By Matthew Roe
There are approximately six and a half million people living within the rural United
States today that have a mental illness of some kind, who also have inadequate access
and sometimes an unqualified number of mental health resources and practitioners
(Morales et al., 2020). Oklahoma is ranked third in the country for any form of mental
illness, second in the country for substance abuse disorders, and second again for
serious types of mental illness (Brosi, 2020). This puts almost one million Oklahomans
with some form of mental health issue (Brosi, 2020) they’re fighting consistently and due
to the lack of resources and care available in many of these rural areas they live, they
do so often alone and with little to no help at all. As of 2022, there are only an estimated
14,000 licensed individuals capable of providing mental health services within the state
(Healthy Minds Policy Institute, 2022). This puts not only a massive strain on the
already existing infrastructure but makes it almost impossible to properly treat and help
everyone who needs it in a timely or even appropriate way to make any major difference
within our communities.
The United States Census Bureau defines a rural location as anything not
considered urban, which is a population of 5,000 or more people or at least 2,000
housing units (U.S. Census Bureau, 2023). This puts much of Oklahoma within the
definition of being rural with the exception of a few major areas throughout the state and
presents a unique set of challenges for mental health practitioners as a whole.
Considering there are only slightly more than 600 practicing psychologists and slightly
more than 700 practicing Psychiatrists with an M.D. or D.O. only registered in the state
(Healthy Minds Policy Institute, 2022), this puts the entire state of Oklahoma at a
Rural Oklahoma Mental Health
significant deficit in mental health professional’s capable of providing care and
diagnosing serious types of mental illness, with even less working within these rural
areas.
Barriers To Mental Healthcare
The lack of licensed professionals are just one aspect of rural areas getting
proper help and treatment, there’s a variety of barriers that are still keeping people from
treatment such as social stigma, transportation, cost of care, and a lack of privacy due
to such a small community are just a handful of things (University of Minnesota Rural
Health Research Center and NORC Walsh Center for Rural Health Analysis, 2019).
This brings in even more problems when you start accounting for unqualified
professionals or a lack of them within the area, it can quickly become too much for any
practitioner in the area and simply just not enough to cover the whole community.
Stigmatization
There are a total of four different forms of stigmatization according to previous
researchers which are (a) social, (b) self, (c) professional, and (d) cultural (Chatmon,
2020). While each one of these are relatively different from one another they all will
ultimately play a role together because of the increased amount of social (Chatmon,
2020), professional, and cultural stigmatization that one experiences, they’re going to be
more likely to also self stigmatize and downplay the actual amount of help they might
need. This is something that can affect anyone though, like construction workers (Eyllon
et al., 2020), fire departments (Johnson et al., 2020), law enforcement (Park, 2022), and
military agencies (Er & Duyan, 2023). This is especially problematic within rural areas
Rural Oklahoma Mental Health
who seem to have a slightly higher stigma surrounding mental health care as a whole
compared to more urban based areas (Rural Health Information Hub, 2021).
Social Originating Stigmatization
Social Stigma in this case is referring to the negative and disapproving attitudes
towards mental illness based on the assumption of the person struggling having weak
character (Chatmon, 2020). As previously mentioned, rural areas tend to experience
significantly more areas of social stigmatization within their communities with a lot of the
reasoning being because of how small and well known people are within one, it makes it
hard to have proper treatment privately.
Cultural Originating Stigmatization
Cultural stigma is referring to the way each individual culture might interpret and
view those with mental illness (Chatmon, 2020). This can lead to the stigmatization of
certain diseases, disabilities, or illnesses based on any number of culturally relevant
views and make it difficult to not only ask for help, but also get the right help based on
or despite those cultural views. This can be difficult enough in urban environments
where there is a higher number of psychologists or counselors available to work with the
public but especially harder within the scope of rural areas due to a more frequent rate
of not just cultural stigmatization but socially as well. This can be even harder to
manage when you take into account how diverse rural areas actually can be, so having
an understanding of how the different cultures within that society, regardless of if its
seen as a moral failing, a punishment from god, or just due to the person not being
strong willed or to weak enough to overcome it (Ahad, 2023).
Professional Originating Stigmatization
Rural Oklahoma Mental Health
Professional stigmas actually come from and reinforced by health professionals
to their clients within any given area (Chatmon, 2020) and while it might be slightly
uncommon, it does happen and can be especially damaging for those who are also
actively working in the field (Brower, 2021). As Dr. Brower mentioned in his paper, this
is something that consistently plagues medical professional’s in all fields and is actively
harmful to not just their clients and patients, but their own working environment, the
health of their employees, and themselves.
