complicated by a lack of colleagues to consult with," said Paulson. "Rural mental health professionals can experience feelings of professional isolation because they do not have easy access to supervision, training, consultation, or networking opportunities. Combine this with heavy and sometimes complicated caseloads, the struggle to manage privacy and boundary issues, and rural mental health professionals are at increased risk for burnout."
Despite being a major asset to the rural communities he worked in, Dr. Rainer admits that he experienced some challenges where specialised training was concerned.
There were a great deal of issues related to privacy, and I had to work double time to maintain that integrity."
"I was the country doctor and I was asked to treat everything from anxiety to depression, to schizophrenia, to eating disorders, to personality disorders to psychosis," Dr. Rainer explained. "I had been trained in graduate school years ago working with adolescents and adults, but when I moved to North Carolina I had to retool and get other training in child and family work, so I went back to school. Doctors who were unwilling to see [a multitude of patients with different needs] in the rural community were seen as being withholding and their competency was questioned."
Additionally, working in less-populated communities leaves little in the way of privacy, both professionally and personally. "In the small town, most of my clients knew where I lived," said Dr. Rainer. "They would see me in the grocery store. I would see a client Friday afternoon at 3 p.m. and then would teach them in Sunday school. The boundaries were very different. There were a great deal of issues related to privacy, and I had to work double time to maintain that integrity. There was such a need and there were so many significant problems. I did the best I could and I burned out."
What are the long-term effects of having limited access to adequate mental health care?
"While drug addiction and suicide are concerns in all communities, individuals living in rural areas may be at an increased risk due not only to limited access to mental health care, but also because they have reduced access to other programs and social support in the community," explained Steelesmith. "Economic issues and isolation are often worse in rural communities than urban ones. This phenomenon can result in more feelings of despair. Compounded with a lack of mental health care to address the stresses caused by these things, it can lead to individuals seeking out other means of coping such as drugs or suicide."
"Economic issues and isolation are often worse in rural communities than urban ones."
Paulson agrees that feelings of isolation can further complicate existing mental health issues. "Untreated mental health conditions can lead to numerous disruptions in an individual's life that continue to feed into the mental health issues they are facing," she said. "Isolation can be a big issue in rural areas where people are not interacting with others and are unable to move beyond their own thoughts and struggles. Further, mental health conditions can lead to job loss and less interaction with friends and family, causing further isolation for these folks. Providing treatment for mental health issues could help break these cycles."
What's being done to give rural residents more access to mental health care?
Although there's certainly a long way to go, mental health professionals are trying to give rural residents resources, but types of care vary based on an individual's needs. "It's important to highlight that there is tremendous variation and heterogeneity in rural cultures and that there is no 'one-size-fits-all' implementation strategy," explained Paulson. "I believe successful programs can identify existing strengths and resources and best practices and adapt them to address the community's needs."
Fortunately, new types of technology — like telehealth services, where you can speak with professionals virtually — have done wonders for individuals living in rural communities.
"Providing internships in a rural setting and recruiting people who have connections to rural areas is vital.
"Telehealth care is becoming more common to improve access to both health and mental health care in rural areas," said Steelesmith. "Specific population groups who may be at risk due to economic or other concerns have also been targeted to ensure they know how to access emergency mental health services." Unfortunately, the use of telehealth services vary by area, and many rural communities haven't taken advantage of such services yet. "These services are growing rapidly but the rates of use are uneven across the country," said Paulson.
Giving individuals more ready access to self-improvement and educational and financial resources is also a step in the right direction. "Offering loan repayment programs and state tax waivers [has been beneficial]," said Paulson. "Providing internships in a rural setting and recruiting people who have connections to rural areas is vital. And offering mental health services in schools and community-based supports such as crisis lines, suicide prevention training and screening, fostering connections will also help."
What resources can people in rural communities use if they're having a mental health crisis?
The farming community has several local and national options — like the Farm Crisis Centre — to help individuals in need of services. "There are also larger hospital and healthcare systems based in urban areas reaching out to rural areas to provide services and link these communities," explained Steelesmith. She added that: "If individuals in rural areas are in a crisis, there is the National Suicide Prevention Lifeline (1-800-273-8255). There is also the crisis text line (741741) anyone can access. Organisations such as local chapters of National Alliance on Mental Illness can also connect individuals in rural areas with local resources."
As for DelPlato, finding the right therapist was key to her recovery. "Taking the guesswork out of finding a qualified therapist is so important," she said. "It's what deters so many people. I will honestly say if my parents didn't do it for me in those beginning stages, I wouldn't have done it myself. I've had the same therapist for years now, so it's definitely become a maintenance thing, but I'm really doing well now."