Protecting the mind and body of rural America
A Publication of the APA Practice Directorate
Vol. 1, No. 1, Summer 1994
Rural Health Bulletin




Table of Contents

  • Congress Acknowledges Unique Concerns for Rural America in Health Care Reform
  • American Psychological Association Responds
  • Rural Initiatives and State Advocacy
  • Psychologists Link with Primary Care Physicians for Effective Substance Abuse Treatment
  • Psychology, Nursing and Social Work: The Training Trio in Utah
  • Women Challenged in Rural America: Response to Farm Crisis Diverse
  • A Message from the APA Rural Health Task Force





  • Congress Acknowledges Unique Concerns for Rural America in Health Care Reform

    Representative Jill Long

    Chair, Congressional Rural Caucus U.S. House of Representatives

    With over 25 percent of the nation's population living in rural areas, it is crucial that health care reform take into consideration the unique problems faced by rural Americans. As chair of the Congressional Rural Caucus, I am concerned that provisions intended to address rural health care problems will be overshadowed by larger issues of reform and not receive the attention that they need and deserve.

    The primary discussion in rural areas about health care reform is not focused on the structure of alliances or the composition of the standard benefits package, but is primarily concerned with the financial stability of the community hospital or recruitment of a new town doctor. I am confident that bipartisan organizations such as the Rural Caucus and the Rural Health Care Coalition will work together to address the needs of rural Americans and ensure that the decision to live in a rural area is not a decision to accept inferior health care.

    Senator Bob Dole

    CoChair, Senate Rural Caucus Senate Minority Leader

    As we consider reforming America's health care system, we must do what we can to preserve and promote health care delivery in rural communities. Two key programs increase access to health care in rural states¾the Essential Access Community Hospital/ Rural Primary Care Hospital Program (EACH/PCH) and the Rural Health Care Transition Grant Program.

    An EACH hospital provides emergency and medical backup services to the primary care hospitals in its network. A PCH hospital is a smaller facility located in a rural area that provides 24hour emergency care and devotes no more than six beds to shortterm (72hour) inpatient care to patients requiring stabilization before being transferred to another hospital. States select hospitals for conversion to EACH and PCH hospitals.

    The Rural Grant Transition Program assists rural hospitals with fewer than 100 beds in developing and implementing projects to modify the type and extent of services they provide. In Kansas, funding has been used to explore ways to offer new services to dispersed rural populations and to recruit physicians.

    American Psychological Association Responds

    Michael Enright, PhD.

    Chair, APA Rural Health Task Force

    The Rural Health Initiative, established by Jack Wiggins, Ph.D., while he was president of the American Psychological Association (APA), maintains the goal of preparing psychology for rural practice in the 21st century. Although thousands of psychologists practice in rural communities throughout America, meeting the unique needs of these residents, psychology has remained invisible to many state and federal policy makers and bureacrats.

    It is my goal as chairman of the APA Rural Health Task force to markedly increase the visibility of psychologists, be they academics providing training and service in rural colleges and universities, administrators in state agencies, public health executives or practitioners quietly providing quality care with little support in public and private programs in the towns and hamlets of rural America.

    The second goal in establishing a vision for the future of psychology in rural and

    frontier communities is to create a new and meaningful collaborative practice relationships with primary providers. One of the most important and least heralded provisions of the Clinton health care plan focuses on training enhancements and research and development of new interdisciplinary models for health care delivery for rural residents.

    This document should be considered a road map for our profession to navigate the twists and turns most assuredly waiting for us in the future. It is vitally important that, as psychologists become more visible in the short run, we work to create more innovative models for primary care and behavioral health teams to work in rural and frontier communities. The Rural Health Task Force will also continue to foster pilot projects with the assistance of agencies such as the Office of Rural Mental Health Research at NIMH to join other health care professionals on the cutting edge of real health care reform.

