Pursuing cultural competence in rural mental health

Rural communities have long faced mental health inequities, driven in part by a lack of access to resources—including licensed psychologists. Depression and suicide impact rural individuals at disproportionate rates, yet provider shortages make it difficult to seek help (Carpenter-Song, E. & Snell-Rood, C., Psychiatric Services, Vol. 68, No. 5, 2017opens in new window). Even when a psychologist or other mental health provider is present, long wait lists and stigmas about seeking professional support often stand in the way of care (Crumb, L., Mingo, T. M. & Crowe, A., Mental Health & Prevention, Vol. 13, 2019opens in new window).

The Psychology Interjurisdictional Compact (PSYPACT)opens in new window, an agreement that allows licensed psychologists to practice telehealth across state lines, can increase access to mental health care in rural communities. Yet psychologists based in urban or suburban areas looking to expand their practice into rural communities may not understand the texture of rural life, which could impair trust between provider and patient. An effective therapeutic alliance with rural patients—and ultimately, effective care—requires its own type of cultural competence.

“We historically don’t always think of it like a culture as we do other identities, but people who live rurally experience their own cultural considerations,” said Tess Kilwein, PhD, a clinical and sport psychologist and chair of APA’s Committee for Rural Health. In their own practice, Kilwein sees patients in states including North Dakota and Wyoming.

Unique socioeconomic stressors such as social isolation, poverty, lack of or underinsurance, and food insecurity drive many health inequities among people in rural settings. On the flip side, many of these communities also have strengths such as community interdependence and rich cultural traditions that can bolster resilience among residents.

Here’s more guidance for working credibly in rural communities:

Every rural community is unique: A farming community in North Dakota isn’t at all like an Indigenous fishing community in Alaska. As you would with any other patient from another culture, take time to understand where your patients live. “Even if you can’t travel there, find ways to investigate whether reading or directly connecting with local leaders like teachers or clergy,” said Cindy Juntunen, PhD, associate provost for research and dean of graduate studies at California State University, Monterey Bay, who has researched rural communities and formerly taught at the University of North Dakota.

Another way to grow your competence is to consult with other mental health or medical providers in the community or surrounding area, said Paul Korte, PhD, a clinical psychologist who was raised on a farm and now works in Columbia, Missouri, serving many rural patients. Along with historical factors that the community is built on—such as industries or shared traumas, including weather or economic events—try to understand community norms. Who do people typically turn to for help during difficult times? How do they view outsiders? What values or beliefs shape how the community sees mental health? “Learn about factors that enrich the community, along with areas of potential sensitivity,” said Korte, who is also vice chair of APA’s Board of Professional Affairs.

Any effort to understand the local landscape can build credibility and trust with patients. “Face time can help you understand the community, but also help the community understand you’re a safe and trustworthy person,” said Diana Prescott, PhD, a clinical psychologist in Hampden, Maine, a small town in rural Maine.

Assumptions and implicit bias about rural life can impair the therapeutic alliance. “We’ve been training psychologists about racial and gender bias for decades, but we haven’t applied the same critical lens to rural communities,” said Juntunen. It’s important to explore whether you carry stereotypes about rural life, whether through media representations and political divides.

Along those lines, you may discover mindsets and norms within a specific community you’re working in—but don’t assume homogeneity. “Not everyone who comes from a rural community is a cookie-cutter of the same thing,” said Shannon Goecke-Watson, PsyD, a counseling psychologist in Apple Valley, Minnesota, who has worked in counties with no fellow psychologists. “There can be a whole wide range of mindsets and identities even within these communities.” Rather than making assumptions about an individual’s political or religious beliefs, for example, ask questions, allow the patient to share their unique experience, and, as always, don’t allow your own beliefs to interfere with treatment.

Even focusing too much on the challenges of rural communities can affect the therapeutic relationship. “We often assume the barriers are the most prominent issues affecting rural individuals, or that if we could just uplift them, they’d be as good as urban communities,” said Douglas Knutson, PhD, associate professor of counseling psychology at Oklahoma State University. “While these communities face difficulties, a negative mindset undermines the coping skills, strengths, and neuroflexibility so many rural individuals possess.”

Seeking out therapy can be intimidating for anyone. Take care to build trust and credibility to improve the likelihood of a strong therapeutic alliance. Rural providers say it’s common for rural patients to feel skeptical of health care professionals, especially if they’ve ever felt overlooked or misunderstood. Taking a collaborative approach to care can reduce any intimidation or power struggles. “I often tell my patients they’re the expert on themselves, and that together, we can work to reduce distress and improve coping and quality of life,” said Emily Selby-Nelson, PsyD, director of behavioral health at Cabin Creek Health System in West Virginia.

If you have any connection to a rural community—you grew up in a small town or visit one frequently to see family—consider talking through that with the patient to build rapport and familiarity. If not, be honest—and share ways you looked into what it’s like where they live. “People want to know if you can relate to them, and they may open up more if they feel you understand their language or context,” said Korte.

