Rural Practice Challenges

The United States defines “rural” communities as those of 2,500 people or fewer. A more natural definition is tied to population density: People who live in geographically isolated, low-population areas where occupations are tied to natural resources have more in common with each other than they do with people in cities and towns of any size. The small size of their communities is key to understanding the vibrancy and tenacity of rural people as well as the peculiar dynamics of relationships and types of problems they experience.

Related to rural and farm life are unique pressures and stressors such as economic issues associated with the weather, lack of control over prices, cost of inputs, drought, disease, land costs and rentals, globalization, rural values, and social dynamics. The mental health community needs to be prepared to care for these people and help them with transitions and other stressors so that they can cope effectively.

Rural Values

Values that undergird rural life tend to be social, based on the family and the community. The social and relational parts of rural life can be powerful in their psychological rewards. Rural people tend to understand what it means to belong to a close-knit community. They put stock in being a good neighbor. They have lifelong relationships with relatives close by and friends who seem like family.

Rural life tends to be characterized by rituals. Most often these rituals concern farming life: sowing and harvesting. They also concern social life: Young people becoming old people in the same place. Rural people accept the interplay between the good and the bad, accommodate themselves to the reality they see, and do what is necessary to be in harmony with their environment.

Rural people often participate in national affairs with great distinction. They offer wisdom in knowing how things fit together, a sense of continuity and history, a restraint against a rush toward change, and an awareness of how decisions will affect the lives of ordinary people.

In addition, rural people may be considered to be place-bound. To be removed from place can be a disorienting experience. One’s importance may be diminished, and by being separated from place, one may lose the vital energy upon which one has come to depend for nourishment, strength, and even life. A high percentage of farm families who are forced out of farming stay in their local communities—possibly because of this characteristic. They may view moving to an unknown place, where they do not know the history and the people, as a drastic uprooting. They may fear not knowing how to act in a place where “place” may not be important.

The Downside of Rural Life

In studying the social dynamics of a small community, psychologist Roger Barker found people take on many social roles to meet community needs. Functioning in multiple roles adds to stress. The same person may serve on different boards and community organizations and as a member of various groups. People may be recruited and pressured into community service.

At the same time, community members often see and meet each other at church, school functions, games, stores, dealerships, card parties, weddings, funerals, community fund-raisers, and local cafes and bars. They “change hats” frequently and make subtle shifts in relationships depending on the roles they are playing.

Rural people may cope with complicated social relationships when goals and ideas come into conflict by being “nice.” Being nice means not engaging in controversy and not giving strong opinions. It means ignoring conflict and living with the differences. In short, rural people often ignore their own feelings or underplay their emotional responses. Being nice is the socially correct way of living in a rural community; to be other than nice invites criticism.

A second concern is nonconformity. To feel out of step, judged, or excluded is painful. People in rural areas who have differences with their communities often live lives of pain, resentments, and anger, because they fear the pathway to reconciliation will cause further and perhaps irreparable harm. They may live with private anger and opinions that they keep to themselves.

A third concern is avoiding personal risks. Those who have difficulty controlling their emotions or resolving conflict find it easier to keep the peace. Being nice means they don’t have to think, take a stand, or risk rejection. If strong feelings and opinions are spontaneously expressed, a rural resident will likely encounter his or her antagonist later in various social settings. The tension between them may be awkward, as it may not be easy to keep roles and agendas separate.

Everyone has vested interests. If one opposes someone strongly in one setting, he or she may block one’s goals in another. Strong political controversy can rip apart the social fabric of a rural community. People may not know how to act when lines of conflict divide the community. To be highly passionate on an issue may create tensions one lives with today, tomorrow, and possibly all throughout life. Harmony is the value that makes the rural community work. Even if power is concentrated and public interest isn’t served, it still seems better to most people than raw, open controversy that upsets the social system.

A related concern is avoidance of conflict. When controversy spills over into the public arena, people may not know how to act. They may become polarized by the controversy. They may personalize the issue and take sides. They may not have enough experience with conflict to know how to negotiate or search for middle ground. Where does suppressed hostility and anger go? How does the community make important decisions and avoid community controversy? Unfortunately, gossip, social ostracism, and other indirect means of aggression may occur.

