While there is a weak statistical association … That is one area of disparity and difference that has been documented several times, is that around mental health literacy, knowing the symptoms and the issues of a behavioral health disorder and where to turn for help. Psychology Today, Why Shrinks Have Problems And so, you really have to sort of blow up and expand the pool of eligible providers to really make a dent in access, in my opinion. 6‐7 Patients have an increased mortality and morbidity associated with a range of physical conditions. We don't talk about that in behavioral health. In Alaska, I mean, I often tell people, if you want to see how you do things in rural, go to Alaska, because I could actually do an hour of just Alaska. I was involved in an iPad project in Alaska where case workers, outreach works would have an iPad with them, and when they were meeting with a client in the community, they could immediately access a psychiatrist to do a med check and do it from the comfort of somebody's home. There are few fields where both the challenges and the rewards are more significant than for those working in Mental Health. Of course, when you talk to folks on the mental health side of the discussion on integration, they're talking more about ensuring that the people that they work with, their partners in care receive adequate healthcare services, to bend that mortality curve and to have better coordination around side effects of medication, etc. And as I mentioned currently directs the WICHE Mental Health Program, which is a collaborative venture comprising 15 western states and Pacific territories and affiliated states. A Lack of Funding. So, we have this chronic shortage of mental health professionals in rural areas and it's been at 60% for ages. We don't have a standard. I don't have any more questions. In addition to the barriers created by a child’s mental health diagnosis many children receiving services face hardships like family instability, abuse, poverty and … We don't have a goal. Today there are very few programs that trained, that specifically train people to work competently in rural places. Almost 20 percent of adults in the U.S. face a mental health problem within a given year, and about one in 25 adults suffers from a serious mental condition that impacts quality of life. 40%? Some of those issues include the following: The health care system in the U.S. is a far stretch from perfect, and some of the toughest challenges belong to the mental health industry. That's where the funding has devolved to over the last 25 to 30 years. So is that our goal? How long should it take for somebody in crisis to be responded to? And at this point in time I think we can turn it over and you can use the question and answer field to ask any questions you might have, and we'll do our best to answer those. >> ROBERTO DELGADO: Thank you so much, Dennis. I think I will close the webinar. To our participants, again, yes, for those that have questions, please make sure you type them in the Q&A box on the right hand side of your screen. But if you put an urban community under the same stressor, you would have the same sort of reaction. Mental health challenges and disorders can happen to anyone. The cold hard facts about mental health and rural America is that more than 60% of rural Americans live in mental health professional shortage areas, that more than 90% of all psychologists and psychiatrists and 80% of Masters of Social Work, work exclusively in metropolitan areas. At WICHE we developed a Psychology Internship Initiative because what we saw that people were not    did not have access to those training opportunities, and in our rural states of the west, our doctoral level psychology programs were producing eight to ten to twelve doctoral-level psychologists each year and they were all leaving the state because there were no psychology internships available in state and there were not rural sites. Caring for a family member with a mental health problem can have many negative effects on the carer. So what do we want to reduce it to? In Illinois, it started as the Farm Resource Center, and basically there was the notion there was that the people that were    that if you waited for farmers and ranchers to come into the clinic to access care, you were going to be waiting too long, and so they recruited professionals and para professionals with farming and rural backgrounds and trained them to serve as outreach workers and sit around the table at the farmhouse and help people figure out what they needed and provide that outreach to people. In the Northern Marianas Islands, a program we've been involved with in the territories, very remote, very rural. We're hearing feedback or static from your line. Research Conducted at NIMH (Intramural Research Program), Attention-Deficit Hyperactivity Disorder (ADHD), U.S. Department of Health and Human Services. Not in a mental health crisis, but just to be able to talk about the help with daily living issues. So for all practical purposes, the retiring psychiatrist was not taking new patients. In 2016, another study at Denver Health concluded that a lack of mental health services and access to them contributed to delays in medical treatment for underserved patients with head and neck and lung cancers. Your kids are on the bus longer. So what's our plan? And follow on to that, what are areas that actually can be addressed? I think there has been a sustained effort in that regard for several years now and we need to deepen that. U.S. News, Under Obamacare, Mental Health Lacking So I want to thank you, Dennis, again, once more, and all the participants for joining us, and look forward to having equally engaging webinar on June 27th. They've worked very    they've done a lot of research to be able to right size the Assertive Community Treatment to small community reality, and now they're in the midst of developing rural specific fidelity measures. In early 2014, an appropriations bill made the way for $115 million to go toward mental health initiatives. We really need to engage in that partnership of care and help people to get from whatever door they walk in to the care that they need. So, I'll turn it over to you now, Dennis. They don't usually talk to me about better care for persons with schizophrenia or changing the mortality rates of persons with serious mental illnesses compared to the non SMI population. However, in some parts of the country, available mental health resources are still severely lacking. There is a higher level of stigma in rural areas that is discussed in the literature quite a bit. I mean, I was