I have worked in Schoharie County New York, which is sparsely populated, with about 32,000 people when I worked there in the mid 1990’s (Town and Village of Schoharie, 1997), and Bennington and Franklin Counties, Vermont. The entire state of Vermont is a rural area, with only two major cities- Burlington and Rutland (State of Vermont, 2014), which are considered small cities by national standards. I have found that these areas of the United States have a very unique culture, which has similarities throughout the US, as well as the UK (Riva, Bambra, Curtis, and Gauvin, 2011) and Australia (Boyd, Hayes, Aisbett, Francis, Newnham & Sewell, 2011). Values, beliefs, and perspectives differ from what is found in urban areas, including how mental illness and substance abuse are defined and treated. The rural environment poses unique treatment challenges, and ethical conundrums. The clinician, who works in these areas, particularly if they originate from and have been raised in an urban center, will have a greater chance of successfully delivering treatment if they are familiar with the cultural norms in rural areas.
The Urban Environment
Cities are population and business centers, which tend to be crowded, noisy, and lacking in green spaces. There is heavy vehicle and pedestrian traffic, multi-lane highways, with elevated interchanges, bridges and tunnels, skyscrapers, concrete, chain stores and shopping malls. Wealthy and impoverished sections are sometimes separated only by a few blocks. There is a, higher crime rate (1), and more pollution. There is a myriad blend of smells, sounds, and sights. Cities are rich sources of culture, art, recreation, learning, and history. There are museums, theatres, restaurants, and sports arenas, to offer recreation, and there are typically numerous resources, hospitals, government offices, and public transportation. There is typically a well-developed infra-structure, and many opportunities for employment and businesses.
The Rural Environment
Rural areas are less densely populated, people are more spread out, there is farmland and depending on the geographic location, woods. Traffic is lighter, there are mostly two lane roads, highways are often not more than two lanes, and are sparsely travelled except for AM and PM rush hours. Buildings are typically not more than four stories. The smells are unique- cow manure fertilizer is prominent at certain times of year, pine, or fallen leaves at others times, depending on what part of the country you are in. It tends to be silent, except for farm machinery, and the calls of birds, frogs and insects. There is wildlife- in Schoharie County traffic (there was one other car behind me, and one coming the other way) I was in had to halt to allow wild turkeys to cross the road. In Vermont and neighboring New Hampshire, caution has to be taken when driving on winding, twisting roads with limited visibility for moose and deer, and the occasional black bear. There is natural beauty- mountains, rivers, streams, lakes and woods to explore – hiking, camping, hunting, fishing, shooting, and riding ATV’s ( All Terrain Vehicles, or Four-Wheelers) or in winter snowmobiles (Snow Machines), downhill and cross country skiing and snowshoeing, as well as ice–fishing. Public transportation may be sparse or non-existent, and resources which are taken for granted in urban areas may be unavailable or far removed. There is a stereotype that rural dwellers have a slower pace of life, less stress, and enjoy better mental health. This is debatable in many places, but ironically there are significant barriers to accessing mental health or substance abuse care, hereafter referred to Behavioral Health for purposes of conciseness. It is noted that in the UK residing in a rural areas is conducive to overall improved mental health. However, they have similar problems with service availability and accessibility as we do in the US (Riva, M. Bambra, C. Curtis, S.E. and Gauvin, 2011).
Unique Situations and Dynamics Encountered in Rural Areas
People in rural areas tend to be less mobile over their lifetime than city dwellers. They are also more connected to each other through extended family and work/friendship and dating relationships. This results in fewer degrees of separation between people. Part of either social acceptance or rejection, and establishment or lack of trust involves who you know. When people meet, it is common to play the who- do- you- know game- Oh, your cousin dated my sister, my uncle works with your brother, and so on. This leads to connection, and opportunity for bonding and attachment, a process which only occurs if there is trust and credibility. Outsiders are typically regarded with mistrust, suspicion, caution, or outright hostility. They have to work their way into a social circle of the community very gradually. It is helpful to have a sponsor so to speak- someone local who will introduce you to others, and by doing so, vouch for your credibility and trustworthiness.
If you have recently relocated or working in a rural areas, expect people to look you over- to notice you, stare at you, or even approach you and ask who you are, and your business. New people are recognized easily- new faces stand out, and are subject to scrutiny. This is even truer if you don’t match the ethnic demographics of the area.