Psychoeducation can also help reduce stigma and increase rapport. Explain that as a psychologist, you have experience helping patients navigate many different issues—from clinical diagnoses to people struggling with sleep, parenting, or chronic illness. “Explain that psychology is so much more than treating mental illness,” said Korte. “Our focus is much more on helping individuals change their thinking and behaviors in order to live healthier, happier lives.”

A thorough biopsychosocial assessment is especially key in rural contexts: By the time a patient comes to you—whether stigma, transportation issues, or a long waitlist kept them from care—their issue may have become more severe. Whether driven by concerns about stigma, confidentiality, or cost, psychological care is often delayed—and in a mental health crisis, there’s not always a place to go. “We’re seeing more clinics and hospitals in rural communities shutting down due to funding issues, so people have to travel hours, if not states away, for mental health treatment,” said Goecke-Watson.

Diagnostic sensitivity is also important. Understanding contextual factors that can impact mental health in rural communities can inform your diagnosis and treatment plan. “If a patient comes to you with anxiety and depression, for example, they may be facing unique economic difficulties related to seasonal work, which should be taken into consideration,” said Kilwein. What you may initially see as depression or grief may actually be tied to adjustment disorder, for example.

The impact of historical trauma or shared difficulties should also be taken into consideration during an assessment. Many rural communities face shrinking populations and waning resources, which can leave rural individuals feeling forgotten, Korte said. Difficult events may be more life-altering for some rural patients. “Many rural communities are connected to land or industry their families have been part of for generations, so it’s part of their identity,” said Juntunen. Failed crops, repossessed land, or lost markets and buyers may not only pose an economic and career crisis, but an emotional, identity-based issue.

Generational trauma can also have long-lasting effects. Ashley Cole, PhD, associate professor of psychology at Oklahoma State University, teaches clinical psychology doctoral students about the unique biopsychosocial context of rural Oklahoma to prepare them for local clinical work. One essential touchpoint is the tribal history of being forcibly removed from their original land to Oklahoma through the Trail of Tears—a shared historical trauma shown in studies to impact physical and mental health for years to come. For example, Cole’s research has shown that children of Indigenous parents who have depression related to discrimination are more likely to experience depression themselves (Cole, A. B., et al., Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 64, No. 12, 2025opens in new window).

While recognizing barriers to care and overall well-being is important for cultural understanding, a purely deficit-focused approach can be harmful. As you challenge your own biases, encourage patients to explore the strengths, resources, and benefits of their community.

Help the patient identify community support, such as family, churches, or civic groups. “Ask them, too, about previous experiences of resilience, strength, and success when planning future coping strategies,” said Selby-Nelson.

Be aware of potential limitations in the process. Referrals you typically make in an urban setting—such as support groups for adolescents or specialty care for queer individuals—may not exist in a more rural area. When relevant, help your patient find a solution, whether telehealth-based individual or group care with a specialist or partnering with a local clinic or school to help the patient tap into or advocate for expanded services.

Be curious about someone’s day-to-day before making lifestyle recommendations that aren’t possible or sustainable. For example, for people with insomnia, psychologists often recommend sleep hygiene—including a consistent sleep schedule and a dark, private sleep space. That may not be the best solution. “In many parts of Alaska, for example, we have 24-hour daylight during the summer, and people can’t always afford blackout shades,” said Sara Buckingham, PhD, associate professor of psychology at the University of Alaska–Anchorage. Further, amidst a housing shortage and due to cultural practices, many families share bedrooms.

Flexibility with your traditional workflow is essential. For telehealth, unreliable internet can be a concern. “Widespread broadband access is not commonplace across the nation yet, especially in rural regions,” said Buckingham.

Try to adapt visits to meet your patients’ needs. Address privacy concerns if a patient needs to attend a therapy appointment in a public setting, such as a school or library.

Depending on the primary industry of the community you serve, you may need to offer extended hours when your patients are most available and potentially keep a few extra open “walk-in” slots when they’re traditionally busy in case of bad weather. Be flexible about cancellations. “If it’s been raining for days, a patient may need to miss an appointment to catch up on outdoor work,” said Korte.

Treating rural patients is rewarding, but the work can be isolating. To prevent burnout, build relationships with other providers serving in the same area, whether MA-level therapists or physicians.

Selby-Nelson also encourages finding ways to stay connected and consult with other psychologists, especially those who also treat rural patients. If you don’t know other professionals who work in this space, consider joining APA’s Division 31 (State, Provincial & Territorial Affairs) Rural Health Section for practice support and networking opportunities.

Staying connected can also expand the reach of your work. Use your expertise to advocate for communities in need, whether teaching psychologists-in-training how to think about practice in rural mental health or getting involved in a professional organization dedicated to rural needs. “Issues affecting rural communities are a public health issue,” said Knutson. “While individual therapy helps, psychologists are also uniquely equipped as advocates.”