Rural Psychology Integrated Care (RPIC)

The American Psychological Association has identified psychological services as a critical need in rural areas (APA, 2010). Rural areas generally have inadequate health services and residents have limited insurance coverage (DeLeon, Wakefield, & Hagglund, 2003). The ratio of psychologists to population is less than half (16:100,000) than that of non-rural communities (39:100,000) according to the Center for Health Policy, Planning & Research (2007). The lack of resources likely contributes to some sobering statistics. Rates of anxiety and depression are higher among rural communities (Texas A&M University's Southwest Rural Health Research Center, 2005), and among those who are depressed, rural patients are significantly more likely to be hospitalized than those in urban areas (Rost, Adams, Xu, & Dong, 2007). In addition, rural areas exceeded the national average for suicide rates in every age category under 64 years from 1994 to 2003 (Kruger, 2005), even though in rural regions deaths are less likely to be classified as suicides (Beeson, 2000).

The rates of substance abuse in rural areas is comparable to urban areas, with a heightened likelihood that rural youth will engage in binge drinking (Cellucci, Vik, & Nirenberg, 2003). However, access to and acceptability of substance abuse services is lower than non-rural areas. Rural adolescents who identify as lesbian, gay or bisexual experience higher rates of affective distress than heterosexual counterparts (Cohn & Leake, 2008). Similarly, access to support services and resources are more limited than those available to their urban and suburban sexual minority peers.

Chronic health conditions are also more prevalent in rural areas, where 46.7% of the population reports chronic conditions compared to 39.95% of the urban population (NRHA, 2002). Many of these chronic diseases, which are responsible for 70% of deaths (Center for Disease Control, 2005), can be prevented or their impact lessened through behavioral health interventions. Beyond these issues people residing in rural communities are exposed to a wide array of stressful life events, different from that of their urban counterparts, many of which are unpredictable and out of their control. Residents deal with things such as weather that is not conducive to crop production, natural disasters, farm crises, and high rates of physical injury, likely due to high proportion of physical labor-intensive employment (DeLeon et al, 2003; Helbok, 2003; Cellucci & Vik, 2001).

As noted above, limited resources and numerous barriers are significant factors in health disparities for rural communities. A disproportionate number of the nation's poor are in rural areas and the persistent poverty is higher in completely rural counties (USDA, 2004). Compared with urban areas, residents of rural areas have traditionally lower educational attainment, greater lack of - or inability to attain - higher formal education, and smaller percentages of people in the labor force as compared with urban areas (Murray & Keller, 1991). This is a fairly consistent trend, as contemporary rural students generally demonstrate fewer indicators of college readiness than students in suburban areas, as reflected by lower college enrollment rates, lower expectations for college attendance by parents, and increased likelihood of not completing high school (Provasnik, Kewal-Ramani, Coleman, Gilbertson, Herring, & Xie, 2007).

Several barriers unique to rural regions are likely to both reinforce and complicate some of the mental health concerns and needs discussed above. People in rural settings tend to be distributed across wide expanses of land, making it difficult to deliver efficient services (DeLeon et al, 2003). Geographic isolation is associated with reduced access to mental health care (Gibbons, Hur, Bhaumick, & Mann, 2005), decreased capacity for early intervention, and increased likelihood of foregoing care (Elliott & Larson, 2004). Also, several aspects of rural culture have been associated with increased mental health concerns. Rural culture, which tends to emphasize a strong work ethic and stoicism, can lead to increased stigmatization of mental health issues (Elliott & Larson) and decreased ability to recognize the signs of depression and other mental health issues (Elliott & Larson). Further, the perceived difficulty of maintaining confidentiality in small towns has been identified as a barrier to seeking services (Elliott & Larson).

A central issue in the shortage of trained mental health professionals in rural areas is the challenge of recruitment and retention. In March, 2002, the National Institute of Mental Health (NIMH), Office of Rural Health Research (ORMHR) addressed the needs of mental health services for diverse populations in rural and frontier areas. An identified critical issue was the severe shortage of specialized mental health professionals and providers in rural communities. One recommended action was to promote training programs for the purpose of creating viable career paths for those interested in rural mental health services. APA has identified improved methods to promote the recruitment, retention and distribution of psychologists in rural areas (APA, 2001). One approach is to expose psychology interns to rural practice earlier in their training rather than to recruit graduates. Giving students a preview of rural practice during their internship may enhance the likelihood of enjoying work in these areas (Boulton-Olson, 2008). Though federal policies which address manpower shortages and geographical maldistribution already exist they need to be strengthened in order to mitigate the health professional shortages (Thorndyke, 2006). RPIC proposes to respond to these suggestions by placing students in rural settings during their doctoral practicum experience.

