National Association for
Rural Mental Health
Each year, the National Association for Rural Mental Health hosts a one-of-a-kind conference focusing on rural and frontier mental health practice, social services, research, and public policy issues. The NARMH Annual conference brings together rural clinicians, administrators, consumers, researchers, and policy-makers. Participants’ learn about national issues and trends; develop new knowledge and skills; hear perspectives from rural consumers and advocates; and are provided with updates on the latest in research, practice and policy; socialize and HAVE FUN!
Rural American has undergone tremendous demographic changes, economic strife and social upheaval during the past twenty years. While governmental policy sometimes has been a catalyst to changes in life in rural America, for the most part these policies have been responses to the continuing evolution of conditions in rural America. With more than 28% of American citizens residing in areas as defined by the U.S. Census Bureau, a substantial portion of the national’s population is significantly impacted by these changes. Yet the decline in residents in rural areas has meant the loss of political influence and power with most policy makers having little first-hand experience with rural issues. The recent revolution that is occurring in health care is having a profound effect on rural America and especially on rural mental health care. This article identifies key changes in the structures of rural American society during the past twenty-five years and discusses accompanying shifts in mental health care to rural Americans. It also discusses the implications for policy of these changes and ways in which policy changes have impacted on rural mental health services.
During the past twenty-five years, some rural communities have declined in population while others have experienced a migration of new residents. In response to economic problems during the farm crisis, many young people left rural communities for economic opportunities elsewhere, creating a disproportionate large number of elderly residents. Communities with a growth of new residents have especially been those areas that border major metropolitan centers in the Northeast, the intermountain West, and other areas where climate and access to employment and recreation opportunities are especially favorable. Increasing numbers of individuals and families are seeking the advantages of living in a rural environment, such a low cost housing, low taxes, friendly relations with neighbors and community citizens, while also balancing these benefits with disadvantages as increased distance to work sites and fewer cultural amenities. Affluent newcomers from urban areas often move to rural areas to capitalize on technological advances in communication and transportation to enable them to combine work with living in their homes. The benefits and disadvantages have not been the same for all segments of the population. Immigrants, minorities and migrant farmers have, for example, not reaped the same higher salaries in rural area as their more affluent neighbors who moved from the city into small towns, recreational communities, and rural housing districts. In addition to lower salaries, these individuals also frequently belong to social and ethnic groups that are not part of the dominant social structure of the community. As a result, they can have difficulty accessing both formal and informal sources of support.
The decline of persons engaged in food production has been another continuing demographic shift. From the mid 1970’s to the mid 1990’s, the number of persons engaged in food production has dropped from 6.4 million to 4.8 million. Ever fewer people are engaged in farming. The average American farmer who is engaged in food production as his or her primary occupation now feeds about 800 persons world wild. The declining economic importance of food as a major necessity of life, along with rising costs of food processing, marketing, and distribution all have contributed to an economic squeeze of farmers and the resulting decline in numbers of farmers and change in the organizational structure of many farms. The proportion of the U.S. gross national product (GNP) spent on food has decreased from 15.8% in 1977 to 9.8% in 1997, behind housing, transportation, and health costs.
Table 1 summarizes the major changes in population distribution of rural Americans. As Table 1 illustrates, the majority of rural Americans live in the traditional South but most rural Americans are not engaged in agriculture. Agriculture and residents in rural areas involved in agriculture tend to be concentrated in the upper Midwest. The relative decline of rural residents engaged in agriculture makes it imperative not to equate agricultural policies with those of rural communities generally.
Sociological Changes over the Past Twenty-five Years: The increase in population in rural areas is largely due to the out-migration of urbanites to rural communities and the influx of immigrants to rural America. Urban residents have moved to outlying communities in many parts of the United States, especially communities near industrial cities, transportation hubs, or communities located in geographically favorable circumstances. The latter are typically those with easy access to the outdoors, opportunities for aesthetic appreciation of mountains, lakes, oceans, and that offer the affordable small tracts of land for hobby farms, gardens, and opportunistic agricultural enterprises. There has been resistance in rural communities to these new residents because they often do not integrate well into the local culture or make the same contributions to the community welfare as do the indigenous citizens. They are often viewed as invaders who contribute to rises in property values and prices because they purchase local land tracts at inflated prices. Compared with native residents, they are viewed as not contributing equally to schools, churches, and community clubs. The economic stimulation brought about the these new residents from urban areas often leads to changes in the community infrastructure such as road construction, modification of local laws and policies, and gradual change in social institutions as immigrants assimilate into their new environments. These changes influence the nature and perceptions of community needs as well as the process of policy decision making at the local level.
Spanish speaking immigrants have settled in rural communities in increasing numbers in the past twenty-five years. Paralleling the general trend away from dominance of farming in rural areas, these new residents are less likely to work on farms and more likely to work in food processing like meat packing plants and industries which have chosen to locate in rural communities. This trend has several implications. First, these new residents have strained community supports such as schools, housing developments, and job training programs. The influx of illegal clients has been particularly hard on local community services, because they often do not qualify for state and federal services. As a result, policy decisions cutting off benefits for illegal immigrants can have an important impact on rural communities. Others may be legal immigrants. Policy debates regarding whether these individuals are eligible for a variety of social service benefits have important implications for these individuals and rural communities.
