Abstract
This manuscript reviews the unique challenges, barriers, and ethical implications of providing mental health services in rural and underserved areas. Community mental health centers in rural areas are often underserved due to shortages of mental health providers and limited resources. Individuals living in rural areas are at increased risk of developing mental health condition with limited access to mental health clinicians and healthcare facilities. These access to care issues are often exacerbated by geographical barriers as well as social, cultural, and economic challenges. A rural mental health professional may encounter several barriers to providing adequate care to individuals living in rural areas. For example, limited services and resources, geographic barriers, conflict between professional guidelines and community values, managing dual relationships, and challenges pertaining to confidentiality and privacy are several barriers to providing adequate care in rural areas. We will briefly summarize the primary ethical domains that are especially influenced by rural culture and the complex responsibilities of mental health providers in rural areas including barriers to care, crisis intervention, confidentiality, multiple relationships/dual roles, limits of competency, and rural mental healthcare practice implications.
References
American Farm Bureau Federation (2020). Impact of COVID-19 on Rural Mental Health. https://www.fb.org/files/Impacts_of_COVID-19_on_Rural_Mental_Health_1.6.21.pdf
American Psychological Association (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/index.aspx
Barbopoulos, A., & Clark, J. M. (2003). Practicing psychology in rural settings: Issues and guidelines. Canadian Psychology, 44(4), 410–424. https://doi.org/10.1037/h0086962.
Bischoff, R. J., Reisbig, A. M., Springer, P. R., Schultz, S., Robinson, W. D., & Olson, M. (2014). Succeeding in rural mental health practice: Being sensitive to culture by fitting in and collaborating. Contemporary Family Therapy, 36(1), 1–16. https://doi.org/10.1007/s10591-013-9287-x.
Bolin, J. N., Mechler, K., Holcomb, J., & Williams, J. (2008). An alternative strategy for resolving ethical dilemmas in rural healthcare. The American Journal of Bioethics, 8(4), 63–65. https://doi.org/10.1080/15265160802147231.
Boydell, K. M., Pong, R., Volpe, T., Tilleczek, K., Wilson, E., & Lemieux, S. (2006). Family perspectives on pathways to mental health care for children and youth in rural communities. The Journal of Rural Health, 22(2), 182–188.
Brems, C., Johnson, M. E., Warner, T. D., & Roberts, L. W. (2006). Barriers to healthcare as reported by rural and urban interprofessional providers. Journal of interprofessional care, 20(2), 105–118. https://doi.org/10.1080/13561820600622208.
Brenes, G. A., Danhauer, S. C., Lyles, M. F., Hogan, P. E., & Miller, M. E. (2015). Barriers to mental health treatment in rural older adults. The American Journal of Geriatric Psychiatry, 23(11), 1172–1178. https://doi.org/10.1016/j.jagp.2015.06.002.
Bureau of Health Workforce. (2021). Designated health professional shortage areas statistics: Third quarter of fiscal year 2021. U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport.
Bushy, A. (2009). Rural health care ethics: A landscape view of life and health care in rural settings. In W. A. Nelson (Ed.), Handbook for rural health care ethics: A practical guide for professionals (pp. 13–41). University Press of New England.
Campbell, C. D., & Gordon, M. C. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional psychology: Research and practice, 34(4), 430.
Center for Disease Control and Prevention (2017, October 5). Americans in rural areas are more likely to die by suicide [Press release]. https://www.cdc.gov/media/releases/2017/p1005-rural-suicide-rates.html
Center for Behavioral Health Statistics and Quality (2017). 2016 national survey on drug use and health: Detailed tables. U.S. Department of Health and Public Safety, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
Chandrasekhar, J. L., Bowen, A. E., Heberlein, E., Pyle, E., Studts, C. R., Simon, S. L., Shomaker, L., & Kaar, J. L. (2023). Universal, school-based mental health program implemented among racially and ethnically diverse youth yields equitable outcomes: Building resilience for healthy kids. Community mental health journal, 1–10.
Compton, M. T., Broussard, B., Hankerson-Dyson, D., Krishan, S., Stewart, T., Oliva, J. R., & Watson, A. C. (2010). System-and policy-level challenges to full implementation of the Crisis intervention team (CIT) model. Journal of Police Crisis Negotiations, 10(1–2), 72–85. https://doi.org/10.1080/15332581003757347.
Dingle, A. D., Fernandez, F., & de Erausquin, G. A. (2022). Developing a rural psychiatry training program on the Texas-Mexico border: A chance for innovation. Community mental health journal, 1–7.
Dobis, E. A., Krumal, T. P., Cromartie, J., Conley, K. L., Sanders, A., & Ortiz, R. (2021). 2021 edition rural America at a glance (Bulletin No. 230). U.S. Department of Agriculture, Economic Research Service. https://www.ers.usda.gov/webdocs/publications/102576/eib-230.pdf?v=4409#:~:text=The%2046%20million%20U.S.%20residents,23%2C000%20people%20compared%20with%20245%2C000.
