In 2009, my husband and I left Minneapolis and moved to Greater Minnesota—which is Minnesotan for any geographic space outside of the seven-county metropolitan area centered around the Twin Cities.
Before we moved, I had conjured up a romantic view of being a therapist in the countryside. I expected a ready-made, tight-knit clinical community where I could practice with supportive colleagues. We would work together to put a dent in the unmet mental health needs of rural America.
This idealistic vision is not what I experienced. Now, nine years later, I have a much deeper understanding of what it really means to provide mental health services in rural America.
Early Learnings in Rural Practice
I didn’t work in the community where we lived. Instead, I practiced in the “hub” of rural south-central Minnesota, a micropolitan city of 39,000. I was hired to develop a primary integrated behavioral health program in a small, newly designated Federally Qualified Health Center (FQHC).
For some time, I was the sole licensed mental health provider in the health center. I was practicing alone, developing a new integrated program and hiring mental health providers. I was working hard to earn the trust of clients, primary care providers, nurses and local community leaders. The learning curve was steep.
I began seeing clients and working hard to meet the many unmet mental health needs of the uninsured and underinsured in 27 counties in south-central Minnesota served by our small community health center. It did not take me long to understand that I was terribly underprepared for the realities of behavioral health practice in a non-urban place.
I remember meeting Lydia after her mother brought her in because she seemed depressed. She was depressed, but she was also fifteen, quite tall, and weighed 65 pounds. The family lived two hours away from two exceptional eating disorder treatment facilities. However, the family was uninsured.
Lydia’s mom worked a high stress job that offered no benefits and a wage that made every single penny count. Both treatment facilities offered residential services, which I knew would be important for this family. When I spoke with the agencies about a patient assistance program, one said, “We don’t have one” and the other said, “Sure, we can scholarship her. But she can’t be in the residential program. She’ll have to do the outpatient program. Someone will have to drop her off at 8:00 every morning and pick her up at 5:00 p.m.”
This, of course, would never work. Lydia’s mom began work every day at 7:00 a.m. She had two other children who needed to get to and from school. They couldn’t afford the gas. Not to mention, who could sustain that for weeks or months, driving four hours every single day? Even if it did mean access to critical, life-saving treatment, it was not a realistic option.
Her mother’s response was exactly what I expected: “I’ll just take her home and fatten her up myself.” I saw Lydia a few times after that. Her mother decided that time with me might be better than no treatment at all, but this meant that I was in a predicament. I consulted with my colleagues in Minneapolis doing this work, so that I could provide some kernel of the level of care she should have been getting. Then, despite multiple attempts to follow-up and brainstorm other options, she faded from my schedule.
Nolan was seventeen when he came to see me with acute psychotic symptoms, following the use of a synthetic version of heroin. He was terrified of the things he saw and heard all day long—things that did not exist outside his own mind. I will never forget the look of sheer terror on his face as he described the hallucinations he experienced most days. I will never forget the gentle way his quiet and kind mother talked with and about him. She was sad and confused and loving.
He was transported to a hospital where he received great care. The hospital was 90 minutes from where his family lived. They were small business owners and were uninsured. They paid in cash for all medical care. His psychiatric hospitalization was an incredible financial burden for this family. Certainly, their insurance status played a role in how long they waited before they brought him in to see me in the first place.
When he was discharged from the hospital some weeks later, they came to see me. The discharge planning team had been unable to locate a psychiatrist who would treat minors within 90 minutes of the family’s home. They had come to see me hoping I had answers. I did not. The provider we located was two hours away. His new list of prescriptions required weekly visits for at least the first month. They took the first appointment they could get.
Ayan was my first referral from the Center for Victims of Torture (CVT). She had witnessed things in Somalia that I never could have imagined. There was nobody else in rural, south-central Minnesota doing refugee mental health work. In partnership with the clinical team at CVT, I worked with refugees, asylees, and other immigrants in an effort to provide competent, accessible, culturally responsive/informed mental health care. I sought and completed a certificate in refugee mental health as quickly as I could. Necessity often drives the decisions we make about “areas of practice” in rural mental health.
