05 Jun 2017

Brighter Horizons for Rural Psychology

Brighter Horizons for Rural Psychology

APA's focus on rural communities continues to improve access for underserved populations.

Rural clients face barriers that can make accessing behavioral health services particularly challenging — not just tangible ones like physical distance and lack of time, transportation and insurance, but a stoical culture that emphasizes self-reliance and a related stigma about using mental health care. 

"Their personal needs tend to get put on the back burner," says Emily Selby-Nelson, PsyD, a clinical psychologist who works at Cabin Creek Health Systems, a federally qualified health center with several locations in rural West Virginia.

Thanks to her rural psychology training, though, Selby-Nelson is well versed in the nature of these problems — and the system she works in helps to effectively address them.

Cabin Creek Health Systems uses integrated primary-care services, a patient-centered approach, integrated electronic medical records and an understanding that behavioral factors can play a major role in health outcomes. As a consequence, patients see Selby-Nelson as a health-care professional who can help them sort out their problems in a brief chat after a visit with their primary care physician, rather than as a stranger intent on analyzing their mental health issues.

What's more, because the system receives federal funds and grants to serve underserved populations, Selby-Nelson's clients aren't as worried about payment or billing concerns. And thanks to technology's ability to connect people and resources, she participates in a full range of professional activities — conducting research, training future rural integrated-care psychologists, and serving in professional leadership roles.

Selby-Nelson's practice is a striking example of how far rural psychology has come in the last few decades. While rural practitioners still face challenges like professional isolation and navigating multiple relationships, mental and behavioral health are becoming a more vital and embedded part of rural health care, thanks in part to psychologists' efforts (see sidebar for a short history).

In fact, rural practice has sometimes led the charge toward more progressive forms of health care, says Paul L. Craig, PhD, a neuropsychologist in Anchorage, Alaska, and longstanding advocate for improved mental health care in rural areas.

"Rural settings have been in the vanguard of demonstrating the viability and efficacy of integrated care," he says.

Expanding care 

Perhaps the greatest boon to rural health care has been the National Health Service Corps, or NHSC, the federal program that repays the student loans of health-care providers who work in underserved areas. Since 2002, 263 psychologists have completed the program.

Today, there are 3,277 NHSC mental health providers in service nationwide. A 2012 survey found that 82 percent of all health-care providers stayed on for at least a year after completing their service commitment, while 61 percent of mental health providers continued to work at the site four years after service completion.

"The program gives people access to mental health services and help they would otherwise not have received," says Darryl Salvador, PsyD, a former chair of the APA Committee on Rural Health who now serves on the national advisory committee for the NHSC. "The presence of these providers has probably saved lives and prevented the higher use of services, like hospitalizations." Such services can be especially costly, he adds, if people have to be flown to external facilities because their own community lacks such services.

Salvador worked as an NHSC loan repayment clinician for a federally qualified health center in rural Hawaii from 2007 to 2011, treating depression, anxiety, substance abuse and post-traumatic stress related to familial abuse. Before coming to the center and learning that a behavioral health clinician was available to treat them, many of these clients had never been treated or had been treated inadequately for such conditions, he says.

"I felt like I was really making a difference," says Salvador.

Innovative programs 

Rural psychologists also have been responsible for adding behavioral components into rural health efforts. Salvador, for example, helped his rural clients learn behavioral strategies to better manage their diabetes and to stop smoking. Diana L. Prescott, PhD, of Hamden, Maine, also a former chair of the APA rural health committee, developed the integrated behavioral health portion of the pediatric obesity program The Way to Optimal Weight, or WOW. Preliminary data show it has helped obese children lose weight and improve their quality of life.

At the Southcentral Health Foundation in Anchorage, Alaska, psychologists have taken an even broader view of helping the community. The facility offers a combination of integrated health and social services to improve family and community well-being, including programs on domestic violence, abuse and neglect, among other issues. The foundation reports that its outreach has helped to reduce emergency room visits by 53 percent and specialty care visits by 65 percent — all while earning a 90 percent consumer satisfaction rating.

Rural psychologists are also leading the way in the use of technology to expand care. In a 2015 article in Training and Education in Professional Psychology, for example, Matt J. Gray, PhD, of the University of Wyoming, and colleagues reported that providing videoconferencing sessions to victims of sexual assault or domestic violence was just as effective as providing in-person sessions. The intervention led to about a 60 percent drop in post-traumatic stress symptoms and a 50 percent drop in depressive symptoms from before to after treatment, as well as consistently high treatment satisfaction, the team found.

The technology helped all of the parties involved, Gray says, adding, "It's a really symbiotic relationship." His students who provide the teleconferencing sessions have a chance to use their treatment skills with more people; off-site clients receive free expert interventions they otherwise wouldn't have gotten; and the staff at crisis centers — who are often overextended and underfunded and whose first expertise is practical rather than psychological help — can link their clients with needed services, he says.

Rural psychologists were also the lead authors of another recent study that supports telehealth's ability to expand access to quality care. A 2015 pilot project found that children in rural Kentucky whose parents participated in an evidence-based group parenting program via videoconference and telephone improved to the same extent as kids whose parents received the program in person. The children improved on measures of internalizing symptoms, such as depression and withdrawal, and externalizing ones, such as aggression and hyperactivity (Psychological Services, 2015).

"The technology does not seem to alter or disrupt the factors or processes that make any psychological intervention helpful," says the study's lead author, Robert J. Reese, PhD, of the University of Kentucky.

Forward thinking 

Psychologists also are weighing in on new challenges in rural areas. One example is hydrofracking: APA's Committee on Rural Health is starting to examine the psychological toll industry practices may be having on small, underserved communities. Anecdotal reports suggest that a variety of ills can accompany the financial gains of fracking, including contaminating water and overcrowding schools and other infrastructures that are unable to properly accommodate new arrivals, says Iva GreyWolf, PhD, a member of APA's rural committee who is spearheading the group's hydrofracking effort.

"When you have people with high poverty and you're offering them an oil lease, it's hard for them to say no," despite the unknown consequences, she says.

Similarly, new drug problems are cropping up in rural areas, with heroin a dangerous and increasingly ubiquitous arrival, and psychologists are working to determine the best treatments (see the February Monitor).

Working to address such problems and improve care for underserved people is "a beautiful opportunity for psychologists," says Prescott.

By Tori DeAngelis

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