Cover Story

In the mid-1950s, the Eisenhower administration commissioned a task force to examine the state of rural mental health in America. Its conclusion was grim: About 60 percent of rural areas suffered from a shortage of mental health professionals.

Several decades later, under the Carter administration, another task force conducted a similar study. Like the Eisenhower commission, it found that about 60 percent of rural America was underserved. The percentage remains essentially unchanged today.

It is hard to pin down any single reason for the lack of improvement over the past 50 years, a period during which mental health professions and rural communities both changed significantly. But, says Dennis Mohatt, director of mental health for the Western Interstate Commission on Higher Education (WICHE), the numbers do highlight the difficulty of the problem, and the failure--so far--of the mental health community's attempts to solve it.

"Really, if you looked at the mental health work force situation we have now, you'd have to conclude that [the mental health community's] strategy has been a failure," says Mohatt, who recently served as a consultant on rural issues to the president's New Freedom Commission on Mental Health.


Not everyone agrees that little has been accomplished. Michael Enright, PhD, a psychologist and nurse practitioner in Jackson Hole, Wyo., who served as the first chair of APA's Rural Task Force, says that some real gains have been achieved over the past 10-15 years.

One has to do with federal efforts to increase the number of rural psychologists and other rural mental health professionals. In the mid-1990s, the APA education policy staff spearheaded a successful effort to extend the loan repayment program of the National Health Service Corps (see page 61) to psychologists working in underserved rural areas.

In Wyoming alone, says Enright, the program has already paid over $500,000 worth of psychologists' loans. And the psychologists who have taken advantage of the program aren't short-timers, says Enright. So far, at least in Wyoming, they seem to be sticking around. The most recent congressional appropriation makes psychologists eligible for rural scholarships as well.

More programs are sorely needed, however, say psychologists who practice in and study rural areas. Despite myths to the contrary, rural communities experience roughly the same rates of mental disorder as urban and suburban communities. Some behavioral problems, such as youth aggression, suicide and substance abuse, may be even more common, researchers say. And the number of psychologists, psychiatrists, social workers and nurses remains far too small.

In fact, the Department of Health and Human Services (HHS) Bureau of Health Professions has designated about two-thirds of rural counties as "mental health professional shortage areas." The designation is based primarily on the ratio of professionals to total population.

Many policy-makers have a growing interest in rural health disparities, but policy change remains a challenge, says Idaho State University psychologist Beth Hudnall Stamm, PhD, president of the Idaho Rural Health Association.

That may be because of what Stamm calls "urbancentrism": a tendency for psychologists and other professionals, as well as the general public, to pay more attention to the problems of cities and suburbs than to those of rural areas.

The word also describes people's willingness to think of rural areas in terms of stereotypes--such as the misperception that all rural people are rugged individualists who never need outside help--that obscure the very real need for better health care, says Stamm.

The understanding gap may be growing larger, for the simple reason that the United States itself is becoming more "urbancentric" every day, according to demographic research. Although about 90 percent of the country's land area is considered rural according to some definitions, less than 25 percent of Americans live in rural areas, and the percentage is steadily decreasing.

Stressful conditions

Research on mental health in rural areas is sparse, but what there is suggests that the population decline and related issues--such as high unemployment--contribute to mental health problems. For instance, APA fellow Rand Conger, PhD, a sociologist at the University of California, Davis, has studied the impact of social and economic hardships on child development and family dynamics in rural areas since the mid-1980s.

In 1987, with farms and businesses closing across the Midwest, Conger and his colleagues at Iowa State University began studying more than 450 families in north-central Iowa. The results of his work suggest that the "farm crisis" of the mid-1980s had a significant impact on the mental health of farm families.

Conversely, psychological factors--such as openness and understanding between couples--appear to be the most important in determining whether a family farm survives an economic crisis, says Conger.

"At an individual level, it was the parents who tended to feel as though they could master difficult situations, who could put up with the downturn and find alternative strategies," says Conger. It was primarily when economic stresses were combined with negative coping strategies and unstable relationships, says Conger, that families broke apart and farms collapsed.

The finding suggests that psychologists and other mental health professionals may be able to help rural families survive times of hardship. In fact, preliminary evidence suggests that those couples who sought professional help had better long-term outcomes than those who did not, says Conger.

Future directions

What will the next 50 years of rural mental health look like? Will new policies be able to lower the percentage of rural areas with health-care shortages, or will the 60-percent figure continue to plague the field?

Mohatt, for one, is pessimistic, at least when it comes to top-down policies. "There's a lot of good things going on out there," he says, "But it's because of good people wanting to do good things, not because of any good policy or planning or research." (At the same time, he says, he's pleased with the New Freedom Commission's focus on rural issues and hopeful that it will translate into heightened attention and more effective policies for rural mental health.)

Examples of promising bottom-up efforts include partnerships between mental health professionals and primary-care physicians, the linking of specialists to rural communities through telehealth and the training of village mental health aides in Alaska Native communities, says Mohatt.

But there are also new developments in the policy arena that could lead to significant improvements, says Enright. At HHS, the National Advisory Committee (NAC) on Rural Health and Human Services has made mental and oral health its two main foci for 2003.

According to Enright, who chairs the NAC's mental health subcommittee, the group is particularly interested in ways to promote collaboration between rural psychologists and primary-care physicians. It is expected to deliver its report to HHS Secretary Tommy Thompson next February. Meanwhile, the Substance Abuse and Mental Health Services Administration has also made rural mental health one if its priorities this year, says Enright.

Changes in prescriptive authority are another arena in which policy could have an immediate and dramatic effect on the availability of care, Enright adds. From the perspective of a psychologist and a nurse practitioner, he says, the benefits of prescriptive authority in New Mexico and other states with large rural populations--such as his home state of Wyoming--seem clear. "Am I sanguine about the changes?" he asks. "Yes."


Further Reading

  • Conger, R.D., & Conger, K.J. (2002). Resilience in Midwestern families: Selected findings from the first decade of a prospective, longitudinal study. Journal of Marriage and Family, 64(2).

  • Stamm, B.H. (Ed.). (2003). Rural behavioral health care: An interdisciplinary guide. American Psychological Association: Washington, DC.