    The final goal of the Rural Health Task Force is to facilitate the removal of artificial barriers to psychological practice in rural areas so that psychologists can work to the full extent of their professional training and competence. Too much talent is wasted in this country because professions are limited by their own expectations or by arcane rules, policy and laws enacted many years ago that do not reflect the current health care environment or the specific advanced training and competence of today's licensed psychologist.

    We psychologists have enjoyed a tremendous increase in the demand for our services and respect for our expertise over the past 15 to 20 years. All too often, however, psychologists trained in a specific model feel ill at ease taking greater responsibility in the rural community or in general hospital settings in rural towns and small cities.

    It is my intention as chair of the Rural Health Task Force to assist our colleagues in stepping forward and accepting the advanced professional roles awaiting them in rural communities. In many locations these opportunities include full participation on the medical staff of the local community hospital. Psychologists have much to offer in this setting, but can they only be effective if they understand the hospital culture and appreciate the wealth of information and professional care that they have to offer in this environment. Less than 10 percent of the 2,200 rural hospitals in American offer any form of mental health services. These hospitals are located in communities whose citizens suffer from the same psychological and emotional stresses as individuals in the rest of the country. It is time for psychologists to take a leadership role with new models for service delivery in these important community institutions. To further this important social agenda, it is the goal of the Rural Health Task Force to assist in expanding the professional scope of practice of psychologists to include, where appropriate, the dispensing of psychopharmacological agents and taking other advanced roles such as the performance of evaluations for involuntary commitments. It comes as no surprise to those familiar with rural health care that psychologists in rural states like Wyoming currently turn to physicians' assistants to find prescriptive assistance for the people in their care in many communities.

    Rural Initiatives and State Advocacy

    by Michael Sullivan, Ph.D.

    American Psychological Association

    States are taking the lead in reforming health delivery systems by privatizing Medicaid programs and by establishing new integrated networks of service delivery. These state health reforms are providing for the special needs of rural areas to be better addressed through creative approaches to accessing care, especially care for psychological problems.

    As the state psychological associations (SPAs) work towards good mental health coverage they are helping to advance rural mental health initiatives in state legislatures. The Practice Directorate has been pleased to support these SPA projects with sizable amounts of technical and financial assistance. On the occasion of this inaugural issue of APA Rural Health Bulletin, we offer our best wishes for every possible success as well as our ongoing support.

    Psychologists Link with Primary Care Physicians for Effective Substance Abuse Treatment

    Collaboration between health care providers and the use of a collaborative practice model between psychologists and physicians is a growing arena for meeting the multiple needs of patients. In rural areas, the lack of specialists places increased pressure on primary care physicians to diagnose and treat a broad spectrum of biomedical and psychosocial problems. Psychologists are often the most highly trained mental health and substance abuse professionals functioning in rural communities. Behavioral threats to good health¾such as smoking, alcohol abuse, teen pregnancy, accidents and occupational injuries¾all have high incidence rates in rural areas. Psychologists' collaboration with family physicians can improve the effectiveness of assessment and intervention.

    The Psychology/Primary Care Linkage Project demonstrated that collaborative practice between psychologists and family physicians could be developed to enhance the assessment and treatment of alcohol and other substance abuse in rural America. This project was supported by Contract #92MF05154001D from the Center for Substance Abuse Treatment.

    Congress Says Rural Mental Health High Priority

    In response to the critical need for mental health research concerning rural populations, the Congressional Appropriations Committees directed the National Institute of Mental Health (NIMH) to give high priority to rural mental health research. To implement this priority, NIMH established an Office of Rural Mental Health Research (ORMHR) within the office of the Director of NIMH, with psychologist Charles Windle, Ph.D., as office director.