In response to the shortage of specialized providers (availability), the challenges faced by rural residents in seeking out and traveling to providers (accessibility) and the increased stigma and threats to confidentiality perceived by rural residents (acceptability), several authors and organizations have called for increased emphasis on integrated health care and cooperation among physical health care providers and mental/ behavioral health care providers and training programs (American Psychological Association, 2008; Gale & Deprez, 2003; Gunn & Blount, 2009; National Association of Community Health Centers, 2004; US Department of Health & Human Services, 2008). RPIC will address this second call by creating a sequence of training that integrates students across three disciplines and places them in Integrated Health Care settings.

North Dakotais a primarily rural state, with a statewide average of 9.3 persons per square mile, compared to a national average of 79.6 persons/square mile (2000 Census). Although the state contains 373 incorporated cities, the majority of the state's population (646,844 as of July, 2009) lives in the incorporated areas of 16 communities. Of the 373 incorporated cities 51% have 200 or fewer residents. Based on a criteria of having six people or less per square mile, 36 of 53 (69%) of the counties in North Dakota are identified as frontier counties, compared to 24% of all the counties within the U.S. Generally, North Dakota has negative population growth, although the 2000 Census number was exceeded for the first time in 2009. (North Dakota State Data Center, 2010).

In general, North Dakotans report rates of mental and behavioral health concerns that are consistent with national averages (Kaiser Foundation, 2010; Mental Health America, 2007). However, some significant disparities do emerge. One population of particular concern is children and youth. In 2006, the child death rate in North Dakota was 23 per 100,000, compared to 19 per 100,000 US average. The teen death rate was even higher, at 87 per 100,000, compared to 64 per 100,000 US average (Kaiser Foundation, 2010). Among North Dakota children age 2 – 17, 72.4% had emotional, developmental, or behavioral health problems and received mental health care, compared to 60% nationally.

American Indians are the largest racial/ethnic minority group in North Dakota, and there are several indications of mental and behavioral health disparities particularly relevant to American Indian tribal and reservation communities. The Indian Health Services (January, 2010a) notes that American Indians have a shorter life expectancy and larger health burden than other racial ethnic groups in theUnited States. They have a greater ratio of death from several behaviorally relevant causes compared to all other US racial groups, including: alcohol-related death (6.2:1), diabetes (2.9:1), and suicide (1.7:1).

A high proportion of North Dakota residents are aging and elder. In fact, projections for 2020 suggest that the elderly will be the largest proportion of the population in most North Dakota counties (North Dakota State Data Center, 2009). Although older adults do not necessarily experience higher rates of behavioral or mental health concerns, they are less likely to seek psychological services. In addition, older adults' mental health issues are often overlooked and misdiagnosed, potentially resulting in greater problems or more severe consequences (White House Conference on Aging, 2005). There is a significant shortage of geriatric behavioral/mental health specialists, despite the national increase in older populations and growing need for culturally relevant services.

Two behavioral health areas of particular concern across populations in North Dakota are substance abuse and suicidality. Although many researchers have found few differences in substance abuse between rural and urban populations (Cellucci et al., 2003), North Dakota ranks the highest in the nation in adult binge drinking (Kruger & Gray, 2005). Methamphetamine abuse is also a significant factor in North Dakota, and has been identified as a top priority for American Indian behavioral health by IHS (2010b). The ready access via highway and under guarded borders with Canada, in addition to the safety from detection afforded by remote and isolated location, has led to increased trafficking and manufacturing of methamphetamines (National Drug Intelligence Center, 2002). It is worth noting that several home-based meth labs were raided and dismantled in one of the communities that will be served by RPIC (the proposed project) on April 7, 2010, as evidence of the continuing threat of methamphetamine abuse in small rural communities. The North Dakota Commission on Drugs and Alcohol (2002) reported that over 40% of 9-12 graders, and 60% of college students, had engaged in at least one episode of binge drinking in the past month, numbers that are significantly higher than the national average. Additionally, the commission noted that approximately 10% of high school students had used methamphetamines in their lifetime. Furthermore, substance abuse inNorth Dakotahas been linked with increased rates of suicide (Kruger & Gray).

