On a cold January afternoon, Glenn Wolfner Ahava, PhD, sat in a chicken coop providing psychotherapy to a farmer who was feeling depressed. Faced with broken coop heaters and other problems on his farm, the man couldn't make the trip to Ahava's office. So the psychologist found himself helping the man in a cold chicken house, ankle-deep in some fowl substances.

While that's no everyday occurrence, an afternoon in a chicken coop or in a house with dirt floors isn't far-fetched for this clinical and forensic psychologist--the only doctoral-level mental health professional in his rural West Virginia county.

On any given day, Ahava is likely to stop by several physicians' offices to interview and consult with physicians on patients, answer emergency pages from the local hospital, make house calls and see a few clients in his office.

"At the end of the day, when I'm 10 minutes away from home and I'm supposed to eat dinner with my wife and 2-year-old daughter, I'll get beeped for another emergency," Ahava chuckles.

Indeed, no day is the same in a rural area that has scarce health and mental services and great needs for them.

"I'm often called on to make decisions that psychologists in metro areas don't have to make," says the 36-year-old psychologist. After all, Ahava smiles, how many psychologists have helped clients deal with chronic pain from being kicked by a bull?

Navigating rural practice

When Ahava graduated from the University of Rhode Island, all he wanted to do was forensic psychology, he says. But after three years working as a substance-abuse coordinator and psychologist at a federal prison, he was disillusioned with the effectiveness of corrections rehabilitation and facing a serious illness that was partly related to work stress. In a decision to find greener pastures, he quit his job last July and opened his rural practice.

"My wife was very supportive of our income plummeting," Ahava laughs, noting that starting a new practice isn't without its drawbacks.

Nine months later, he has no regrets and a new career that is both challenging and fulfilling. And even though his days are a lot longer now--a 12-hour one isn't uncommon-- they're also more rewarding. In fact, his advice to anyone considering starting a rural practice is to go out and do it, and then find a primary-care health-care provider who's willing to collaborate.

Ahava shares office space with Jerry Hahn, MD, who heads a multioffice primary-care practice. While not formally part of the physician's practice, "we collaborate quite integrally," says Ahava.

"Because we're in the same office," Hahn explains, "patients see Dr. Ahava as an extension of the practice." And that means they're far more likely to follow through on a referral, Hahn says.

Their partnership covers a five-county area, with a population of 78,000. It can take two or three hours to drive to some of the areas they serve.

Ahava frequently works with midlevel providers in Hahn's five offices, such as physician assistants and nurse practitioners. Most of these collaborations start in the physician's examination room when he's called in to consult with a patient, whether it's to negotiate medication compliance, assess a patient for depression or intervene in violent family situations.

Before he steps into the room with a new client, Ahava thoroughly reads the patient's medical charts, checking for medication regimens that could create depression, anxiety or other psychological side effects--an intervention that remains rare among most other practitioners.

"Some of our kids have ADD, developmental delays, learning disabilities," says Hahn. "Dr. Ahava's picked up on those things and really stressed it with the school system, saying 'Hey, this is what you need to do, instead of kicking them out of school.'"

In addition to his psychotherapy and collaboration with Hahn's practice, Ahava wears a few other hats. Because he's one of the few qualified professionals in the county, he's often called to testify at involuntary commitment hearings. He's also on staff at the local hospital, which calls him into the emergency room and onto the floors for consultations and assessments. And he helps physicians plan for patients' care when they are discharged from the hospital.

Recently, Ahava received an appointment to the West Virginia University department of behavioral medicine and psychiatry to train medical students, interns, residents, nurse practitioners and physician assistants during their rural family health practice rotation. Ahava helps teach these students to screen for and treat mental health disorders in primary-care settings--especially in areas like substance abuse or family violence, which are commonly missed.

"There's not a neat split between mind and body," says Ahava. "Fortunately, most of the practitioners I work with agree with me [on that]."

Providing integrated care

To provide integrated care, psychologists who work with physicians need to make an extra effort to learn about medicine, says Ahava.

"Physicians think in fundamentally different ways from psychologists," he says. "And you need to know how they think so you can work well with them."

Collaborating psychologists need to understand medical terminology and how to read medical charts.

Ahava also recommends using plain language, especially when making notations in charts. If medical providers don't understand what psychologists are getting at, they can't follow through on their recommendations.

"Unfortunately, graduate training is woefully inadequate in this aspect of preparation," Ahava sighs.

To get up to speed, he suggests signing onto a medical information service, like Medscape (www.medscape.com), or a continuing medical education service such as Audio Digest (www.audio-digest.com), and spending a few weeks shadowing a family practice physician. Ahava garnered much of his knowledge during the 15 years he spent as an emergency medical technician and from what he's learned from his wife, Lisa, a physician assistant who works with Ahava one day a week.

But no matter how much a physician knows about psychology or a psychologist knows about medicine, Ahava has found it's critical for collaborators to set professional pride aside.

"Egos don't have a real place in it," he emphasizes. "We all work together."

Ahava proudly recalls the case of a 4-year-old boy that he says is a perfect example of physicians' and psychologists' collaborative work. The boy had been diagnosed with attention-deficit hyperactivity disorder, but Ahava observed some problematic behavior that was similar to autism.

"It was a mystery to me, and I didn't want to let go of it," he remembers. So Ahava researched many possibilities and shared his discoveries with the boy's physician and physician assistant. Working together, they diagnosed him with a rare genetic disorder that was confirmed at an out-of-state hospital. Ahava and the physician consulted with other professionals, including a geneticist, a developmental specialist and occupational therapists, to advocate for services and develop a treatment plan.

"This kid could have gone through life with no accurate diagnosis, no directly targeted treatment, no accurate education plan," Ahava says. "His life has a lot more hope now than it did a month-and-a-half ago. Collaboration made the difference."