Protecting the mind and body of rural America
A Publication of the APA Practice Directorate
Vol. 2, No. 1, Summer 1995
Rural Health Bulletin

Table of Contents

  • The Senate Rural Caucus Catalyzing Innovative Rural Health Initiatives
  • Psycholgist-Physician Collaboration Helps Fill Primary Care
  • Psychology Training Programs Offering Rural Focus Double in Past Decade
  • Medicaid Waivers--Innovation or Devastation for Rural America?
  • American Indians Into Psychology Pipeline
  • Women's Health Challenged in Rural America Spotlight on the Alaskan Bush Country--Kodiak Island


    Pat DeLeon, Ph.D., J.D. and Mary Wakefield, Ph.D., RN
    U.S. Senate Staff

    With the recent convening of the 104th Congress, the issue of ensuring high quality health care to rural America has once again become a Congressional focus. The Senate Rural Health Caucus, co-chaired by Majority Leader Robert Dole and Senator Tom Harkin, has begun to coalesce formally. During the last Congress, approximately 70 percent of U.S. Senate elected to join the caucus which, with its cross-committee focus, historically has been the catalyst for many of the more innovative rural health initiatives.

    It is interesting to reflect on the probability that, in many ways, striving to provide the type and level of health resources to meet the needs of rural America is almost an overt contradiction to the underlying notion of aggressively reducing the degree of government intervention -- not to mention the federal deficit. The widely accepted perception is that these reductions reflect the hallmark of the November elections and the Clinton Administration's priorities. However, almost by definition, the lack of a critical mass, the paucity of professional resources, and a fundamental lack of economic opportunities are the defining characteristics of rural America.

    The Senate Rural Health Caucus was formed originally during the 99th Congress expressly because it had become clear that the needs of rural America were so unique -- and traditionally so unappreciated by every Administration -- that it was highly unlikely that the private sector or 'government as usual' would ever be responsive to rural needs. Even today's call for 'providing greater flexibility at the state level to target local priorities' may mean that rural America will continue to be underserved -- resulting in significant adverse health consequences. We further note that relying upon local health policy decision makers is particularly problematic for ensuring that a wide range of health care providers will be recognized appropriately under various service delivery (i.e., reimbursement), training, and research programs.

    Over the years, the Senate Rural Health Caucus -- along with its counterpart in the House of Representatives -- has been successful in opening up nearly all federal reimbursement programs (such as Medicare) to ensure that, for example, nurse practitioners and clinical social workers would be autonomously recognized and that the federal government's Title VII (health professions) training programs would provide resources for interdisciplinary and multidisciplinary efforts. Rural health transition grants, innovative programs to keep rural hospitals open, authorizing a rural health task force within the Department of Commerce, as well as special 'set asides' for non-physicians under the National Health Service Corps scholarship program are all accomplishments of the caucus. The caucus has most recently become particularly interested in the inherent potential of evolving advanced technology, including telecommunications, the use of computer patient profiles, and other information age technologies. In our judgment, it is significant that throughout the efforts of the caucus, discussions leading up to the comprehensive Office of Technology Assessment (OTA) 1990 report on rural health care have provided a systematic plan for based on what has worked and what priorities should be.

    As we begin the 104th Congress, one of the political notions currently being seriously considered is that of program consolidation, perhaps along the lines of that instituted by the Reagan Administration. If blindly implemented, this approach should pose very real concerns for those professionals interested in the well-being of rural America. The past would strongly suggest that as a practical matter, 'consolidation' may mean the elimination of any systematic rural focus. Simply stated, the reason that special rural programs were established is that, historically, federal priorities have not been responsive to rural America's uniqueness. This is evident whether one is considering the drafting of facility staffing regulations or the establishment of programs to ensure that the all important psychosocial aspects of health care are duly considered.

    It is also interesting to reflect upon the probability that, given the magnitude of change that occurred during the November Congressional elections, as well as the general inability of the Congress to effectively address comprehensive national health care reform during the last session of Congress, many have undoubtedly assumed this issue would now be moot. However, there are numerous indications that this may be far from the case. For example, during the President's January State of the Union Address, he again specifically raised the issue of health insurance reform, this time proposing to work collaboratively with the new Republican majority and specifically with Majority Leader Dole. And, of course, our nation's health care costs continue to rise faster than any other segment of our economy -- a situation that simply cannot continue. The broad-based political interest in addressing health care remains quite strong as evidenced by the growing number of states that have decided on their own to explore a wide range of state-oriented health insurance plans, often with a significant 'managed care' orientation.

    Editor's note: Drs. DeLeon & Wakefield are health professionals with long & impressive histories of involvement in health care policy-making on Capitol Hill. They are currently serving as chiefs-of-staff for Senators Daniel Inouye (D-HI) & Kent Conrad (D-SD), respectively.