Self Originating Stigmatization
Self stigma is the result of an individual internalizing the other external
stigmatizations and can often result in the person being unable, or unwilling, to come
forward and seek treatment for their mental health (Chatmon, 2020). This becomes
even more problematic when the individual’s cultural, professional, and societal
versions of stigma all clash against each other within various settings that can make it
difficult for the mentally ill individual to fully process and get help within rural areas
where each of these different versions seem to have higher rates of stigma associated
in all forms (Rural Health Information Hub, 2021).
The Four A’s Of Rural Practices
Stigmatization isn’t the only barrier rural communities face in getting treatment,
there are four other aspects to consider as well which are affordability, accessibility,
availability, and finally acceptability (Garrison, 2022; Rural Health Information Hub,
2021). In some cases, these are going to be an even bigger deciding factor on the help
one is able to receive and the stigmatization of getting treatment will be less of an issue
when these are present.
Rural Oklahoma Mental Health
Affordability
The affordability of treatment is probably the worst factor to overcome and will
definitely affect the accessibility of treatment for the person (Garrison, 2022). In the
United States, over half of those with mental illness were unable to afford treatment with
just under 47% of the 158,000 Oklahoman’s were unable to get treatment due to costs
(National Alliance on Mental Illness, 2021) and this becomes an even bigger problem
when you consider roughly 15% of those in the state are uninsured. This means, even
with insurance the mental health services within Oklahoma are still unaffordable to
almost 30% of those who need it.
Accessibility
According to Mary Garrison, the accessibility of mental health services are
referring to an individual's knowledge of how, when, and where to obtain those services
to begin with (Garrison, 2022) which can be rather problematic within rural communities
due to things like stigmatization being a common barrier to begin with and the already
lacking infrastructure for these services present. Recent studies have shown that the
older generation were just as likely as the younger to seek mental health treatment
when the problems were known to be psychological in nature (Knight & Winterbotham,
2020) which hints that the rural population’s lack of mental health treatment isn’t limited
to just affordability, but also just understanding when a problem requires mental health
treatment and how to seek help in the first place.
Availability
Availability is another significant barrier to mental health care within rural
communities. In the United States, half of the counties with populations of 2,500 to
Rural Oklahoma Mental Health
20,000 don't have any type of master or doctoral level social worker or psychologist
available within communities (Hastings & Cohn, 2013). In Oklahoma alone, over 1.5
million people don’t have enough practitioners in their communities which makes it even
harder to get help when you have to travel around the area to do so. With 15.8% of
Oklahoman’s being in the poverty level (Shrider & Creamer, 2023) this puts an even
greater burden and cost to treatment due to their inability to travel around as freely to
receive care in those areas who do have practitioners.
Acceptability
The acceptability of a practitioner within rural communities isn’t just limited to
stigma though and in this regard, Garrison says it’s about the constant issues and
negative perceptions that are surrounding the need for mental health services
(Garrison, 2022). This goes beyond the typical views of stigmatization because while
some cultures might not look down on the mental health problems themselves,
receiving professional help rather than just “talking it out” with family or friends can also
be a barrier for someone with some cultures maintaining an attitude of “keeping it in the
family” and leaving outside influences away from discussions surrounding health and
family matters (Augsberger et al., 2015). Within many small towns though, it’s common
for people to just bump into each other while out and about and just as common for
someone to see someone heading into somewhere which can limit the perception of
acceptability by the individual, which can be another form of self-stigmatization. Not
understanding the town’s culture as a whole, including the sub-cultures within them like
religious, sexual orientation, and racial cultures can also warp the acceptability of
mental health care as a whole and will risk running off people who might otherwise be
Rural Oklahoma Mental Health
open to receiving care. This can further lead to the perception of the practitioner being
incompetent, regardless of the factuality of those views (Garrison, 2022).
Filling The Void
In order for rural citizen’s to be able to get the care they need, it’s important to
consider multiple avenues of support for them to choose from based on what they find
comfortable and culturally relevant. This can be done through different options like
telehealth and internet based services, creating workshops on and offline in order to
teach skills relevant to the individuals, creating media campaigns locally and
incorporating social media to help boost awareness, as well as different forms of play
therapy and weekend retreat style approaches could be effective in combating the
stigmatization and potential embarrassment of seeking help.
Local Newsletter and Media Campaigns
Another way that can be used within a rural context is for practitioners to
maintain a social media, email newsletter, or physical newsletter platform to help reach
other residents who are unable to receive more one-on-one care for whatever reason.