Family Names and Reputation
In any rural area, it is common to see the same surname in the local news regularly- either associated with some accomplishment, recognition, award, - or their names is preceded by terms such as aggravated assault, burglary, or possession of a controlled substance. One’s surname, whether you are close to your extended family or not- can make or break your reputation in a rural area. You may receive respect or disdain based on your last name, even if you have not spoken to the cousins or uncles in question for years.
Values, Beliefs, and Attitudes in Rural Areas
In rural areas, there is an emphasis on hard work, typically with your hands, self-reliance, and toughness in that minor- or not so minor- physical injuries are shrugged off, emotions are held in except for anger- and after working hard, you drink hard. People may be a little– or a lot- more crude and rough. Some people in rural areas live in generational poverty, with little hope of climbing up the socioeconomic ladder. In rural areas there are concerns about privacy, and confidentiality being maintained due to people being so connected (Boyd, Hayes, Aisbett, Francis, and Newnham & Sewell 2011).
Professional Ethics in Rural Areas: Boundaries and Encountering Patients in Public
This is inevitable. In the clinics I have worked at in rural areas, it was procedure to not acknowledge patients in public unless they acknowledged you first. Some will greet you warmly, want to introduce you to their spouse/friends as their counselor, and make small talk in public. Some people are more concerned with privacy and confidentiality than others and will not want to be acknowledged, and have awkward questions result when a spouse or friend inquires who you are. The clinician must operate on the assumption that any patient they encounter in public is in the latter category unless they greet you first. Conversations ahead of time about how you are required to respond in public can prevent problems from occurring- your spouse/partners/ family should know that if someone greets you publically, don’t ask too many questions. It can be even more awkward to bring your car into a garage, go to a local diner, or have a plumber or repairman come to your home- and it is someone you had in your office last week.
Firearms and Rural Areas
Guns are part of rural culture. People hunt and shoot, and keep them for self-defense against wildlife or intruders, as police may be a significant distance away, or have an understaffed department, or there is a lack of trust in local law enforcement, It is common in many areas to carry a gun in a vehicle, especially during hunting season, or to carry a concealed firearm. This can make for some very awkward interactions and often unnecessarily tense or anxious situations. When a patient’s jacket opens, or shirt rides up to display a handgun, or if someone’s rifle or shotgun is clearly visible in a gun rack in an SUV in the parking lot. The response must be appropriate to the situation, not a panicked overreaction. I have had a patient come in to my office before with a concealed sidearm. It was not that big a deal- I just asked him to leave it in his vehicle and he complied. A calm and matter of fact response is probably all that is warranted in many cases.
It is noted that the suicide rate in rural areas is higher than in urban centers (Gaam, Stone & Pittman, 2010). Over an eight year period, a 21% increased risk of suicide was observed in rural areas as compared to urban areas and the rate of suicide was 14.6% higher in rural vs urban areas (McCarthy, Blow, Ignacio, Ilgen, Austin, and Valenstein, 2012). This may be due to use of firearms as a means of suicide, being farther removed from emergency medical services and trauma centers, and length of time before discovery, or lower probability of being interrupted or rescued. A very high rate of suicide among veterans has been observed in rural areas – as well as a 15% higher rate of use of firearms in this population, as compared to urban centers (McCarthy, Blow, Ignacio, Ilgen, Austin, and Valenstein, 2012).
Gun owners are very connected to their guns. If a gun-owning patient is suicidal, firearms should be removed from their residence, as firearms are the most effective means for an individual to commit suicide. This is a situation to be handled with empathy toward the gun owner- enlist a trusted friend or family to “hold on to the guns for a while”. Point out that firearms ownership is a cherished right, and with that right comes responsibility. There will be times when a person is in an emotional state where it is best not to have easy access to a firearm.
Drugs and Alcohol Use in Rural Areas
Work hard – drink hard. The local definition of moderate use of alcohol can be a 12 pack of beer, or only a pint of whiskey instead of a quart. It may be hard for some rural people to see alcohol as a drug. Other concerns are the use of Methamphetamine and diverted prescription opiates, chiefly OxyContin, typically referred to as Oxy’s. The use of diverted OxyContin is so prominent in rural areas that it has been called hillbilly heroin (Urban Dictionary, 2013). Methamphetamine is also a drug of growing popularity. One factor in this increase is it is easier to hid methamphetamine labs in rural areas.