    By Russ Newman
    Director for Professional Practice, APA

    The Washington Post reported on November 29, 1994 that 'Of the more than 50 million Americans living in rural areas, more than 21 million are in areas that don't have enough health care providers to meet their basic primary care needs.' Psychologists serving rural clients can have a major role in alleviating this situation through collaborative practice with primary care physicians. The psychologist's role is to prevent and treat the estimated 40 to 60% of patients who present to primary care physicians with health problems that have a behavioral etiology. Psychology is a health profession which can make significant contributions to primary health care in addition to its traditional role of treating mental illness and substance abuse. Psychologists collaborate with physicians on the behavioral and emotional problems of patients, assess and treat the psychological component of physical illness, and collaborate with physicians in insuring adherence to all aspects of treatment.

    The first issue of the Bulletin reported successful collaboration between rural psychologists and primary care physicians in identifying and treating substance abuse in a project supported by the federal Center for Substance Abuse Treatment. The psychologist/physician pairs found that, in addition to substance abuse, they often collaboratively treated adults with anxiety and depression as well as children with attention deficit disorders. In order to explore additional practice opportunities for psychologists working with primary care physicians, I established a Practice Directorate (PD) staff working group. As part of their yearlong endeavors, the working group held a forum at the 1994 APA Convention for members with an interest in primary care collaborative practice to discuss possible initiatives with me and the working group. The report generated from these discussions was distributed to participants and the Committee for the Advancement of Professional Psychology (PD's oversight committee), which in turn formed a Task Force on Primary Care to promote practice opportunities for psychologist's primary care activities as well as to identify ways in which to promote an 'upgraded vision' of psychology - influence public opinion and policy in such a way that primary care will be defined as including psychological/behavioral health services.

    The Primary Care Task Force will be exploring the multitude of acute and chronic conditions where primary care collaborative practice is possible in disease prevention and health promotion. Because of the nature of rural practice where psychologists are often the only behavioral health professional available and primary care physicians are hard-pressed to provide all the care that is needed, rural practice presents the ideal venue for expansion of psychology's role in primary health care.

    Psychology Training Programs Offering
    Rural Focus Double in Past Decade

    by Catherine D. Gaddy, Ph.D.
    Assistant Director, APA Office of Program Consultation and Accreditation, Education Directorate

    Psychologists who have extensive experience working in rural settings and training students to do so call attention to the need for special training models. What is so different about preparing psychologists for work in rural areas? Several unique features in the education of rural practitioners have been identified, including:

    Twenty-eight psychology internship programs reported having a rural component in the mid-1980's in a survey conducted by Singer and Heyman (Journal of Rural Community Psychology, Summer,1986). That number more than doubled in the ensuing decade. During the past year, a survey of graduate departments and schools of psychology and APA-accredited predoctoral internship programs was conducted by APA. Nearly 70 academic and internship programs reported that they offer courses or seminars, conduct research, or provide practice opportunities for their students or interns that explicitly address rural issues.

    Recently, a more in-depth follow-up survey was sent to these respondents in order to further explicate how training is conducted vis-a-vis rural needs. The data obtained will provide an up-to-date resource for APA staff, potential students and interns, faculty and staff, and others seeking to identify psychology programs with specialized rural training and research components. Information on education and training programs having a rural emphasis or component will facilitate matching students with programs and faculty with their colleagues. This information exchange will be one step in addressing the needs for education and training of psychologists to function effectively in rural settings. For further information please call Marquette Turner, Office of Rural Health (202.336.5857).


    by Michael F. Enright, Ph.D.
    Chair, APA Rural Health Task Force

    The health care reform debate has rapidly changed its focus from Capitol Hill in Washington, D.C., to state houses across the country. Many of the quality of care issues that professional psychology fought for in the federal health care reform initiative, such as a reasonable mental health care benefit, portability of coverage, confidentiality of psychological records, and professional control of clinical decision- making are being lost as state departments of health begin bidding out mental health care contracts to the lowest bidder among managed care companies.

    This rapid revolutionary change is taking place through a process of granting HCFA 1115 waivers to states. Section 1115 waivers allow states to set aside regulations and protections guaranteed by Congressional legislation under normal Medicaid procedures in order to deliver behavioral health services more economically. Initially, these waivers were granted as a way to allow a small number of states to experiment with novel service delivery systems. Today, however, with the prospect of receiving hugh monetary contracts to capture whole state behavioral health care delivery systems, the managed care industry is promoting a wholesale auction of public mental health service delivery. More than twenty states have applied for 1115 waivers thus far.

