Community Mental Health in Small Communities: Why We Need More Therapists

I have lived in the rural Midwest for most of my life. Even though this is true, I’ve never lived on a farm and I know very little about farming, animal husbandry, or agriculture in general. I’ve spent time in bigger cities during an off-campus experience in my undergrad and while studying for my MSW degree, but I keep coming back to small town life. Small town life can be idyllic in some ways—everyone seems to know one another and usually, if your family experiences any sort or major transition (birth, death, adoption, illness) you will likely receive more food than your family can eat in a month. Small town life can be quieter and more serene with less traffic, fewer people, and general feelings of safety and security. But, is there still human need and vulnerability within small communities? Yes, there is, and even though that need is sometimes hidden, the mental health and well-being of people living in small towns and communities is often just as threatened in rural areas as it is urban centers and cities.

This fall, I read this new story about a farmer—he lived just a few hours away from me—who committed suicide because of the financial crisis his family farm was in. I’ve also heard about this study that found high rates of suicide among farmers and agricultural workers. The CDC also published statistics in 2017 which demonstrate that Americans living in rural areas are more likely to die by suicide than those living in urban areas. People living in rural communities experience similar mental health concerns to those living in more urban areas, but oftentimes the tendency in these rural areas is for people to hide these needs. The “pull yourself up by your own bootstraps” mentality still dominates much of the mindset in rural American when it comes to mental health and mental illness. A strong work ethic seems to encourage people who are struggling to just “work harder” to overcome their symptoms. And, because religiosity remains high in many rural areas, people often feel as if it’s a lack of faith that might be causing their struggles—if they just pray harder, they should be able to feel better. Some religious people may feel that a mental health problem is punishment from God and then may be less likely to seek treatment.

Historically, living in an urban area has been considered a risk factor for certain mental health diagnoses. However, in a study conducted in 2014 with over 50,000 adolescents and over 100,000 adults, Breslau, Marshall, Pincus, and Brown found that the data to support this has often been inconclusive or even contradictory. Their study found only slightly higher risk in both adolescents and adults living in urban areas and identified the biggest difference in risk was found in those who lived in what they called “small metropolitan” or “semi-rural” places of residence. The current pressures of life in a rural area are such that mental illness continues to be on the rise, but the numbers of people seeking care has not reflected this increase. So, why aren’t people getting help for their severe and acute mental health concerns? There are three main barriers:

• Accessibility: Rural residents may find mental health care to be expensive as well. They may be uninsured or under-insured and therefore have no mental health care coverage available to pay for the services they need. Paying out of pocket for such services is usually quite expensive which may mean that those seeking treatment are only able to pay for a limited number of sessions or opt out of treatment all together. Finally, finding transportation to an appointment with your therapist or psychiatrist can be difficult or even impossible. I live in a small town of just over 1,500 people and we have no mental health professionals working in our town (we may have some who live there, but travel to other towns for work). We also have no (or limited) public transportation options, so this can leave some people who need mental health care unable to get it.
• Availability: There is also a shortage of mental health professionals in rural areas, so those who do seek help may have to wait before they can see a counselor who can meet their needs. While most therapists are trained to treat a wide range of diagnoses, they also want to ensure that they’re practicing within their field of competence and this may mean that someone with a unique problem (like an eating disorder or a specific phobia) may have to travel a distance in order to find someone with experience or training in that area.
• Acceptability: Stigma around mental health continues to impact people’s decisions to seek treatment. Seeking mental health treatment and letting others know that you’re doing so can lead to feelings of shame and disgrace for a variety of reasons, some of them cited above. People living in rural areas might also fear a lack of anonymity or confidentiality when seeking mental health treatment within the communities where they live. Although mental health information is protected just like physical health information (HIPAA), it is difficult to entirely reassure an individual going to counseling that no one will know or find out.

Our mental health and well-being is an important part of what it means to be a well and healthy child of God. If those of us living in small communities and rural areas don’t have access to quality mental health care, this piece of our collective well-being is at risk. Having access to quality mental health care is essential to have a thriving, flourishing community, and while awareness around mental health needs continues to improve, when people still feel stigmatized or ashamed for seeking treatment we can be assured there is still progress to be made. We need more therapists in our small communities to help normalize mental health and mental illness and also to help promote this key aspect of well-being. Clinical social workers and counselors can help raise awareness in our small communities and can be actively involved in talking about mental illness, mental health, and mental wellness in our schools, churches, and workplaces. By bringing this topic into these places, mental health professionals can continue to educate and inform while also normalizing the need for clinical intervention.

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