North Dakota has a rate of depression among adults that is below the national average (Mental Health America, 2007). However, depression rates were somewhat higher among youth ages 12 – 17. This same pattern has been observed in suicide rates. According to the National Center for Injury Prevention and Control (CDC, 2007), suicide was the second leading cause of death in North Dakota for the age groups of 10-14 year, 15-24 years, and 25 – 34 years in 2004, second only to death by unintentional injury. Although the suicide rate in 2004 for ND citizens across all ages was very close to the US average (11.48 vs 11.05), the rate among youth and young adults is significantly higher. Specifically, the suicide rate in ND for the age groups 10 – 29 was 15.83 in 2004, compared to the national rate of 8.51 (both crude rates, CDC). This is the fourth highest rate among this age group in theUnited States and the second highest rate of states in the Midwest, second only to South Dakota (18.90), which shares several similar rural culture characteristics. More specifically, the rate for White 10 – 29 year-olds was 13.43; the rate for American Indian (based on low incidence) was 53.66. Further, between 1999 and 2002, youth aged 15 – 19 years accounted for 19% of all hospitalized suicide attempts in the state, with a rate of approximately 130 per 100,000 (Suicide Prevention Resource Center; SPRC, n.d.).

One of the key reasons that behavioral and mental health are of particular concern in North Dakota, as in other rural areas, is the sheer lack of adequately trained service providers. The North Dakota Healthcare Workforce committee reported in 2006 that 94% of North Dakota counties were experiencing mental health care shortages. Further, an inadequate number of students ―in the healthcare pipeline was predicted to continue to present enormous challenges for the health care infrastructure, the economic viability of many rural communities, and ultimately the health status of the state's population.

Currently, forty-seven of the fifty-three (89%)of the counties in North Dakota are either fully or partially designated as Health Professional Shortage Areas (HPSA), Medically Underserved Areas (MUA), or both. Sixty-eight percent of the forty-seven underserved counties are either full or partial HPSA and 81% of the counties are either full or partial MUA. In 2008, 34.4% of North Dakota's population lived in a Mental Health Professional Shortage Area (HPSA), compared to 18.7% nationally (Kaiser Foundation, 2010). The proposed RPIC program will serve residents of eight North Dakota counties, all of which are designated as Mental Health HPSAs by HRSA, as ofApril 13, 2010. The counties in the designated service area (with HPSA priority scores) include: Benson (18), Cavalier (18), Eddy (18),Grand Forks(10, 16), Nelson (9), Pembina (9), Ramsey (18), and Walsh (16).

Clearly, the needs of rural populations for increased mental and behavioral health services are well-established. What is less evident is the need for specialized training programs. One could argue that high-quality training resulting in competent providers ought to be sufficient to meet the needs of rural communities. However, there is ample evidence that this is simply not the case. Despite efforts to facilitate the preparation of mental health providers for rural settings, few graduate programs have established comprehensive rural mental health training. (Pinterits, et al., 2008; Hovestadt, 2002). APA published a curriculum for rural health training entitled, Caring for a Rural Community, which brought together APA, the American Nurses Association, and the Council on Social Work Education (APA, Office of Rural Health, 1995). The curriculum, designed to train skills in rural interdisciplinary practice, has never been fully put to use (Boulton-Olson, 2008). An exhaustive search for APA-accredited programs with a rural mental health emphasis has yielded only four programs, a very small proportion of doctoral training programs. There is a significant need for a specialized program that can integrate best practices identified thus far. Specialized training programs must attend to several key issues in order to meet the needs of rural communities successfully:

1. The interdisciplinary preparation of new psychologists, substance abuse counselors, and nurses to address rural mental and behavioral health needs, and
2. The culturally competent preparation of these health professionals to provide care in the context of rural cultures. In doing so, specialized training programs should
3. Intentionally address the recruitment and retention of mental health providers in rural communities.

These needs, addressed by the RPIC program, are detailed below.

Interdisciplinary preparation for Integrated Health Care (IHC). Rural programs should promote collaboration by training students in these professions to establish interdisciplinary professional relationships. From a training perspective, Harowski, Turner, Levine, Schank, & Leichter (2006) commented:

Current training models in graduate psychology are out of touch with the practice demands of rural psychologists. Our traditional doctoral programs train psychology students in isolation, only in their own discipline, and by their own faculty, and often in their own departmental clinics. Rural practice preparation requires interdisciplinary collaboration among multiple disciplines and health care faculties and a rich diversity of professions rather than a monoculture of psychology. (p.161).