Eisenreich, R., & Pollari, C. (2021). Addressing higher risk of suicide among farmers in rural America. National Rural Health Association. https://www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/NRHA-Policy-Brief-Increases-in-Suicide-Rates-Among-Farmers-in-Rural-America.pdf
Gale, J. A., Shaw, B., Hartley, D., & Loux, S. (2010). The provision of mental health services by rural health clinics (Working Paper No. 43). Portland: Maine Rural Health Research Center. Retrieved from http://muskie.usm.maine.edu/Publications/rural/WP43/Rural-Health-Clinics-Mental-Health-Services.pdf
Han, X., & Ku, L. (2019). Enhancing staffing in rural community health centers can help improve behavioral health care. Health Affairs, 38(12), 2061–2068.
Hastings, S. L., & Cohn, T. J. (2013). Challenges and opportunities associated with rural mental health practice. Journal of Rural Mental Health, 37(1), 37. https://doi.org/10.1037/rmh0000002.
Hirko, K. A., Kerver, J. M., Ford, S., Szafranski, C., Beckett, J., Kitchen, C., & Wendling, A. L. (2020). Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. Journal of the American Medical Informatics Association, 27(11), 1816–1818.
Hughes, M. C., Spana, E., & Cada, D. (2022). Developing a needs Assessment process to address gaps in a local system of Care. Community Mental Health Journal, 58(7), 1329–1337.
Jameson, J. P., & Blank, M. B. (2007). The role of clinical psychology in rural mental health services: Defining problems and developing solutions. Clinical Psychology: Science and Practice, 14(3), 283. https://doi.org/10.1111/j.1468-2850.2007.00089.x.
Jensen, E. J., Wieling, E., & Mendenhall, T. (2020). A phenomenological study of clinicians’ perspectives on barriers to rural mental health care. Journal of Rural Mental Health, 44(1), 51. https://doi.org/10.1037/rmh0000125.
Johansson, P., Blankenau, J., Tutsch, S. F., Brueggemann, G., Afrank, C., Lyden, E., & Khan, B. (2019). Barriers and solutions to providing mental health services in rural Nebraska. Journal of Rural Mental Health, 43(2–3), 103. https://doi.org/10.1037/rmh0000105.
Kee, J. A., Johnson, D., & Hunt, P. (2002). Burnout and social support in rural mental health counselors. Journal of Rural Community Psychology, 5(1), 1–16.
Knutson, D., Irgens, M. S., Flynn, K. C., Norvilitis, J. M., Bauer, L. M., Berkessel, J. B., & Zlokovich, M. S. (2023). Associations between Primary Residence and Mental Health in Global marginalized populations. Community Mental Health Journal, 1–14.
Komiti, A., Judd, F., & Jackson, H. (2006). The influence of stigma and attitudes on seeking help from a GP for mental health problems. Social psychiatry and psychiatric epidemiology, 41(9), 738–745. https://doi.org/10.1007/s00127-006-0089-4.
Lin, C., Pham, H., & Hser, Y. I. (2023). Mental health service utilization and disparities in the US: Observation of the first year into the COVID pandemic. Community Mental Health Journal, 1–14.
Lombardi, B. M., de Saxe Zerden, L., & Greeno, C. (2022). Federally qualified Health Centers Use of Telehealth to deliver Integrated behavioral Health Care during COVID-19. Community Mental Health Journal, 1–9.
Matias, T., Dominski, F. H., & Marks, D. F. (2020). Human needs in COVID-19 isolation. Journal of Health Psychology, 25(7), 871–882.
Moore, T., Sutton, K., & Maybery, D. (2010). Rural mental health workforce difficulties: A management perspective. Rural and Remote Health, 10(3), 1519. https://doi.org/10.22605/RRH1519.
National Institute of Mental Health (n.d.). Office for disparities research and workforce diversity (ODWD). https://www.nimh.nih.gov/about/organization/od/office-of-rural-mental-health-research-ormhr
Nelson, W. A. (2009). Rural health care ethics: Introduction. In W. A. Nelson (Ed.), Handbook for rural health care ethics: A practical guide for professionals (pp. 3–12). University Press of New England.
Pettrone, K., & Curtin, S. C. (2020). Urban-rural differences in suicide rates by sex and three leading methods: United States, 2000–2018 (data brief). National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db373-h.pdf
Pomerantz, A. (2009). Common ethics issues in rural communities: Ethics conflicts in rural communities: Overlapping roles. In W. A. Nelson (Ed.), Handbook for rural health care ethics: A practical guide for professionals (pp. 108–205). University Press of New England.