    NIMH gives research priority to several issues of rural mental health, including: special problems of delivery in rural areas; increasing the availability of qualified providers of mental health services in rural areas; methods of financing services to impoverished populations; assessing the diversity of rural conditions in relation to service needs and use; development and testing the use of telecommunications to overcome service access problems; and issues pertaining to health care reform and their implications for rural areas. These and other areas of interest are described in an NIMH program announcement for research on mental disorders in rural populations.

    This special announcement and a listing of recent and currently funded rural mental health research can be obtained by writing staff members Charles Windle, Ph.D., Anthony Pollitt, Ph.D., or Armand Checker, M.S., in the Office of Rural Mental Health Research, NIMH, 5600 Fishers Lane, Room 10104, Rockville, Maryland 20857, or by calling 3014439001.

    Psychology, Nursing and Social Work: The Training Trio in Utah

    By Ted Packard, Ph.D.

    University of Utah

    Making maximum use of available personnel is one strategy for providing health and mental health services in rural areas. Building on work that began in the spring of 1991, members and staff of the American Psychological Association (APA), the American Nurses Association (ANA) and the Council on Social Work Education (CSWE) are approaching completion of a curriculum for psychologists, nurses and social workers working as an interdisciplinary team to treat mental health problems in rural areas. The developers of the project submitted an application that resulted in support by the Bureau of Health Professions, DHHS. The University of Utah used a draft of the curriculum to conduct an interdisciplinary seminar this spring with psychology, nursing and social work students.

    The curriculum is designed to incorporate the following features: It will be applicable to preservice and inservice training; the use of community support systems will be an integral part of the curriculum; it will be in a format flexible enough to be adapted for use in other rural areas of the U.S.; and it will offer didactic instruction and practicum experience in providing mental health care in a manner sensitive to ethnic minority populations, specifically those of American Indian and Hispanic cultures.

    The associations are collaborating with the Department of Educational Psychology, the College of Nursing and the School of Social Work at the University of Utah to develop the curriculum. The three rural sites selected for curriculum development are Lame Deer, Montana, Las Vegas, New Mexico, and Jackson, Wyoming. The rationale undergirding the site selection was to access two distinct ethnic minority populations (American Indians and Hispanics) and one population that is served from a small, acutecare hospital setting. Curriculum development will include participation at the sites by local mental health and public health officials as well as by local practitioners, educators and students.

    Women Challenged in Rural America: Response to Farm Crisis Diverse

    Ursula Delworth, Ph.D.

    Associate Dean College of Education, University of Iowa

    Rural and farm women are a diverse group. While most grew up in rural areas, some have urban backgrounds. Increasingly, they are employed outside the home/farm, especially in the wake of the farm crisis of the 1980s, and continuing economic problems in rural America. Over onehalf of the farm women consider themselves cooperators/managers with their husband, and 60 percent feel that they could operate their farm alone. For many of these women, offfarm employment adds a 'third shift' to the already fulltime work of child care and home/farm duties.

    Research results are mixed in terms of depression in rural women. For some women, the loss of the farm and/or need to be employed off the farm have been very negative and stressful. Others, however, have been reenergized by the opportunity to return to school, start their own business or return to a career. For all of them, however, the decline of businesses and services in rural areas has added stress in terms of time and travel schedules.

    Women's Subcommittee: Focusing on Unique Needs

    Sylvia Shellenberger, Ph.D., of the Mercer University School of Medicine, Macon, Georgia, chairs the Women's Subcommittee of the APA Rural Health Task Force. Other members represent widely diverse rural regions and institutional affiliations.

    They include:

    Ursula Delworth, Ph.D., Associate Dean

    College of Education, University of Iowa

    Iowa City, Iowa

    G. Rita Dudley, Ph.D., M.P.H.

    Assistant Commissioner of Health

    Christiansted, Virgin Islands

    Debra Dunivin, Ph.D.

    Psychopharmacology Post Doctoral Fellow

    U.S.U.H.S., Bethesda, Maryland

    Mary Beth Kenkel, Ph.D., Chancellor

    California School of Professional Psychology

    Fresno, California

    Pamela Mulder, Ph.D.