Having publicly available content to readily turn to within these settings can be
beneficial to more generalized topics and depending on the scope of the conversation
can also include more in-depth information that can be included to help them work
through something on their own. Creating different media campaigns to help inform the
community of the common problems present within itself can help reduce stigmatization
while maintaining the ability of reaching people who might not otherwise know like
researchers Knight and Winterbotham say will typically result in the individual seeking
care if possible. This can also be beneficial in cases where some people may be unable
Rural Oklahoma Mental Health
to find available resources on their own, or unable due to parental or cultural
preventions.
Therapeutic Recreational Activities
Rural Oklahoma is filled with a wide range of natural environments from
mountains like Black Mesa, Wichita, Glass, and Ozark (Johnson, 1998) to the vast
amounts of rivers, streams, lakes, and ponds present throughout the state (Johnson,
1998) and even prairies and grasslands. These types of natural environments have
been shown to greatly improve mental health, especially when hiking through rural and
remote areas (Weir, 2020). Due to the natural environment rural areas have, with an
emphasis on the Lincoln County area which is part of the crosstimber ecoregion that is
a cross between forests, mountain areas, and prairie fields it offers a great environment
to use as a way of helping more people achieve better mental health in a group setting,
which until the disparities found in rural and urban environments are fixed, is an
important type of practice and therapy session to consider as an option to be included
within any rural psychologists practice.
Different Workshop Concepts
Workshops can come in three different styles which are digital, in person, or
hybrid. Digital workshops are typically online although they can be downloaded onto
DVDs, CDs, and MP3s to be able to listen to them anywhere without internet. In person
workshops are typically those that are hosted with a group of people in a “room”, with
common hybrid models being a cross of in person meetings that are then recorded and
given away or sold online, or instead streamed through webinar, video conferencing, or
live streaming through social media networks to a live audience. By incorporating these
Rural Oklahoma Mental Health
models into rural settings it can help in boosting the accessibility, availability, and
affordability of certain services while also helping to avoid stigmatization potentials if not
minimize the stigma as a whole.
Telehealth Services
Telehealth services saw a significant increase in usage over the COVID-19
pandemic (Haque, 2021; Farrer et al., 2022) as a way of still being able to reach and
treat patients; however in many rural areas throughout the United States, it’s common
for there to be poor or no internet services. Within rural areas, 22% of the population
lacks broadband coverage with 27% of tribal lands lacking it (United States Department
of Agriculture, 2020). Telehealth isn’t meant for everything or everyone though with
many psychologists choosing to avoid this method when dealing with complex problems
like trauma (Farrer et al., 2022). Despite this, for many instances telehealth services in
most forms are beneficial as an overall method of use with many individuals potentially
seeing better results on reaching goals set from weekly text message check ins (Saviet
& Ahmann, 2021).
Conclusion
Rural mental health care as a whole is vastly underfunded, underrepresented,
and understaffed for many communities both in, and outside, of Oklahoma. This makes
it even harder for those communities to be helped, or even want to accept the help due
to a lack of cultural understanding. To help reduce stigma, increase accessibility,
affordability, and awareness of both good and poor mental health, practitioners should
create local social network and newsletter campaigns covering problems found within
their communities and direct residents to a variety of different resources within their
Rural Oklahoma Mental Health
town, county, and state organizations. Rural therapists and psychologists are frequently
overworked and having some of these systems in place could also help in the reduction
of workload or pushback within their communities.
References
Ahad, A. A. (2023, May 26). Understanding and Addressing Mental Health
Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review.
NCBI. Retrieved November 9, 2023, from
Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. C. (2015, December 8).
Factors influencing the underutilization of mental health services among Asian
American women with a history of depression and suicide. NCBI. Retrieved
Rural Oklahoma Mental Health
November 28, 2023, from
Brosi, M. (2020). Intro to Mental Health | Oklahoma State University. Oklahoma
State University Extension. Retrieved October 28, 2023, from
Brower, K. J. (2021, May). Professional Stigma of Mental Health Issues:
Physicians Are Both the Cause and Solution. NCBI. Retrieved November 9,
Chatmon, B. N. (2020, July-August). Males and Mental Health Stigma. American
Journal of Men’s Health.