Some of the common dilemmas and problems facing people in rural communities are as follows:

  • Dealing with powerful social expectations and pressures
  • Finding it difficult to say no
  • Not feeling reinforced for engaging in leisure or specialized interests unless community obligations are fulfilled
  • Being expected to participate in time-consuming social and community events
  • Being too successful in a community where others are easily threatened
  • Being judged by social comparisons to peers in the local community
  • Becoming easily upset or disturbed by adverse public opinion
  • Maintaining appearances at a personal cost of being unauthentic; not feeling emotional safety in expressing feelings, problems, or divergent opinions—being criticized for being too open, spontaneous, and honest
  • Getting behind a mask—social gain at the personal expense of stifling true opinions and feelings
  • Not being able to solve problems because conflict itself is viewed as harmful—greater ease in covering up a problem than in getting people to try out poorly developed conflict-resolution skills
  • Being too different or out-of-step with strict community standards

An urban person might say, “Who cares what other people think?” A rural person knows there is social accountability and obligation.

Counseling in Rural Areas

Life in rural communities has its own value system with unique pressures and stressors. Social obligations, leadership, and volunteering associated with responsible community life lead to very busy, stressful lives. Another issue is the rural economy. The rural economy continues to suffer because of out-migration, declining population, and consolidating forces in the larger economy. Depression and anxiety are common problems when personal or business finances are precarious. Finally, complex technology, expensive inputs, seasonal pressures, the combination of the work and home environments, labor shortages, supervisory responsibilities, and other on-farm enterprises and off-farm employment all test the compatibility and coping skills of farm families.

Rural marriage problems also occur. The interplay between the demanding profession and being self-employed while working at the family residence can create marital conflict. Some male farmers are single-minded in their approach to farming and neglect the emotional needs of their spouse and children. Counselors have to give weight to the very real responsibilities and pressures farmers feel and to give voice to the spouse’s need for a warm and nurturing relationship.

Another area of concern is helping farm families work effectively in intergenerational and multifamily farm and ranch operations. There are boundary issues as family members work out common goals and share a common enterprise. Problems can build and create tensions and resentments while solutions may be stymied by poor communication and problem-solving skills.

The anonymity issue and accessibility of services are also counseling obstacles to overcome. There may be denial about depression, family problems, and alcoholism. There is a strong stigma about admitting a drinking problem rather than a mental health problem. Family doctors and mental health professionals become gatekeepers for the alcohol and substance abuse professionals. The social acceptability of alcohol use for adults and teens in many rural social situations can add to personal problems. While rural communities do not have a corner on alcohol problems, a lack of entertainment and recreation activities can lead to the use of alcohol to enliven social life. Some people are vulnerable to alcoholism or to the social pressures that go with regular drinking.

What are necessary skills for rural counselors? These counselors need to be approachable and down to earth. Effective counseling may be difficult if clients perceive counselors as being better than they are. Being respectful makes a huge difference. Counselors also have to be real and genuine. Additionally, being conversant and knowledgeable about rural dynamics and relationships can set clients at ease. Most clients do not want to feel as though they must educate their counselor about their problem. For most rural clients, travel is not an obstacle in seeking the right counselor.

Counselors also have to be trustworthy in terms of keeping confidences, because everybody knows everybody in rural communities. Dual relationships interfere with good treatment and are ethically dangerous, though sometimes unavoidable, in rural communities. There may be a clinical half-life to a professional living in a small community.

References:

  1. Bray, J. H., Enright, M. F., & Easling, I. (2005). Psychological practice in rural primary care. In R. G. Frank, S. H. McDaniel, J. H. Bray, & M. Heldring (Eds.), Primary care psychology (pp. 243-257). Washington, DC: American Psychological Association.
  2. Fenell, D. L., & Hovestadt, A. J. (2005). Rural mental health services. In R. G. Steele & M. C. Roberts (Eds.), Handbook of mental health services for children, adolescents, and families (pp. 245-258). New York: Kluwer Academic/Plenum.
  3. Jameson, J. P., & Blank, M. B. (2007). The role of clinical psychology in rural mental health services: Defining problems and developing solutions. Clinical Psychology: Science and Practice, 14(3), 283-298.
  4. Roberts, L. W., Warner, T. D., & Hammond, K. G. (2005). Ethical challenges of mental health clinicians in rural and frontier areas. Psychiatric Services, 56(3), 358-359.
  5. Sawyer, D., Gale, J., & Lambert, D. (2006). Rural and frontier mental and behavioral health care: Barriers, effective policy strategies, best practices. Waite Park, MN: National Association for Rural Mental Health.

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