With Lydia and Ayan, I found myself operating in a practice realm where I lacked competency—a significant ethical question. So, I actively sought consultation from the experts. The alternative was to send Ayan home and state that “we don’t do that here.” Telling a family without health insurance and limited disposable income that they could access the care they desperately needed for their son as long as they drove two hours to get there was not an easy conversation. These were the everyday dilemmas of a “generalist” rural mental health practice.
The burden of the gaps in our behavioral health care system was felt deeply by these young people and their families. And it was felt at a time when things were alreadyoverwhelming and hard.
The Reality of Rural Mental Health Practice
Our rural mental health workforce is in crisis. These are some things that I know to be true today.
- The burnout rate for behavioral health providers in rural America is higher than it is in urban centers.
- The weight of unmet psychiatric needs is felt exponentially in rural parts of the country due to workforce shortages, especially for children and youth.
- Specialty care programs (dual diagnosis chemical health treatment, eating disorder treatment, treatment for sexual behavioral disorders, acute psychiatric care, etc.) are limited or non-existent in many rural communities, making this kind of critical care inaccessible for many who need it.
- Federal and state loan forgiveness programs are effective at drawing newly graduated providers into rural practice, but that most will return to urban places once their service requirements are fulfilled.
- Stigma about seeing a mental health provider is often felt even deeper in rural settings and that it has grave consequences for those who suffer alone.
- The reality of the “generalist practice” is stretched to its limits in rural settings. And that a clinician’s responsibility of identifying “this is where I end and the next provider or specialist begins” doesn’t always work when specialists or alternative providers are nonexistent or over two hours away by car. That is, if your client has one.
- There are some very concrete things we could do to improve the rural mental health workforce shortage, but that most often, we don’t.
Building a Workforce for Tomorrow
Here is a non-exhaustive list of recommendations for creating a stronger rural mental health workforce.
- Build more rural opportunities into every graduate program that trains mental health providers. Research shows that when students and young professionals are exposed to rural practice and have the support of a supervisor or attending provider, they are more likely to be successful when they graduate and enter practice in a rural setting.
- Recruitment efforts should target students in high schools, community colleges, etc., as research tells us that those who grow up in rural communities are most likely to return to and/or stay in their hometown.
- Build content on the culture of rural mental health practice into graduate program curricula. Studies show that exposure to content about rural practice and its contrast with urban practice is a powerful factor in determining who will explore and sustain a rural practice.
- Use telehealth and establish rural mental health provider networks to connect rural mental health providers for support and consultation.
This fall, I start my fifth year as Assistant Professor of Social Work in a Master of Social Work Program, with a focus on practice in rural and small communities. I am thrilled to be part of an academic community dedicated to improving the rural mental health workforce in Minnesota and in our nation. All of my experience transitioning from an urban to rural practice informs the way I teach my students about rural social work practice.
When we cannot retain and support mental health providers in rural parts of the U.S.—where approximately 20% of our total population currently lives—our small communities suffer the most. We must address our pervasive workforce issues if we wish to make a dent in both the unmet mental health needs, and the chain reaction of other challenges, that so often accompany this reality.
Jennifer Andrashko is an Assistant Professor of Social Work at Minnesota State University, Mankato. She earned a Master of Social Work degree from the University of Minnesota and an undergraduate degree in French and Global Studies at the University of Wisconsin at Eau Claire. Jennifer developed and implemented a primary integrated behavioral health care program at a Federally Qualified Health Center (FQHC) in south-central Minnesota. In this role, she worked as both clinician and administrator providing trauma-informed clinical therapeutic services to clients and leadership to the Behavioral Health Department. She also spent time living in southern France working primarily with low-income, Muslim immigrant adolescents in the public school system.