While mental health services are in short supply throughout the country, rural residents have long faced significant access disparities. For historically marginalized populations, these provider availability struggles compound other longstanding health inequities as well as potential cultural stigma around mental health topics. As the country's rural areas become more racially and ethnically diverse, it's imperative to address these growing mental healthcare needs in culturally humble ways.
Widespread mental healthcare access challenges
Nationwide, there are numerous reasons why people are unable to address their mental health needs. A 2022 Access to Care Survey, which was conducted on behalf of the National Council for Mental Wellbeing, pointed to barriers ranging from wait times and proximity to providers to a lack of diversity in these positions.
These challenges are further complicated in rural areas. For one, there are well-documented provider shortages. Mental health providers are not equally spread across the country, with some estimates pointing to 65% of nonmetropolitan counties not having a psychiatrist. Even for those willing to travel for care, there can be transportation and cost hurdles.
More demand, less mental health providers
Too often, areas that require the most mental healthcare have the least number of providers. This interactive map from the American Psychological Association shows the distribution of psychologists by county as well as that county's drug overdose mortality rates and suicide rates.
Choosing Robeson County, North Carolina on the map, the display reveals a low distribution of psychologists and high drug overdose mortality rates. That county is not alone in this concerning coupling of high need and low mental health service availability. In fact, the pattern persists throughout many of the country's rural regions.
Privacy as a barrier to rural mental healthcare
Access challenges aren't the only hurdle to seeking mental healthcare in these communities. Stigma, or the feeling of shame and negativity surrounding this kind of care, can also play a role.
Imagine a small community where everyone seems to know everyone else. Maybe their children go to school together, they attend the same church, or they regularly encounter neighbors while running errands. While these social connections can improve wellbeing, they can also create privacy concerns.
The lack of anonymity can pose a hurdle to seeking mental health treatment in rural areas, according to findings described in a brief from the Rural Health Information Hub, a clearinghouse on rural health issues funded by the Federal Office of Rural Health Policy. Rural residents may experience embarrassment if friends, family or coworkers see them walk into a mental health clinic. In small communities, the provider may also be known in the community as a friend or associate, creating awkward feelings about sharing personal information.
These fears may deter people from seeking care altogether.
Ours is an increasingly diverse population
These well-documented mental health access and utilization gaps that persist throughout the country are even more prevalent when one considers historically marginalized communities. In fact, a review of academic publications on the topic found “mental health is one of the most underused services in healthcare, particularly in underrepresented minority communities."
There is a pressing need to address these compounded inequities.
The 2020 Census reported 24% of rural Americans were people of color. The median rural county saw a 3.5 percentage point increase from the 2010 census, according to a 2021 Brookings Group analysis of census data. In some 10% of rural counties, those figures are considerably higher with the majority of the population people of color, the group found. This is especially the case in rural counties in the South and West of the country.
Compounding health inequities in rural mental health
Rural residents often face numerous health gaps when compared to urban peers, inequities that widen when also considering one's race and ethnicity. For example, rates of premature death are higher among rural residents compared to their urban counterparts, according to the Rural Health Research Gateway, a group that compiles research from rural health centers nationwide.
In addition to those rural/urban differences, the rates of premature death are greater for people of color compared to white residents, the report adds.
Finding diverse rural mental health providers
In many of these places, it may be challenging to find a provider who shares the same cultural background as the patient.
“With fewer mental health provider options, it may be more difficult for ethnic and racial minority patients living in rural America to find providers who share or understand their culture," according to the Rural Health Information Hub. “As a result, it is particularly important for rural mental health providers to work toward being culturally competent."
Cultural humility can help address rural mental health treatment gaps
Having a provider with a similar cultural background can create a sense of trust and openness, breaking down barriers to care and communication. But that doesn't mean providers and patients need to share the same race or ethnicity. Differences can be bridged by using a culturally humble approach to care, approaching new patients with interest and curiosity.
Cultural humility does not mean a provider must understand everything about a culture and its history and traditions. Instead, this approach refers to the creation of an ongoing, non-hierarchical relationship between patient and provider. It involves a commitment to listening and paying attention to underlying factors that may have shaped one's impressions of mental healthcare. These may include stigma, cultural values, spiritual beliefs and even a historic lack of access to care.
With cultural humility, the provider approaches the patient with a sense of genuine curiosity and empathy, considering the role people's distinct life experiences may have played in shaping their mental health needs.
The long-lasting impact of historic trauma
Asking questions and approaching patients with a sense of humility, respect and empathy can lead to a heightened understanding of the experiences that may have created psychological trauma and led to mental health struggles such as substance abuse.
For example, American Indian and Alaska Native populations have disproportionately high rates of mental health problems compared to the U.S. population overall, according to the American Psychiatric Association. These high rates of substance abuse disorders, posttraumatic stress disorder, suicide and attachment disorders “have been directly linked to the intergenerational historical trauma forced upon them…" the organization describes in a brief on mental health and disparities.
This trauma includes “forced removal off their land and government-operated boarding schools which separated AI/AN children from their parents, spiritual practices, and culture," according to the report.
Consider language barriers
Considering someone's preferred language is also an important facet in culturally humble mental healthcare.
Even though a patient may be proficient in English-language communication, they might struggle to express feelings in their non-native tongue. A humble care approach may also consider the fact that words people use to express mental health needs can have cultural roots and meanings.
For example, differences in language may impact how treatment is discussed, points out a tip sheet from NAMI, the National Alliance on Mental Illness. In many indigenous languages, words such as “depressed" and “anxious" do not exist, the group notes.
Harnessing a community's strengths
An approach of cultural humility can also help in addressing the community's overall mental health needs – and address possible stigma. Understanding the connections and social fabric of a community can help create outreach pathways in places where people feel the most trust and comfort.
In many rural communities, there are strong roots in the faith community. Informal mental health communication may already exist in the form of pastors communicating with community members, asking questions about how they're handling recent events and life experiences, monitoring how they're faring in times of need.
A culturally humble approach to care might build on those strong, established connections. Faith leaders demonstrating trustworthiness and compassion may bridge access care gaps in areas that don't have a strong mental health infrastructure.
Use existing community supports to improve rural mental health services
Considering these existing community frameworks and peer networks can also help in addressing stigma. One might look at the role a church community could have in breaking down mental health barriers and engaging its members. What approaches might generate a sense of trust and acceptance when seeking mental health help?
There are many more ideas to explore, including efforts to integrate mental health services with primary care clinics in underserved areas, a holistic approach that has experienced some well-documented successes. When considering these idea and approaches, it is important to use culturally sensitive lens that builds on a community's strengths while understanding its history.