Preparing for practice in rural communities

Several years ago, a psychology practicum trainee in North Dakota met with an adolescent who was clearly at risk for suicide. The local hospital didn’t have anyone with the expertise to assist, the nearest emergency room was more than an hour away from the local community, and no one was available to transport the vulnerable patient. “[The trainee] did not have the training necessary to manage that complex set of circumstances,” said Cindy Juntunen, PhD, dean of education and human development at the University of North Dakota in Grand Forks. “And they did not have a psychologist on-site, so they called their supervisor,” she said, which led to a three-way phone consultation that got the adolescent to another site where care was available.

That experience inspired the psychology faculty, supervisors, and students at the University of North Dakota to work with the local hospital to create a new suicide response protocol for future situations, Juntunen said. “But in that moment, the student called and said ‘OK, this is more than I can manage,’” she recalled. “And they were correct.” A critical part of supervision is both being readily available, Juntunen said, as well as regularly reinforcing with trainees that they will not be competent to handle all situations.

The demand for mental health clinicians to practice in rural areas has never been more acute. Nearly two thirds of U.S. counties with fewer than 10,000 residents lack any psychologists, according to an analysis of 2015 data (Andrilla, C. H. A., et al., American Journal of Preventive Medicine, Vol. 54, No. 6, 2018opens in new window). Federal officials have identified 3,426 mental health professional shortage areasopens in new window in rural regions of the country as of fall 2021, a gap they estimate would require nearly 1,600 practitioners to fill. Psychologists who supervise interns and advanced practicum students in rural areas describe such training experiences as vital to helping future clinicians determine if working in a smaller community is a good fit for them.

To be successful, they say, trainees must be prepped on what they should expect as part of their rural practice, including navigating ethics, confidentiality, and the limits of competence. Given the more limited resources in rural communities, including places to refer patients, supervisors must be easily accessible to trainees, particularly as some communities may be coping with higher suicide and drug overdose rates, said Jason Malousek, PsyD, an assistant professor of clinical psychology at the Kansas City University of Medicine and Biosciences in Missouri, and former chair of the APA Committee on Rural Health.

Moreover, supervisors provide a crucial role in professional mentorship, walking trainees through funding resources such as the National Health Service Corps Loan Repayment Program (PDF, 203KB)opens in new window that may enable psychology trainees to practice longer term in a rural area, Malousek said.

“You are preparing your supervisees for that next step,” he said. “It’s about, ‘What are your next five years, and how can I help you to have the best next five years possible?’”

Even within the context of rural regions, there can be substantial variation regarding community size and geographic accessibility, said Iva GreyWolf, PhD, a cultural consultant for the Alaska Psychology Internship Consortium, which places trainees in Alaskan communities that can have as few as several hundred residents.

“One of the things that is really important is for [trainees] to explore the reality of what they might be stepping into,” said GreyWolf, who also is a former president of the Society of Indian Psychologists. Given the often limited local entertainment options, she said, “You have to be very comfortable with yourself. It’s a struggle especially for a younger person, who is at that time in their life where the socializing is very important.”

It is not uncommon for trainees providing care in Alaskan communities to be snowed in for weeks at a time, and supervisors must help them hone a wilderness mindset, stocking up on food and other emergency supplies, GreyWolf said.

“Safety is first for the trainee,” she said. A stranded car can be a potentially deadly situation. “Always make sure that they understand how to protect themselves. When they go out, they need to know how to survive when they get stranded.”

Before moving to the community, trainees should be strongly encouraged to read about the region, its customs, and its cultural history—to be familiar with everything from historical leaders to prior epidemics and other traumatic events, GreyWolf said. Once on-site, they should identify one or more local elders with whom they can consult on local customs and protocols, she said.

It’s also important to volunteer at the senior center and attend local activities and events to build trust, GreyWolf said. “People are more likely to be open with you.”

Trainees accustomed to working in a traditional office setting may be surprised to learn how many therapeutic interactions occur elsewhere in remote and Indigenous communities, said Susan S. Woodhouse, PhD, director of the counseling psychology program at Lehigh University in Bethlehem, Pennsylvania. She has collaborated with GreyWolf and other colleagues on a series of qualitative interviews to learn more about effective therapist approaches when working with Indigenous communities in Alaska.

“It’s important to be ready to do psychological work with people while they are involved with berry picking or at fishing camp or in the laundromat,” Woodhouse said. “It’s a new way of thinking about integrated care.”

As trainees develop therapy goals, they should exert care to keep the client’s cultural framework in mind, Woodhouse said. While in some cultures an effort to achieve more independence may include taking steps to move out and get an apartment, that arc may be different in Indigenous cultures, she said.

“In this context, an equivalent treatment plan would be about helping a person begin to contribute to their family’s subsistence fishing,” she said. “That would be the equivalent of an independence plan, so that they can be more productive contributors.”

Supervisors should caution trainees not to layer their own cultural assumptions onto a therapeutic situation, particularly when potential child protection issues are involved, Woodhouse said. For instance, she said, trainees can benefit from consulting with someone in the community to gain insights into local customs related to parenting.

“So you really understand the context, so that you’re not needlessly disrupting families because of your bias about what’s good parenting,” Woodhouse said. That community contact can explain cultural parenting norms so trainees can provide effective therapy while working within the patient’s culture.