Difficulties with Service Acquisition in Rural Areas
Problems include transportation to treatment (Hough, Willging, Altschul, and Adelsheim (2011). You may have an individual at the critical moment where they have hit bottom, and are ready to start the change process- a bed in a detox/rehab is waiting ,and they are willing to go0 but they have no way to get there. They lost their driver’s license due to a DUI, and have angered and upset family and friends past the point of anyone being willing to help them. How are you going to get them there? Weekly appointments are needed with a counselor, the first visit went well, trust was established, and they want to come back- but they have limited access to transport. This is a frequent problem in areas where there is no public transport, and people do not have a vehicle or cannot legally drive.
Psychiatrists are largely unavailable (Gaam, Stone & Pittman, 2010). The MH health care infra-structure tends to be much sparser in rural areas as compared to urban centers (Gaam, Stone & Pittman, 2010). This is not a problem limited to the United States; it is noted in Australia as well (Boyd, Hayes, Aisbett, Francis, Newnham & Sewell 2011) and the UK (Riva, M. Bambra, C. Curtis, S.E. and Gauvin, 2011). Generally speaking, mental health services are underutilized, in rural areas- this holds true of adults, adolescents, and children (Gaam, Stone & Pittman, 2010). And medication management may fall to PCP’s (Primary Care Physicians). The delay in access of services in rural areas, can cause exacerbation of mental illness or addiction, and necessitate require more complex or aggressive treatment (Hough, Willging, Altschul, and Adelsheim, 2011).
Rural areas need behavioral health providers, especially psychiatrists (Gaam, Stone & Pittman, 2010). Working in a rural setting offers many challenges, but also many rewards. Going into the setting with a basic knowledge of rural cultural norms can help the clinician operate more efficiently, and develop a good reputation in the community.
Boyd, C.P, Hayes L, Nurse, S, Aisbett D.L, Francis K, Newnham K, and Sewell J. (2011). Preferences and intention of rural adolescents toward seeking help for mental health problems. Rural and Remote Health 11: 1582. Retrieved October 7. 2014 from: http://www.rrh.org.au
Gaam, L., Stone, S., and Pittman, P. (2010). Mental Health and Mental Disorders- A Rural Challenge: A literature Review. Rural Healthy People. 97-114. Retrieved October 7. 2014 from http://sph.tamhsc.edu/centers/rhp2010/08Volume2mentalhealth.pdf
Hough, H.L., Willging, C.E., Altschul, D., and Adelsheim S, (2011). Workforce Capacity for Reducing Rural Disparities in Public Mental Health Services for Adults with Severe Mental Illness. Rural Mental Health. 35(2): 35–45. PMCID: PMC3258030. NIHMSID: NIHMS338737
McCarthy, J.F. Blow, F.C., Ignacio, R.V., Ilgen, M.A., Austin, K.L, and Valenstein, M. (2012). Suicide among Patients in the Veterans Affairs Health System: Rural–Urban Differences in Rates, Risks, and Methods. American Journal of Public Health: Vol. 102, No. S1, pp. S111-S117. doi: 10.2105/AJPH.2011.300463
Riva, M. Bambra, C. Curtis, S.E.and Gauvin, L. (2011). Collective resources or local social inequalities? Examining the social determinants of mental health in rural areas. European journal of public health. 21 (2). pp. 197-203
State of Vermont. (2014). Vermont.gov. Retrieved October 10, 2014 from http://www.vermont.gov/portal/vermont/index.php?id=262
Town and Village of Schoharie. (1997). Town and Village of Schoharie Comprehensive Plan. Retrieved October 10, 2014, from http://www.schohariecounty-ny.gov/CountyWebSite/townsch/SchoharieCP.pdf
Urban Dictionary. (2013). Hill Billy Heroin. Urban Dictionary. Retrieved October 10, 2014, from http://www.urbandictionary.com/define.php?term=hillbilly%20heroin
It can be debated the overall actual crime rates are higher per capita in cities. There is likely a great deal of underreporting in rural areas, and more crime behind closed doors, such as domestic violence, whereas crime is more visible and public in cities.