Counseling Rural Populations

Although there are numerous definitions for the term rural, most often, rural encompasses the geographic and population particulars not accounted for when defining urban (U.S. Census Bureau, 2012). Rural areas are located outside of urbanized areas and clusters (U.S. Census Bureau, para. 1) and typically have a population size of 2,500 or fewer people (U.S. Department of Agriculture Economic Research Service, 2013, para. 2). Frontier areas, a type of rural area, are “the most remote and geographically isolated areas in the United States…usually sparsely populated and in addition to extreme weather, they often face extreme distances and travel time to services of any kind” (National Center for Frontier Communities, 2012, para. 1). The resources listed below can help determine if one’s geographic residence is considered rural.

As of 2010, approximately 19% of the U.S. population resided in a rural area, which encompasses almost 59.5 million people (U.S. Census Bureau, 2013, para. 6). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2009, the percentage of children, adolescents, and adults with mental health concerns was slightly higher in rural or nonmetropolitan areas than in small and large metropolitan areas (SAMHSA, 2012).

Additionally, it was found that “…states with a large proportion of the population living in rural areas had a greater shortage of mental health professionals” and fewer mental health facilities (SAMHSA, 2012, p. 76).

Resources:
National Center for Education Statistics: Urban Education in America: School Locale
Definitions: http://nces.ed.gov/surveys/urbaned/definitions.asp
Office of Management and Budget: List of Rural Counties and Designated Eligible
Census Tracts in Metropolitan Counties: ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf
Rural Assistance Center: Health and Human Services Information for Rural America: Am I Rural?
http://ims2.missouri.edu/rac/amirural/
U.S. Department of Health and Human Services: Health Resources and Services Administration:
Rural Health Grants Eligibility Analyzer: http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvisor. aspx

Cultural Considerations
The Rural Assistance Center (2002-2014) defined rurality as “the quality or state of being rural” (para. 22). Rural communities differ across the United States (Carnes-Holt & Weatherford, 2013; Cohn & Hastings, 2013; Townsend, 2010). For example, rurality may be experienced differently among individuals living in rural Alaska, Appalachia, Missouri, Texas, Florida, and Maine, to name a few. In fact, the results of a study conducted by Sutton and Pearson (2002) indicate that, although similarities do exist, there are many differences between rural communities.

There are distinctive cultural characteristics typically observed in rural areas and among individuals from those areas (Harowski, Turner, LeVine, Schank, & Leichter, 2006). Counseling professionals are charged with the responsibility of being aware of and knowledgeable about their community’s rural culture and/or the cultural characteristics with which their clients identify (Cohn & Hastings, 2013; Smalley et al., 2010). Rural culture may include, but is not limited to, the following characteristics: community interconnectedness, self-reliance, distrust of outsiders, importance of family, pride in the rural community, and religiosity (Sutton & Pearson, 2002; Townsend, 2010). Individuals who live in or are from rural areas are also diverse, representing the interplay of multiple cultural variables (Gifford, Koverola, & Rivkin, 2010; Townsend, 2010). For example, a female client may identify as a lesbian, Hispanic, and with the rural culture of her community.  Therefore, rural culture cannot be deduced to a specific, static set of characteristics but rather is defined by the individuals within and from rural communities.

As with other cultures, discrimination against individuals from rural areas has been identified. Ruralism “involves discrimination on the basis of factors stemming from living in a rural area...a pervasive form of discrimination largely unrecognized, unacknowledged, and unexamined” (Bassett, 2006, p. 944). Ruralism can exist dichotomously with both negative and positive stereotypes abounding.  For example, individuals from rural areas can be described as either backward and uneducated or sweet and innocent. Regardless, both positive and negative stereotypes can reinforce incorrect images of rural areas and individuals (Bassett, 2006). Therefore, counseling professionals are also charged with the responsibility of being aware of any personal biases and assumptions in regards to rurality.

Resources:
Center for Rural Affairs: http://www.cfra.org/
Slama, K. (2004). Rural culture is a diversity  issue. Minnesota  Psychologist. Retrieved from http://www.apa.org/practice/programs/rural/rural-culture.pdf

Additional Considerations
Despite efforts to increase service provision and utilization, presently, there are several barriers to mental health care in rural areas. One barrier is the shortage of mental health professionals (Carnes-Holt & Weatherford, 2013; Cohn & Hastings, 2013; Gifford et al., 2010; Townsend, 2010). In fact, Sutton and Pearson (2002) found that school counselors might be the only mental health resource available in some rural areas. Fortney, Harman, Xu, and Dong (2010) indicated that individuals in rural areas may depend more heavily on psychopharmacotherapy when psychotherapists are unavailable.

Other barriers may be connected to specific cultural characteristics. For example, a distrust of outsiders and stigma associated with seeking mental health services (Cohn & Hastings, 2013; Townsend, 2010) may result in the avoidance or delay of service utilization. For this reason, individuals in or from rural areas may seek services from other professionals or community members. For example, Deen, Bridges, McGahan, and Andrews (2012) indicated that individuals from rural areas “utilized primary care at a slightly higher rate than specialty mental health care...perceived primary care services as more useful and had more favorable outcome expectancies for primary care than for specialty mental health services” (p. 148). Additional barriers to mental health service utilization include a lack of knowledge about the availability or purpose of services, lack of available transportation, inability to pay due to having a low-income or being uninsured, and concerns about privacy (Cohn & Hastings, 2013; Smalley et al., 2010; Townsend, 2010).