Er, F., & Duyan, V. (2023). An Overview of the Stigmatization of Soldiers in the
Context of Mental Health from a Social Work Perspective. DergiPark. Retrieved
November 4, 2023, from https://dergipark.org.tr/en/download/article-file/2600864
Eyllon, M., Vallas, S. P., Dennerlein, J. T., Garverich, S., Weinstein, D., Owens,
K., & Lincoln, A. K. (2020, June). Mental Health Stigma and Wellbeing Among
Commercial Construction Workers. ResearchGate. Retrieved November 4, 2023,
Eyllon/publication/342173141_Mental_Health_Stigma_and_Wellbeing_Among_C
ommercial_Construction_Workers_A_Mixed_Methods_Study/links/5f32a7a7299b
f13404b857f9/Mental-Health-Stigma-and-Wellbeing-Among-Commercial-Constru
Farrer, L. M., Clough, B., Bekker, M. J., Calear, A. L., Werner-Seidler, A., Newby,
J. M., Knott, V., Gooding, P., Reynolds, J., Brennan, L., & Batterham, P. J. (2022,
March 31). Telehealth use by mental health professionals during COVID-19.
Rural Oklahoma Mental Health
PubMed. Retrieved November 28, 2023, from
Garrison, M. E. (2022, March 21). Understanding the “4 A's” of rural mental
health | SIU Medicine. SIU Medicine Home. Retrieved November 19, 2023, from
Haque, S. N. (2021, January 1). Telehealth Beyond COVID-19. PubMed.
Retrieved November 28, 2023, from https://pubmed.ncbi.nlm.nih.gov/32811284/
Hastings, S. L., & Cohn, T. J. (2013). Challenges and Opportunities Associated
With Rural Mental Health Practice. Journal of Rural Mental Health, 37(1), 37-49.
10.1037/rmh0000002
Healthy Minds Policy Institute. (2022, December 16). Surveying Oklahoma's
behavioral health workforce. Healthy Minds Policy Initiative. Retrieved October
28, 2023, from https://www.healthymindspolicy.org/research/surveying-
oklahomas-behavioral-health-workforce
Johnson, C. C., Roth, J. C., Vega, L., Kohalmi, A. L., Howell, B. R., & Van
Hasselt, V. B. (2020). Enhancing Mental Health Treatment for the Firefighter
Population: Understanding Fire Culture, Treatment Barriers, Practice
Implications, and Research Directions. Professional Psychology: Research and
Practice, 51(03), 304-311. http://dx.doi.org/10.1037/pro0000266
Johnson, K. S. (1998, June). Mountains, Streams, and Lakes of Oklahoma.
Oklahoma Geological Survey. Retrieved October 26, 2023, from
Rural Oklahoma Mental Health
Knight, B. G., & Winterbotham, S. (2020, June 24). Rural and urban older adults'
perceptions of mental health services accessibility. PubMed. Retrieved
November 28, 2023, from https://pubmed.ncbi.nlm.nih.gov/30761911/
Morales, D. A., Barksdale, C. L., & Beckel-Mitchener, A. C. (2020, May 04). A
call to action to address rural mental health disparities. Journal of Clinical and
Translational Science, 4(5), 463 - 467. https://doi.org/10.1017/cts.2020.42
National Alliance on Mental Illness. (2021, February). Mental Health in
Oklahoma. NAMI. Retrieved November 28, 2023, from
Media/StateFactSheets/OklahomaStateFactSheet.pdf
Park, M. (2022, February 3). Mental Health Stigma and Law Enforcement
Officers. UMass Global ScholarWorks. Retrieved November 4, 2023, from
xt=edd_dissertations
Rural Health Information Hub. (2021, October 20). Rural Mental Health
Overview. Rural Health Information Hub. Retrieved November 19, 2023, from
Saviet, M., & Ahmann, E. (2021, January). ADHD coaches' experiences with and
perceptions of between-session communication with clients: a focus group |
Request PDF. ResearchGate. Retrieved November 28, 2023, from
riences_with_and_perceptions_of_between-
session_communication_with_clients_a_focus_group
Rural Oklahoma Mental Health
Shrider, E. A., & Creamer, J. (2023, September). Poverty in the United States:
2022. Census Bureau. Retrieved November 28, 2023, from
-280.pdf
United States Department of Agriculture. (2020). Broadband. USDA. Retrieved
November 28, 2023, from https://www.usda.gov/broadband
University of Minnesota Rural Health Research Center and NORC Walsh Center
for Rural Health Analysis. (2019, February 12). Barriers to Mental Health
Treatment in Rural Areas – RHIhub Toolkit. Rural Health Information Hub.
Retrieved October 29, 2023, from https://www.ruralhealthinfo.org/toolkits/mental-
health/1/barriers
U.S. Census Bureau. (2023, September 26). Urban and Rural. U.S. Census
Bureau. Retrieved October 28, 2023, from https://www.census.gov/programs-
surveys/geography/guidance/geo-areas/urban-rural.html
Weir, K. (2020, April 1). Nurtured by nature. American Psychological Association.
Retrieved October 26, 2023, from https://www.apa.org/monitor/2020/04/nurtured-
nature