Given the aforementioned concerns, and as Cynthia Belar, APA's executive director for education affirmed in 2003, the - requirements of the workplace need to drive the curriculum. The curricular aim of IHC socialization is to facilitate more comprehensive care to clients (Jameson & Blank, 2007; Pinterits, et al., 2008).

RPIC training settings in the rural communities will emphasize interdisciplinary collaboration and cooperation with other professionals. Coordination is necessary for clients' care as often individual's problems are varied and intertwined based on physical health, mental health, financial concerns, or abuse of various sorts. Individuals frequently suffer from numerous problems aside from the presenting mental health issue that might require consultation and collaboration with other professionals such as those from the medical fields, clergy, teachers, judges, police officers, and paraprofessionals, to best serve the client (Beeson, 1998; Smith, 2003).

Rural context of mental and behavioral health issues. Specialized programs in IHC for rural communities should attend to the preparation of these health professional trainees to provide care in the context of rural cultures. Trainees must be familiar with and educated in how rural life and identity impacts clients. Currently, there are few doctoral training programs in psychology that offer courses or practica that adequately present the differences between working in rural versus urban populations. Most psychologists are trained according to an urban model of psychology and most of the practical experiences students undergo, including practica and internships, are occurring in urban areas where there is access to a wealth of services (Pinterits, 2008).

The Rural and Northern Community-Based Training Program of Manitoba emphasized to its interns that they will be ―wearing many hats and providing services that their urban counterparts would never consider within their scope of practice (Stamm, 2003a, p.17, as cited in Boulton-Olson, 2008) including supervisory, administrative, and leadership roles. The context of rural culture includes (a) developing the cultural competencies for effective work as well as (b) anticipating the adjustments to rural life.

Developing cultural competencies for rural communities involves addressing the dynamics of the rural context and mental health concerns such as suicide and substance abuse, vocational concerns such as joblessness and underemployment, minority statuses such as American Indian or sexual orientation minorities noted above. In addition, culturally competent practitioners must address the intersections of rural status, socioeconomic status, ability status, age, and religion as well (Cox, 2008; Pinterits, 2008). For example, interns in Manitoba's Rural and Northern Community-Based Training Program were trained to understand diversity not only in terms of ethnicity or language, but also in ways in which work life and economic factors influence various communities' cultures and individuals' health status and behavior (Boulton-Olson, 2008). Kropf (2003) advocated that trainees must develop leadership skills in order to exert influence in communities that often may have characteristics of closed systems. In her view, students need to learn how to be aware of the local-decision making factors, processes, influential leaders, and power structures as a way to enact change (Boulton-Olson, 2008).

Anticipating the adjustments to rural life is a central way in which specialized programs in IHC for rural communities should attend to the preparation of these health professionals to provide care in the context of rural cultures. Anticipatory socialization includes appreciating rural communities and adjusting to challenges such as transportation concerns, paucity of formal resources, isolation, constant visibility, lack of privacy, and burnout (Pinterits, et al., 2008; Sullivan et al., 1993). The Manitoba Training Program reduces potential burnout and isolation and maximize support through weekly case conferences via telehealth (McIlwraith, Dyck, Holms, Carlson, & Prober, 2005; Boulton-Olson, 2008). New professionals should be familiar with intervention models such as telemedicine or telemental health due to the geographic distances and potential lack of resources in rural communities (Kropf, 2003).

Another aspect of rural adjustment programs should incorporate is the need for generalist practice. Hargrove and Breazale (1993) note that training models must motivate and develop practitioners with generalist skills including management and administrative tasks, collaboration with those outside of the field of psychology, and working with others in the community. They contend that those who enjoy the challenges of being a generalist are likely to enjoy and succeed in a rural environment (Harowski et al., 2006; Kersting, 2003; Schank & Skovholt, 2006). Practicing as a generalist in a rural community could mean caring not only for one's individual caseload, but caring for the needs of the larger community (Oetinger, 2007). Collaboration and in essence, caring for the needs of the larger community is an objective of the RPIC training program.