An increase in the numbers of these new immigrants who are involved in industry also has implications for health policy decisions regarding job safety regulations. These individuals may be reluctant to advocate for stricter enforcement of safety policies because they lack a sense of security in their jobs and their permanent status in the community and the nation.
Another significant trend is for members of farm families to be employed in enterprises off the farm. As a result, production of food is being subsidized by non-agricultural activities. While there has been the gradual trend for mothers to be employed outside the homes through the United States, the shift of farm women into the labor pool over the past twenty years has been a dramatic one. In 1977, 40% of farm women worked in enterprises off the farm in 1977; by 1998 nearly 80% did so. This sociological change has led to many accompanying modifications in farm family livelihood. Of particular interest are the following changes.
Changes in women’s employment responsibilities outside the home heighten the importance of policy decisions regarding support for dependent care—both children and the elderly--because women have traditionally been responsible for these members of the family.
Healthcare and mental health care as part of the larger picture: Healthcare in America is currently heavily influenced by the movement to managed care and reactions to managed care. Managed care has had a significant impact upon health care in rural areas. Although mental health care in rural areas has traditionally been a public activity, this has been changing rapidly as states are arranging to have Medicaid privatized under managed care contracts. Managed care conglomerates in heavily populated areas have sought to capture an easily defined population and provider pool. In rural areas these companies have had a more difficult assimilating consumers and providers. In the context of service system designed to eliminate duplication, managed care in rural areas faces different problems in providing services to consumers. There are approximately 605 counties in the United States without a medical health care provider. The situation is even more dramatic in terms of mental health because approximately 1600 counties in the United States do not have an accredited mental health provider. Given the diversity within rural communities, access to medical health care and mental health providers is extremely variable in rural areas. Quality of care also differs widely.
Governmental Policy Influences: Successes and Failures: It can be argued that governmental policy over the past two decades has been both a response to conditions in rural America and a contributing factor to these conditions. It is probably fair to say that a major trend in governmental policy at the federal level has been away from federal toward state and local regulation. In many ways the federal government has been stepping out of the role as a societal leveler and has been allowing natural capitalistic trends to occur. Within the health care industry this trend has been manifested by the emergence of just a few large health care conglomerates which manage medical and behavioral health care services. As a result, these few large managed care companies have been moving ever closer toward the policy of “One size fits all” Unfortunately, inequitable distribution of health care providers, especially in the behavioral and mental health arenas in rural areas has led to a deterioration of services. While the trend away from federal regulation may be good for most parts of the country, it has resulted in fewer available healthcare services in rural areas and to more variable quality of these services.
Telemedicine has begun to emerge in rural areas as a response to the inequitable distribution of health care providers and quality of services. While there are probably limits to the types of behavioral health care that can be rendered through telecommunications, the overall effect of electronic delivery of services has been particularly beneficial to rural communities. The potential for electronic service delivery of behavioral health care is unknown but may well be tremendous.
The trend away from federal support and regulation and toward state and local regulation and resources is also affected by the burgeoning populations of immigrants in rural areas. This population can have increasingly difficulty in obtaining needed mental health services. If the federal government does not help provide services to immigrants, then the burden must fall on state and local resources. Local hospitals and services agencies feel ethically bound to provide necessary services to these individuals but without federal funds, the capacity of the service providers is severely strained.
The federal government has not totally abandoned rural mental health providers. The National Health Service Corps has been of great help to rural areas. These areas have benefited by the decision to broaden its assistance to include psychologists, nurse practitioners, and physicians’ assistants as eligible for benefits as well as physicians. The establishment of Rural Mental Health Research Institutes (currently eight) is creating an important source of knowledge of which to build practice and influence policy. They are attempting to keep track of changing behavioral health care needs. Some of their notable research has focused on farmers and their families.
Farmers and their families are in particular need of behavioral health care supports. Stress among farm families is rampant. Farmers and their families need to know how to manage stress more effectively. As result, prevention and outreach programs as well as traditional ways of providing services remain important.
There remains inadequate federal support for training rural mental health providers. There is currently no doctoral level program in psychology that specialists’ in this area. Residencies to train psychiatrists in rural mental health are extremely limited. The issue of equalization of Medicare reimbursement rates for rural and non-rural providers is a potentially important incentive for persons to serve in rural areas and would probably nourish the development of rural mental health training programs.
Conclusion: Governmental policy affecting rural mental health care has largely been away from federal to more local control. Notable failures of this shift are recognizable in the form of inequitable reimbursement rates of rural mental health service providers in comparison to their urban counterparts, uneven distribution of mental healthcare providers in rural areas, limited access of rural citizens for high quality mental health services, increasingly reliance of the rural poor and immigrants on local services which do not have adequate revenues, and the lack of training programs in rural mental health. Notable positive changes include emerging telecommunications technology to deliver mental health services funding of Rural Mental Health Research institutes and expansion of the National Health Service Corps assistance to mental health providers. The future direction of rural mental health and policies that are supportive of rural communities and services should capitalize on identifying the successes and recognizing the failures from the past.