With time, though, trainees can benefit significantly from being exposed to and learning about a culture that might be different from their own, Woodhouse said. For example, “the humility they learn from encountering a community that’s different from what they’re familiar with and making that connection,” she said. “There is a huge need for mental health care in rural and remote communities,” she said. “So it’s an opportunity to really make a difference while you’re also growing and changing yourself.”

Emily Heavner, a PhD student at the University of North Dakota’s counseling psychology program, is accustomed to rural areas as she grew up in a small Missouri community. A few days every week, she drives an hour from Grand Forks to see clients at a community health clinic and critical access hospital in Park River, a town of about 1,400 residents.

Heavner describes the region served as “a little more like a frontier, a remote-type area.” For instance, some local schools may enroll only a couple of students in a grade, she said, noting that those tight community bonds can create ethical challenges.

“Your clients know each other,” she said. “They might even talk about each other at times. You have to be prepared to see a client anywhere, at any time.”

When Heavner first meets with her patients, she emphasizes the absolute nature of confidentiality. She suggests that they consider how they would prefer to interact, or not, if they cross paths outside of the office.

“Different clients are more comfortable with different things,” Heavner said. “That’s why it’s important to have that conversation: ‘We might see each other. How do you want to handle that?’”

Heavner reaches out to her supervisor in Grand Forks if she encounters a situation that bumps up against the edges of her competence. In one such case, she sought help after an emergency room referred to her an adolescent girl with suicidal ideation and complex custody-related issues. Her supervisor advised Heavner to contact the hospital social worker, who assisted her in reaching the appropriate family members and getting them connected with resources for the girl.

While trainees always must remain aware of the limits of their competence, it is particularly important for supervisors to watch out when trainees are practicing in rural areas, Juntunen said. Frequently trainees are acutely aware that referring a patient elsewhere could entail a lengthy drive and other complicated logistics, she said.

“Most people go into this because they really want to help,” said Juntunen. “The pressure to help and the recognition that you can’t help everyone are sometimes very difficult.”

Amid the overlapping and close-knit ties common in rural communities, trainees will find it difficult to entirely avoid dual relationships, Malousek said. “They are not inherently unhealthy unless there’s a chance for harm or exploitation,” he said.

If there is only one car mechanic in town, and that individual also is a client, that dual relationship likely can be managed, Malousek said. Other situations can be more challenging to finesse, and a supervisor may need to help the trainee think them through, he said.

Take a scenario in which a trainee serves in the parent–teacher association (PTA) with the parent of a child they are treating, Malousek said. While serving together in the association likely does not present an issue, the trainee should probably not work on a specific PTA project with that parent, and politely decline any offers to get coffee after the meetings, he said.

“That can be hard to do if you’re in a small town and friends are limited and you’re isolated,” Malousek said. “You limit your social circle as a psychologist working in a rural area.”

To offset that potential isolation, supervisors can play a significant role by assisting trainees in building ties elsewhere, such as by introducing them and their expertise to the local courts, nearby schools, and other entities, Malousek said.

“It also brings about leadership development,” he said. “With that leadership development, they’re seen as leaders in the community. They still are a member of the community. And they are engaging in their community in a very appropriate and professional way.”

Given the dearth of psychologists in some rural regions of the country, programs are increasingly incorporating telesupervision, Juntunen said. “They’re doing that because there are no psychologists available in the areas where people are trying to provide services.”

Along with meeting the Commission on Accreditation requirements for the use of telesupervision, there may be other logistics that academic programs have to work through in advance, Juntunen said. As one example, she described how a few psychology trainees from the University of North Dakota see clients at a rural hospital, which does not have a psychologist on-site.

The trainees are supervised by a psychologist practicing elsewhere. But the University of North Dakota first had to work out an agreement with the hospital, Juntunen said. That enabled the psychologist supervisor to access the hospital’s electronic health records to review the trainees’ clinical notes, among other elements of supervision, she said.

Heavner, at her North Dakota advanced practicum site, estimates she meets with only about half of her patients in person. She provides some teletherapy only by phone, because the patient either is not comfortable with video technology or does not have access to a reliable internet connection.

Providing therapy by phone lacks the visual interactions, Heavner said. “And it’s already still a little bit tricky reading those cues over something like Zoom or another video platform,” she said. “I definitely think not having those social cues or emotional cues can be difficult—you are listening extra hard to see if you can figure out what’s going on.” A supervisor can help trainees develop this skill, Juntunen said, by modeling how to focus on affective cues in language and by role-playing interactions on telephone or video to prepare them for the remote platform.

Even if trainees later decide that a rural practice is not the best fit, the breadth of experience they gain can burnish their skills for the next stage of their career, Juntunen said. “They are able to say, ‘Here I had to be able to really triage and think on my feet and think about how to have the most impact in a community where there’s some dramatic evidence of lack of services and vulnerability.’”

Heavner, who hopes to work long term in a rural community, feels like her practice site has broadened her exposure to ethics and other challenging situations. Plus, she’s found it profoundly rewarding.

“Because there is such a lack of access to care, there are so many people who want and need your help,” she said. “There can a homeyness about it, too. I like hearing people’s stories. And rural culture is definitely a storytelling culture.”