Rural Health Information Hub (2018). Rural mental health. https://www.ruralhealthinfo.org/topics/mental-health
Rural Health Information Hub (2019a). Defining mental health in rural communities. https://www.ruralhealthinfo.org/toolkits/mental-health/1/definition
Rural Health Information Hub (2019b). Barriers to mental health treatment in rural areas. https://www.ruralhealthinfo.org/toolkits/mental-health/1/barriers
Rural Health Information Hub (2020). School based health centers. https://www.ruralhealthinfo.org/toolkits/sdoh/2/healthcare-settings/school-based-health-centers
Rural Health Information Hub (2021). Federally qualified health centers (FQHCs) and the health center program. https://www.ruralhealthinfo.org/topics/federally-qualified-health-centers
Sherman, M. L., Barnum, D. D., Buhman-Wiggs, A., & Nyberg, E. (2009). Clinical intake of child and adolescent consumers in a rural community mental health center: Does wait-time predict attendance? Community Mental Health Journal, 45, 78–84.
Siantz, E., Hiller, S., Ojeda, V. D., & Gilmer, T. P. (2022). Barriers to accessing Mental Health Care under the Mental Health Services Act: A qualitative case study in Orange County, California. Community Mental Health Journal, 1–10.
Slama, K. (2004). Rural culture is a diversity issue. Minnesota Psychologist, 53(1), 9–12.
Steelesmith, D. L., Fontanella, C. A., Campo, J. V., Bridge, J. A., Warren, K. L., & Root, E. D. (2019). Contextual factors associated with county-level suicide rates in the United States, 1999 to 2016. JAMA network open, 2(9), https://doi.org/10.1001/jamanetworkopen.2019.10936.
Stuber, J., Rocha, A., Christian, A., & Johnson, D. (2014). Predictors of recovery-oriented competencies among mental health professionals in one community mental health system. Community mental health journal, 50, 909–914.
Substance Abuse and Mental Health Services Administration (2018). National mental health services survey (N-MHSS): 2018. Data on Mental Health Treatment FacilitiesU.S. Department of Health and Human Services. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NMHSS-2018.pdf
Summers-Gabr, N. M. (2020). Rural–urban mental health disparities in the United States during COVID-19. Psychological Trauma: Theory Research Practice and Policy, 12(S1), S222. https://doi.org/10.1037/tra0000871.
Swinton, J. J., Robinson, W. D., & Bischoff, R. J. (2009). Telehealth and rural depression: Physician and patient perspectives. Families Systems & Health, 27(2), 172. https://doi.org/10.1037/a0016014.
Tarlow, K. R., McCord, C. E., Du, Y., Hammett, J., & Wills, T. (2020). Rural mental health service utilization in a Texas telepsychology clinic. Journal of clinical psychology, 76(6), 1004–1014. https://doi.org/10.1002/jclp.22903.
Tummala, A., & Roberts, L. A. (2009). Common ethics issues in rural communities: Ethics conflicts in rural communities: Stigma and illness. In W. A. Nelson (Ed.), Handbook for rural health care ethics: A practical guide for professionals (pp. 186–206). University Press of New England.
Turner, E., Cheng, H. L., Llamas, D., Tran, J. G. T. T., Hill, A. X., Fretts, K. M., J., & Mercado, A. (2016). Factors impacting the current trends in the use of outpatient psychiatric treatment among diverse ethnic groups. Current Psychiatry Reviews, 12(2), 199–220. https://doi.org/10.2174/1573400512666160216234524.
Wagenfeld, M. O. (2003). A snapshot of rural and frontier America. In B. H. Stamm (Ed.), Rural behavioral health care: An interdisciplinary guide (pp. 33–40). American Psychological Association. https://doi.org/10.1037/10489-000
Weaver, K. E., Geiger, A. M., Lu, L., & Case, L. D. (2013). Rural-urban disparities in health status among US cancer survivors. Cancer, 119(5), 1050–1057. https://doi.org/10.1002/cncr.27840.
Werth, J. L. Jr., Hastings, S. L., & Riding-Malon, R. (2010). Ethical challenges of practicing in rural areas. Journal of Clinical Psychology, 66(5), 537–548. https://doi.org/10.1002/jclp.20681.
Williams, C. (2021). Using the hub and spoke model of telemental health to expand the reach of community based care in the United States. Community Mental Health Journal, 57(1), 49–56.
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All authors contributed to and certify responsibility for the manuscript. Conceptualization and idea generation: Alfonso Mercado, Julia Takishima-Lacasa, and Emily Selby-Nelson; Writing – literature search and original draft preparation: Amanda Palomin; Writing – review and editing: Alfonso Mercado, Julia Takishima-Lacasa, Emily Selby-Nelson, and Amanda Palomin; Supervision: Alfonso Mercado. All authors read and approved the final manuscript.
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Palomin, A., Takishima-Lacasa, J., Selby-Nelson, E. et al. Challenges and Ethical Implications in Rural Community Mental Health: The Role of Mental Health Providers. Community Ment Health J 59, 1442–1451 (2023). https://doi.org/10.1007/s10597-023-01151-9
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DOI: https://doi.org/10.1007/s10597-023-01151-9