"President's Message," Rural Health FYI, March/April, 1998
Tim Size, President, National Rural Health Association
We are our own barrier to effective mental health care.
As I thought about rural mental health and substance abuse care (behavioral health care) and the particular challenges of rural access to services, a lifetime of remembered images came unsolicited into view: the empty but still hanging noose of a failed suicide, a gun locked away during a downward spiral of clinical depression, the involuntary but horrific reaction to a medically proscribed treatment of steroids, a final decline into dementia.
I've personally been blessed with few days that would even be characterized as blue, but from the experience of preparing this column came an unsettling realization. A reasonably random sample of family, friends, colleagues and acquaintances have experienced heart disease, cancer and other illnesses but it seems that only a much closer circle of immediate friends and relations have had an illness of the brain. People in my wider community but close enough to know and personally care about--colleagues, neighbors and folks at church--seem somehow immune to this type of affliction, presenting the perfect picture of mental health.
Then came the obvious suggestion that so strong is our collective fear/stigma of mental illness that most of the time we participate in a conspiracy of silence about its very existence. We are left with an unsettling sense that mental illness is a private burden to bear or in the opposite extreme, fed by the tabloids, that it only effects the rich, famous and/or criminal (and even then, not those in or running for public office.)
The classic dynamic in rural communities of "neighbors helping neighbors," so effective in addressing other common challenges, is immobilized. The tradition becomes largely inoperative if your neighbor's need is hidden, or worse yet, if the problem causes your neighbor to no longer be considered a neighbor. It is real hard for a community to raise and organize resources for a challenge that is not seen or accepted.
The very structure of this column, initially unintended, reflects the pervasive challenge of mental illness. I couldn't and still can't imagine writing this without offering you an assurance, as I did at the beginning of the second paragraph, that there can be no question of my own personal mental soundness (or only if you get your own column). We understandably have a great fear of any illness that attacks our basic sense of self and our most fundamental means of connecting with others. This fear limits our ability to identify, discuss or intervene at the local level, most especially in rural communities without the benefit of urban-like anonymity. Rural neighborliness is in this case a barrier to care.
Even by rural standards, resources are scarce.
"The behavioral health status of rural areas has not generally been separated from the overall status of the U.S. population, but a 1994 report examined the available data on mental health and substance abuse problems in rural areas. Not surprisingly, it was found that rural Americans have similar rates of behavioral health problems as those affecting the population living in metropolitan areas. Nonetheless, access to behavioral health care, even compared to other rural health care services, is too often downright scarce. The reasons for this are complex, but they include rural cultural factors (including stigma), a public reluctance to recognize the unique nature of rural areas, the failure of health reforms in rural 'markets' and the poor distribution of behavioral health providers." (Conversation with Gil Hill, American Psychological Association.)
"Most rural Americans live in federally designated mental health professional shortage areas. Over 1600 of 3,000 U.S. counties (all rural) have no mental health professional residing in them, compared to 150 counties without a physician. The shortage of local care leads to a cascade of problems: 1) rural persons enter care for mental illnesses later in their course; 2) they enter care with more disabling symptom 3) they enter care requiring more intensive intervention (e.g. hospitalization) 4) the required care may be delivered further from family, community, work, and natural support and 5) as they are less likely to receive adequate aftercare there is an increased likelihood of relapse." (Dennis Mohatt, past president, The National Association For Rural Mental Health)
The challenge is to integrate care while recognizing special needs.
"There is every reason for us to be concerned about how well the general health care system and the behavioral health care system are working together. This becomes critically important in rural areas where inefficient and ineffective use of limited resources can put both systems, and their patients, at risk. We have had only limited success in building true collaborative relationships between general health care professionals and behavioral health care professionals. There is great benefit to be had for both patients and providers in better integrating general health care and behavioral health care. In rural areas, because we often know each other personally, we have a good chance to bring general health care and behavioral health care together for the benefit of our patients and ourselves and our communities. This is hard work, but it is both necessary and important. We can no longer pretend that compartmentalization of disorders or care makes good sense either clinically or economically." (Peter Beeson, president-elect, The National Association For Rural Mental Health)
"Dr. Robert Merrill (in Rural Clinician Quarterly, Fall 1997) describes "One Physician's Struggle With Managed Mental Health Care:" "I am not intrinsically anti-managed care. In fact, health maintenance organizations (HMOs) usually promote preventive care and have helped re-establish the central role of the primary care physician in the patient's health care. Unfortunately, this centrality has been eliminated in the area of mental health. Most plans "carve out" the care of mental illness into a separate provider network with a host of restrictions on the patients access to care. The struggle to maintain our ability to perform this essential component of primary care is important to every family physician."
The federal National Advisory Committee on Rural Health at its winter meeting adopted a series of recommendations to Secretary Donna Shalala challenging the widespread managed care tool "of 'carving out' behavioral health care services from standard managed care plans. This practice is not consistent with holistic concepts of integrated health care, wellness, and prevention, but perpetuates the historic separation of care for persons with mental illness and addictive disorders."
Market forces may be leading to a reintegration of currently "carved out" services but not without bringing new challenges: "As states begin to enroll (into managed care plans) more and more disability groups, they will be pressed to consolidate and coordinate population-based programs into a more unified system. How to develop a coherent managed care policy without compromising the special needs of and services for people needing substance abuse or mental health services will be a challenge for public sector decision makers." (The Lewin Group, July, 1997)
Are all of us at least a little "crazy"?
Hopefully as our understanding of the organic basis or contribution to various mental illnesses improves, it will become easier for all of us to understand and accept the continuum of mental health as an integral part of both ourselves and our community health care systems.
"Last year addiction, a mental illness, was found to be on a continuum with a normal personality trait. Researchers discovered an abnormally long version of a gene on chromosome 11, found more often in heroin addicts than in non-addicts. Here's where the continuum comes in: the long version of the gene is also common in mentally healthy people who exhibit 'novelty-seeking' behavior according to research in Israel and at the National Institute of Health. Such people tend to be impulsive, fickle, excitable, quick-tempered and extravagant; they seek thrills... This gene is only one of an estimated 10 or so that determine novelty-seeking. Someone with 2 or 3 of the 10 might be a little impulsive. Someone with all 10 might be a risk freak-or a heroin addict. In just the last two years, researchers have discovered several genes that may account for personality quirks and, in combination with other genes, trigger mild or full blown mental illness." (Sharon Begley, "Is Everybody Crazy?," Newsweek, 1/26/98)
What can NRHA do?
We fear "losing our mind" more than the Grim Reaper (or at least that is the intended point of the earlier cartoon). For now, I don't believe there is a class of illnesses with a greater stigma than those affecting the brain. Rural communities due to their size and social structures are particularly subject to the stigma that accompanies mental illness, limiting the development of needed services. If we as rural health providers and advocates lay claim to community based care we must speak out more openly and widely on behalf of patients with a mental illness.
But as importantly and most certainly more difficult, rural health care generalists and their behavioral health counterparts need to speak and work with each other. To that end, the NRHA Policy Board is currently revisiting association policies to assure that our advocacy and program activities lead us towards further integration of the still all-too-separate worlds of physical and behavioral health. Another step that I hope to see accomplished is the development of an even closer collaborative relationship between NRHA and The National Association For Rural Mental Health. In closing, I would ask each of you to consider your own attitudes about mental health and substance abuse and how they may contribute to or hinder friends' and neighbors' access of needed health care.
