Slightly more than one-quarter of our nation's population lives in rural America. Nearly one-third of all rural counties are designated as Health Professional Shortage Areas, with another third partly so designated. Here, more than 8 million Americans have no health insurance and 4.5 million are underinsured. Since President Jimmy Carter's Commission on Mental Health, the federal government has consistently reported that mental health personnel are not available in many rural communities, even in larger ones, and that long distances, rough terrain, large concentrations of elderly, persistent poverty and poorly organized delivery systems contribute to significant health-care needs. Unacceptable health disparities exist for minorities throughout rural America.
A decade ago, the U.S. Office of Technology Assessment noted that economic barriers prevent many rural residents from receiving adequate health care and often outweigh strictly physical barriers. Rural areas find it increasingly difficult to recruit and retain the variety of qualified health professionals needed. No single strategy seems appropriate for all rural areas or all health providers.
Mental health professionals face problems similar to those of other rural health professionals with fewer training opportunities, fewer colleagues with whom to discuss professional issues and more diverse demands on their time than their urban counterparts have. Primary-care physicians provide much of the mental health care, but receive relatively little training in mental health diagnosis and treatment. The severe shortage of appropriately trained providers and the types of services most acceptable suggest that integrating mental health within health care is especially important in rural areas.
The question is: What is APA doing? In 1996, APA's Council of Representatives identified rural health as a priority and designated the rural health task force, established by APA Past President Jack Wiggins, PhD, as a continuing committee. The Committee on Rural Health and Office of Rural Health are located within the Practice Directorate state advocacy program. In many ways, all of the major policy issues relevant to psychology are vividly displayed in rural America, including the "master's issue."
Members of the Committee on Rural Health have been extraordinarily active in the era of telecommunications. The potential of telemedia for treatment, education, research and health infrastructure development is increasingly evident. Yet, challenging policy concerns remain--for example, licensure mobility, scope of practice (obtaining prescriptive authority), reimbursement and confidentiality (probability of dual relationships). The rural initiative has actively explored new models for professional practice, including reconceptualizing psychologists as primary health-care providers, and has emphasized interdisciplinary collaborative practice from the beginning, with psychology expressly identified as a "health profession." Because women are disproportionately represented in rural areas, a rural women's work group on behavioral health-care needs was convened, with support from the APA Council's women's caucus.
Presently 38 doctoral training programs self-identify as having a rural emphasis. A priority for psychology is developing support for rural internships and postdoctoral training through the National Health Service Corps. These efforts have important implications for practice, education, science and public interest. It is refreshing that our rural health initiative places APA among the rural health professional leaders nationally. Key links have been forged with the National Rural Health Association, a major player at the national level, with APA co-sponsoring and assisting in planning its annual meeting. Relationships have been forged with primary-care physicians, dentists, social workers and nursing organizations; publications and training modules encourage the provision of behavioral care to underserved rural populations. Under Katherine Nordal's leadership as chair of the Committee on Rural Health, APA is making a real difference. For more information, visit www.apa.org/rural, a part of the Practice Directorate home page that is a center for rural behavioral health care and offers links to many other rural health sites.
There is no one approach
My weekly calls to members around the country bring home the importance of our governance enhancing its relevance to society's needs and providing visionary leadership for member participation. We are one family--possessing tremendous expertise. How can we utilize those who have already served as presidents of their state associations? Perhaps one answer resides within rural America. There is no one correct approach. Every situation is unique. A former Congressional Science Fellow, Katherine Nordal appreciates the importance of personal involvement. We could devise a plan. The technology and human resources exist. Rural America also highlights the importance of ensuring that every state and every APA division possesses its own vote on our Council of Representatives. Each of us must have a voice in our governance. Aloha.