    Department of Psychology, Marshall University

    Huntington, West Virginia

    The goal of the subcommittee is to develop strategies for addressing women's psychological needs in rural areas and for encouraging rural women to avail themselves of existing services. The Subcommittee will address issues related to psychological training, research and intervention for rural women.

    Call for Nominations

    APA's Board of Directors has authorized the establishment of a Commission on Ethnic Minority Recruitment, Retention and Training in Psychology. Nominations and questions should be directed to Bertha G. Holliday, Ph.D. at APA's Office of Ethnic Minority Affairs, (202) 3366029 by August 31, 1994.

    Rural Health and Related Topics

    Date: 8/12 Time: 7-8:30 am

    Place: Garden Room West, LA Hilton and Towers

    Discussion: Rural Health Forum

    Date: 8/14 Time: 10-10:50 am

    Place: Westin Bonaventure Los Angeles, Lobby Level, San Pedro Room

    Symposium: Benefits of Working in Community Mental Health

    Date: 8/14 Time: 10-10:50 am

    Place: Los Angeles Convention Center, Level Two, Concourse Meeting Room 402A & 402B

    Symposium: Predoctoral Training for Rural Service

    Date: 8/14 Time: 11-12:50 pm

    Place: Los Angeles Convention Center, Level Two, Concourse Meeting Room 402A & 402B

    Symposium: Postdoctoral Training and Education for Rural Service

    Date: 8/14 Time: 2-2:50 pm

    Place: Los Angeles Convention Center, Level Two, West Meeting Room 502B

    Workshop: Small Town & Frontier Independent Practice¾Clinical & Personal Challenges

    Date: 8/15 Time: 2-3:50 pm

    Place: Los Angeles Convention Center, Level Two, West Meeting Room 515A

    Conversation Hour: Future Evolutions for Professional Psychology

    Date: 8/16 Time: 10-10:50 am

    Place: Westin Bonaventure Los Angeles, Lobby Level, San Fernando Room

    Symposium: Making Psychology Public Training & Service for Mental Health

    A Message from the APA Rural Health Task Force

    The time for action is now. Our profession must decide whether we want to continue and expand our role as leaders in the delivery of psychological and behavioral health care in rural areas or simply be another 'mental health care provider' in the system. The rural health task force of the American Psychological Association has accepted these challenges and has begun bold new programs in support of our agenda. Please join us in this effort. We need your ideas, energy, and support. Thank you.

    Rural Health Bulletin is published twice a year by the Practice Directorate of the American Psychological Association.

    Russ Newman, Ph.D., J.D.

    Exective Director for Professional Practice

    Gil Hill

    Director, Office of Rural Health

    Debra Dunivin, Ph.D.

    Editor, Rural Health Bulletin

    APA Practice Directorate

    Main Phone: 202.336.5800

    Fax: 202.336.5797

    Rural Health: 202.336.5857

    APA Rural Health Task Force

    Chair Michael Enright, Ph.D.

    Jackson, WY

    Vice Chair James Bray, Ph.D.

    Houston, TX

    Members Paul Craig, Ph.D.

    Anchorage, AK

    David Scott Hargrove, Ph.D.

    Oxford, MS

    Mary Beth Kenkel, Ph.D.

    Fresno, CA

    Arthur McDonald, Ph.D.

    Lame Deer, MT

    Jerry Morris Psy.D.

    Nevada, MO

    Sylvia Shellenberger, Ph.D.

    Macon, GA

    Senior Advisor Jack G. Wiggins, Jr., Ph.D.

    Cleveland, OH

    Staff Liaison James G. (Gil) Hill

    Washington, DC

    Office of Rural Health

    American Psychological Association

    Practice Directorate

    750 First Street, NE

    Washington, D.C. 200024242

    Return your comments and suggestions to the Office of Rural Health at the address above.




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