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Historically, few doctoral programs have paid much attention to the unique challenges rural psychologists encounter on the job. These include practicing in a local culture, working as a generalist and dealing with the added financial concerns of working in an impoverished community.

"I think the state of rural training [has been] pretty thin," explains psychologist Garret Evans, PsyD, who heads the National Rural Behavioral Health Center at the University of Florida. "There's a lot of training that goes on in rural communities--but not enough of that is focused on the needs of these particular patients. Programs that want to address rural needs absolutely need to pay greater attention to the idiosyncrasies of working with a rural population."

He and others are hopeful, though, that the tide may be turning in that direction. As the nation increases its focus on problems in rural health-care delivery, Evans believes others will increasingly emulate programs like his--which offers a rural curriculum and a two-course sequence in rural behavioral health to clinical psychology PhD candidates in the university's department of clinical and health psychology.

A few programs are already starting to do so by offering didactic elements focused on rural practice and placements for students in rural areas. For example, at the Institute for Rural Health at Idaho State University, undergraduate through postdoctoral health-care professionals, including psychologists, have the chance to participate in rural research, educational outreach, policy creation and clinical activities.

"We give [students] the extra training they need to foster a smooth transition into a rural professional life," says psychologist Beth Hudnall Stamm, PhD, deputy director at the institute.

Striving for cultural compatibility

Such training should focus largely, she says, on understanding cultural differences between rural and urban settings. For example, attitudes may differ regarding racial prejudices, binge drinking and domestic violence may be more frequent in the population, and there's often resentment of highly educated professionals.

A community's insularity and socioeconomic disadvantages can play into those differences, says Evans. "The range of problems aren't any different than any other clinical psychologist deals with, but when you're dealing with communities with entrenched poverty and racial prejudices, there's a cultural divide that can make diagnosis and treatment more complicated," he explains.

In fact, such cultural understanding--or openness to it--has become a criterion for selecting students for some training programs. A self-described "rural girl," Stamm says successful students need to be well-prepared for the transition.

One way of recruiting rural providers is to identify promising undergraduates--and even high school students--from rural areas and encourage them to consider psychology so that they can bring the rural cultural perspective into the profession, she adds.

"Even the five years or so someone spends training at an urban university can change them and make it hard for the community to accept their care," Stamm says. "So it's helpful if we can keep them in [rural] communities part of the year through summer placements and practica."

However, having a rural background is not the only key to success. In recruiting students for his program in Florida, Evans says he instead looks for students who can integrate complicated factors like culture, race, family structure and ethics in a treatment philosophy-- but isn't concerned so much that they have a rural background.

"If you come into the program having grown up in a cosmopolitan area and you find the belief system in these areas somewhat intolerable, you're obviously not going to do well," Evans says. "But I find it's more important for these students to be naturally sensitive to racial and cultural issues and to have great psychological acumen for looking at what special root causes exist for explaining what they experience in rural areas."

Working as a generalist

Often, rural psychologists will be the only provider in a 50- or 100-mile radius, making it necessary for them to be comfortable treating a range of disorders and working closely with other health-care providers in integrated primary-care facilities.

"More than for most psychologists working in urban areas," Stamm says, "rural practitioners need to be competent in all areas of psychology. There's no room for specialization."

Psychologists may also find themselves asked to step up to senior administrative duties early in their rural careers, so they need to tap available resources--something that can be aided by courses on everything from developing integrated health centers to seeking referrals in areas where other professionals are in short supply, Stamm says.

"It's important to recognize that just a rural practicum is probably not enough to think you've been trained in rural psychology," Stamm says. For example, rural psychologists need to be fluent in health-policy issues and perform outcome evaluations for government grants.

Making it financially

In addition to finding grants to fund services in rural areas, psychologists also need to be their own financial managers--able to run a practice without the benefit of teaming up with others or practicing in a major medical facility. They also need to know how to supplement their private practice with contract work for organizations like schools and prisons.

"We're very aggressive on teaching students how to be financially stable," Evans says. "You can't send these students out there and assume they'll be able to succeed without some training in how to build finances, apply for grants and deal with Medicare and Medicaid. We talk very frankly about what clinical psychologists bill and what rural salaries are."

And government programs that support treatment of underserved populations, including the National Health Service Corps (see Slot offers loan repayment and other rewards) and the Graduate Psychology Education program, can offset some of the costs of training programs, says Stamm.

"I think finance is one of the most profound barriers," Stamm says. "Usually, loans are needed for training in psychology, and if you take a job in a rural area that pays less than a job in a city, you're going to have even more trouble paying off those loans.

"This is where grants can make a huge difference in access to the field."

Further Reading

For more information on rural behavioral health training programs and support:

 
National Rural Behavioral Health Center at the University of Florida:

 
www.nrbhc.org

Institute for Rural Health at Idaho State University:
www.isu.edu/departments/irh

National Health Service Corps opportunities list:
http://nhsc.bhpr.hrsa.gov/ opportunities_list