Recruiting and retaining trainees for work in small communities. Overall, in order to recruit and retain students for work in rural areas it is important to review what the field is already doing or not doing to provide trainees with the education, skills, and knowledge they need to work successfully and happily in a rural setting. As highlighted previously, only a handful of private initiatives or graduate programs have demonstrated an ongoing commitment to rural training. RPIC will address ways in which to - home grow or recruit students who are interested in rural practice. Harowski, et al. (2006) made the following recommendations:

Specialized education and training are needed to achieve the New Freedom Commission on Mental Health's, 2004 Goal 3:2: Improve access to quality care in rural and geographically remote areas. Innovative rural psychology training programs need to address the issues of rural communities such as inordinate difficulty in recruiting and retaining mental health professionals because of factors such as lack of training in the unique aspects of rural practice at the graduate or postgraduate level, professional isolation, lack of a cohesive mental health community, the added personal stress of disconnected rural mental health infrastructure, lack of community resources to retain mental health providers, and lack of familiarity with the multidisciplinary crossover culture of mental health delivery in rural areas. (p.162).

As noted above, RPIC is designed to address these recommendations. In addition, RPIC is considering reasons that contribute to retention of practitioners. Personal interests and lifestyle preferences play a very large role in one's interest in pursuing a rural career and profitable success in rural practice (McIlwraith, Dyck, Holms, Carlson, & Prober, 2005). RPIC trainees who are culturally similar may find the rural lifestyle easier to manage. Much like Kropf (2003) suggested, promoting strategies to ―home grow professionals from persons who are part of rural areas is a valuable approach as it may have an advantage in retaining a workforce of people already familiar with life and experiences within these contexts. Some practitioners may have always intended to return to work in a rural area, or plan to eventually return to a rural setting to be close to family and friends or to fulfill a sense of loyalty to one's hometown rural community (Oetinger, 2007).

In contrast, some doctoral-level psychologists interested in entering rural practice have not resided in a rural area and may not be prepared for responsibilities inherent in working in rural communities; this may create a reluctance to take positions in rural areas (Jerrel & Herring, 1983). In addition to recruiting home-grown rural trainees, RPIC will actively seek trainees who have an interest in working in rural practice, but until graduate training have had little exposure to small communities. RPIC trainees will be provided with an opportunity to learn more about rural issues through exposure to those issues found within those communities. Students will see first-hand how the roles of rural psychologists and mental health service providers differ from those of psychologists in more urban settings. They will gain experience in the lifestyles and responsibilities of rural psychologists. Furthermore, they will be exposed to and informed of the ethical issues and practice challenges that may arise in rural settings. We will actively recruit trainees with values consistent with those of rural areas to alleviate some of these feelings or possible fears and make long term service more promising (Schank & Skovholt, 2006).

The RPIC commitment to interdisciplinary collaboration will open doors for consultation opportunities early on in training and will decrease the stress, burnout, and professional isolation and lack of social support often cited as major concerns for the rural practitioner. This, in turn, will support the retention of providers. As Kersting (2003) and Woloschuk and Tarrant (2002) suggested, the specialized training of RPIC will provide educational opportunities and internships in rural settings that may directly influence the number of mental health providers practicing in rural location and mitigate the dearth of mental health services for rural communities.

Researchers consistently identify that approximately a quarter (25-30%) of all visits to primary care physicians are related to mental health issues—including (but not limited to) depression, anxiety, substance abuse, and physical manifestations of stress/distress (Ansseau, Dierick, & Buntink, 2004; Gunn & Blount, 2009; Kahn, Halbreich, & Bloom, 2004). Additionally, over two-thirds of people with a diagnosable mental health disorder turn to their primary care physical, not a psychologist, for assistance (Blacker & Clare, 1987; Miranda, Hohnmann, & Attkisson, 1994). Most startling of all, almost half (45%) of completed suicides occur within a month of a primary care visit (Luoma, Martin, & Pearson, 2002). While these statistics are compelling in and of themselves, they are disconcerting when coupled with the fact that most primary care physicians feel they do not have adequate training to deal with mental health issues (Longlett & Kruse, 1992).

One response to the apparent need for mental health care in medical practice is the integration of psychologist into primary care settings. Several institutions have implemented such a model, most noticeably the Veteran's Administration (VA; Elder & Silvers, 2009). Elder and Silvers (2009) particularly note the significant benefits of locating psychologists in VA primary care clinics; including ―dramatically increased compliance with recommended mental health treatment, significantly reduced concerns regarding stigma (because of the medical setting), and the noticeable improvement of patients presenting to primary health providers with mental health concerns. Similar results were also found in a study completed by Kolbasovsky, Reich, Romano and Jaramillo (2005) in a non-VA primary care setting. Specifically, these authors found significant improvements in patient mental health (including patient vitality, social functioning, and emotional health), and significant primary care provider satisfaction, when psychologists were integrated into the primary care setting.