Ethical issues may be magnified in rural communities due to the nature of rurality. Counselors may feel a need to practice outside of their areas of competence due to the shortage of mental health professionals in rural communities (Cohn & Hastings, 2013; Weigel & Baker, 2002). There is a higher risk for multiple relationships due to smaller population sizes and community interconnectedness (Cohn & Hastings, 2013; Erickson, 2001; Weigel & Baker, 2002). The confidentiality and privacy of both the rural counselor and client may be jeopardized (Morrissette, 2000; Sutton & Pearson, 2002; Weigel & Baker, 2002). For example, clients may feel uneasy seeking services from a provider who is located in the center of town in fear of being seen or recognized. Additionally, given the heightened visibility of their role as a mental health provider, counselors may be approached when at the grocery store or bank about issues related to their work. Finally, the practice of bartering may be more common in rural communities and, therefore, may arise more frequently during the counseling process (Cohn & Hastings, 2013).

Resources:
Breen, D. J., & Drew, D. L. (2012). Voices of rural counselors: Implications for Counselor
Education and Supervision. VISTAS 2012. Retrieved from http://www.counseling.org/docs/vistas/vistas_2012_article_28.pdf?sfvrsn=3

Rollins, J. (2010). Learning the ropes of rural counseling. Counseling Today. Retrieved from http://ct.counseling.org/2010/04/learning-the-ropes-of-rural-counseling/

Rural Assistance Center: Mental Health Frequently Asked Questions: What are some of the challenges to accessing and providing mental health services in rural areas? What can a community do to minimize these challenges? http://www.raconline.org/topics/mental-health/faqs#challenges

Intervention Strategies

Marketing
The marketing of mental health services is one of the many ways in which counseling professionals can increase awareness in the community about the availability and purpose of services (Cohn & Hastings, 2013; Townsend, 2010). This can be easily accomplished by utilizing the marketing resources available in the community (e.g., the local newspaper, the telephone book, and placing brochures and flyers in local businesses).

Program Development and Implementation
Counseling professionals have the ability to develop and implement programs that are catered to the rural community.  In order to accomplish this, counseling professionals should first assess the existing mental health needs (Smalley et al., 2010). Successful programs in urban communities should not be automatically transferred to rural communities as the needs and characteristics of these communities may be very different.

Collaboration
Collaboration with other professionals and members in the rural community is essential to the success of rural counseling. Interdisciplinary collaboration with primary care providers, school personnel, and religious leaders, among others, can provide a referral network and promote the successful coordination of care (Cohn & Hastings, 2013; Myers & Gill, 2004; Smalley et al., 2010; Townsend, 2010). Additionally, collaborating with community members can help familiarize rural counseling professionals with the culture and help market the available services by word-of-mouth (Morrissette, 2000; Smalley et al., 2010; Weigel & Baker, 2002).

Generalist Counseling
Counseling professionals who are preparing or currently working in rural communities should take measures to become competent generalist providers. This may include utilizing a wide range of service delivery methods (e.g., psychoeducational workshops, peer mentoring programs) as well as nontraditional approaches for service provision (e.g., using technological mediums, in-home counseling; Fortney et al., 2010; Smalley et al., 2010; Townsend, 2010; Weigel & Baker, 2002).

Strength-Based, Holistic Therapeutic Approaches
When deciding which therapeutic approaches/interventions to utilize, counseling professionals should take into account the cultural characteristics with which the client identifies. For example, using a strength-based, holistic approach that is focused on wellness can build on many of the cultural characteristics of rurality (i.e., self-reliance, religiosity; Gill, Barrio Minton, & Myers, 2010; Myers & Gill, 2004).

Advocacy
Counseling professionals who work within and outside rural communities should participate in advocacy efforts to increase the provision of available resources, financial and otherwise. Specific advocacy initiatives could include recruiting counseling professionals for work in rural communities, providing training opportunities to students and professionals to increase rural counseling competence, offering workshops to prepare potential counseling professionals for life in rural communities, writing letters to state representatives regarding the need for additional resources, and presenting at local, state, and national conferences, among others (Bradley, Werth, & Hastings, 2012; Carnes-Holt & Weatherford, 2013; Gifford et al., 2010; Harowski et al., 2006; Morrissette, 2000; Myers & Gill, 2004; Smalley et al., 2010; Townsend, 2010).

Resources:
Contemporary  Rural Social Work: http://journal.und.edu/crsw/index

Gustafson, D. T., Preston, K., & Hudson, J. (2009). Mental health: Overlooked and disregarded in rural America. Lyons, NE: Center for Rural Affairs. Retrieved from http://files.cfra.org/pdf/Mental- Health-Overlooked-and-Disregarded-in-Rural-America.pdf

Journal of Rural Community Psychology: http://www.marshall.edu/jrcp/ National Association for Rural Mental Health: http://www.narmh.org/

National Board for Certified Counselors Foundation: Rural Scholarships: http://www.nbccf.org/rural

National Rural Health Association: http://www.ruralhealthweb.org/

Shepard, B., & Quressette, S. (2010). Possible selves mapping intervention: Rural women and beyond. VISTAS 2010. Retrieved from http://www.counseling.org/docs/vistas/vistas_2010_article_51.pdf?sfvrsn=3