    Unfortunately, no organized system of accountability other than rather vague Medicaid guidelines is in place to provide control or oversight. These changes have the potential of creating devastating effects on service delivery for rural populations, where large behavioral health corporations will be tempted to create systems that appear to provide services on paper, but in fact, create real barriers to delivery for rural citizens. When changes are based primarily on cost containment, it is unlikely that lessons from the past regarding service delivery for psychological conditions (emotional and behavioral) will be considered. We have learned from past experience that mental health service delivery must take into account such factors as geography, e.g., mountain passes and treacherous winter road conditions, the particular transportation limitations of poor and elderly citizens, as well as the fact that rural citizens relate to their own towns and communities for health care needs based on longstanding significant ethnic and cultural ties.

    Professional psychologists, who have long been advocates for the behavioral health care needs of rural citizens in both the public and private sectors, now, more than ever before, must be more vigilant to insure that the bottom line of cost cutting does not mean a deterioration, or de facto elimination of, quality services in rural and frontier America.


    by Art McDonald, Ph.D.
    President, Dull Knife Memorial College Lame Deer, Montana

    For the past six years, Dull Knife Memorial College has conducted graduate psychology training in conjunction with the psychology departments at the University of North Dakota, the University of Montana, the University of South Dakota, Utah State University, Denver University, and Pace Institute. The twofold purpose of this collaborative training program has been to introduce students to the diverse cultural realities of rural frontier populations in general and the Northern Cheyenne Reservation in particular.

    Students come to the reservation for an entire academic year and carry a full academic course load taught by rural and or Native American Indian psychologists. In addition, the students work in the College Psychological Services Center, teach one undergraduate course per semester and participate in the ongoing center research projects. The client-related work is supervised by a clinical psychologist licensed in the state of Montana. The students earn a specialty in Rural Minority Psychology and are prepared to practice in the frontier areas and to work for agencies such as the Indian Health Service.

    Editor's note: In the final moments of the 103rd Congress, Senator Burns introduced an amendment (No. 2387) to the Department of the Interior Appropriations Act which appropriated $250,000 for the recruitment and training of Native Americans in graduate level psychology programs. Although authorized by the Indian Health Care Improvement Act of 1992, funds were not appropriated for this purpose until passage of the Burns Amendment.


    Pamela Baglien, PhD, Kodiak Island Mental Health Center
    Sylvia Shellenberger, PhD, Medical Center of Central Georgia

    Kodiak Island is a rocky and mountainous projection in the North Pacific inhabited by fewer than 16,000 persons. The diversity of the population and the isolation make it more similar to another country than a remote extension of the U.S. Coast Guard members receive overseas pay for their duty on the island despite being on the country's largest Coast Guard base. The weather during the week prior to this writing included 90 mph wind gusts and -30 degree chill factor.

    The Alaska Native population on Kodiak is primarily Aleut. The initial Caucasian population consisted of Russian explorers and fox traders, followed by Scandinavian fishermen. The economy is based on fishing and has brought a variety of additional ethnic groups from around the world, nearly all of whom speak different languages, and many of whom are refugees from political horrors. Each of these cultural groups has either come with families or worked hard to be joined by their families. Consequently, there is a mixed array of displaced women and children for whom English is not their first language and for whom cultural adjustment provides major hurdles. In addition to being in a new culture, many residents face long working hours in fish processing plants, long periods of seasonal unemployment and multifamily living situations.

    Since its inception in 1970, Kodiak Island Mental Health Center has been the primary (and usually the only) provider of mental health services on the island . Providers are challenged to find creative solutions to delivering services to women in a place where a good deal of the population can be reached only by boat or float plane, and where many persons do not speak English.

    Challenges in Kodiak Similar to Other Areas . . .

    Many of the issues facing women and girls in remote, rural areas such as Kodiak Island are similar to issues faced by women and girls throughout the country--sexual assault, domestic violence, teen pregnancy, alcoholism, depression, economic insecurity, and lack of education and training. In some rural communities, however, these problems are even more pronounced than they are elsewhere. For example, mortality rates for American Indian women are considerably higher than for women in the general population for alcoholism, homicide, liver disease, and motor vehicle accidents.

    Women and girls in rural areas may be inhibited from availing themselves of existing health and mental health services for environmental, economic, and cultural reasons as well as for reasons of intergenerational vulnerability. Harsh environments and economic disadvantage may preclude women from using services at their time of greatest need. Sociocultural factors such as political, social, and religious constraints may also inhibit helpseeking. The intergenerational nature of trauma and victimization in certain populations, may lead them to mistrust available services.

    Making services more readily available in order to make women and girls feel safer about using these services is a challenge which health professionals face, particularly in such remote communities. Attempts to address this challenge include making health and mental health services available to girls at school. Also, respected women leaders in the community have been trained to meet with women at risk to assess their health and mental health status and provide information about various resources.

    Harsh environments and great distances, as in the Alaska bush country, are impediments for men, women, and children who would otherwise take advantage of existing services. Spanning these distances between service providers and rural and frontier Americans is as much a challenge for providers as for their clients.

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