just normal. Rural people are oftentimes not well informed about either mental health conditions or the options for care. But one of the things I wanted to talk about in Alaska is they knew they were never going to get master's level folks out to the small villages in remote Alaska, but that didn't mean that people in remote places of Alaska didn't need help. And that means that states can exercise their option not to provide it. We don't often plan what works. How to Improve Mental Health on a Daily Basis Beyond this ambiguity, a second challenge is that … Making sure patients have access to needed medications. I want to welcome everyone today for the second offering in our 2018 webinar series. Thank you, Dennis, again, for a very comprehensive overview on rural mental health, as well as the insights and responses that you gave to the participants and their questions. It is important to appreciate that any care plan should meet the needs of the individual and to ensure that the family/carers are also supported. So this is actually what you typically would see in a children's mental health system operating in the community. Danger to Self or Others (Lessard v. … This law applies to Wales and England – Scotland and Ireland have their own separate legislation, and the laws in other countries vary, too. So I've had that conversation with hundreds of people in one shape or form. It needs to be proximal. We use words like "chronic," and I listen to people oftentimes talking about Assertive Community Treatment, for example, where you don't get out. We don't have that standard. It's just that it's actually formally put in the school system, and the school system has the money for the children's mental health system up to a certain point. And then enthusiastically. And you have to be able to demonstrate your competency and your ability to do that, and then Alaska has also invested a lot of time to ensure that the supervision is there for aides, so that they    so the supervisors have to be trained both to help the aide develop the competencies to do their scope of practice, and then they have to be    and then they're also trained to be able to enhance those competencies and ensure that those competencies are  current. Getting there and paying for it, availability, that there's actually someone there when you get there. So, how did it get this way? Recommendations are made in relation to preparation strategies and training for sign language … Comprehensive services as a result are not available. Get the latest public health information from CDC: https://www.coronavirus.govGet the latest research information from NIH: https://www.nih.gov/coronavirusGet the latest shareable resources on coping with COVID-19 from NIMH: https://www.nimh.nih.gov/covid19. ... mental health patients. Mental health professionals who work with children and adolescents face a variety of unique challenges. And if we, researchers and policymakers, have a hard time putting our thumb on who is there to help, the typical person seeking care has an even harder time. Specialty providers are highly unlikely to be available in rural areas. I see one more question that has come in. I think that there's... in Hawaii, for instance, that was in Michigan that the former example was from. And with that, I'm going to just wrap up. And it too has helped provide information and support and referral and has reduced the amount of crisis response needed. And it doesn't work in mental illness and in substance abuse. I do wonder what kind of mental health nurse I will be and whether I will have the emotional resilience to deal with the challenges that lay ahead. Mental Health America, Mental Health Policy, Time, America’s Failing Mental Health System: Families Struggle to Find Quality Care, The White House, New Funding to Increase Access to Mental Health Services and New Protections Under the Health Care Law, U.S. News, Under Obamacare, Mental Health Lacking, Psychology Today, Why Shrinks Have Problems, National Alliance on Mental Illness, Mental Health By the Numbers. That is:  What role do you see in the use of telehealth in shrinking the distance people need to travel in bringing specialists to rural areas? I have a slide here with the pictures of the WICHE team and contact information on how to get in touch with WICHE. Objective: The aim of this present paper is to highlight some of the issues faced by therapists and sign language interpreters when working with deaf patients. I would like to say I was brilliant in doing that, but basically I knew this primary care group that had office space and they wanted to fill it and we could share reception staff, and I was able to cut my costs and they were able to recover more cost for their space to help reduce some of their economic tensions. We don't have one. Are there any similar examples of successful models implemented within or in partnership with schools? We haven't made the investment in developing of strategies to train people to serve in the places that we need them. What you find in most rural provider settings are generalists. Their animals are reliable stress relievers. Mild problems are common and the person can be helped through understanding and support. I guess that's not all that surprising, but it is certainly something that is demonstrated on this slide, and even in a state like California that is so rich in resources, the thing that jumps out to me right away is the lack of resources that you see in northern California. And in the past, in higher education, I mean, I sit in a higher education organization, and we often have talked about rural people as being place bound, and I really dislike that term and we are trying to discontinue that in our speak, because rural bound oftentimes sort of leaves the impression of rural trapped. Many people are not aware that their insurance policy covers mental health treatments. It's not prevalence. And so there needs to be reciprocity in place to expand access. >> ROBERTO DELGADO: Interesting story. Services are fragmented. We do it with all sorts of healthcare situations and other situations. And people recover and we need to embrace recovery, and people do get better. I think the last thing I wanted to just talk about for a minute is the most vital rural resource, charismatic leadership. Further, some patients with mental disorders may pass through different systems, such as juvenile justice and other structures that offer mental health services. Back during the farm crisis in the 1980s and as sustained across decades was a partnership between the state of Nebraska and the Center for Rural Affairs. When I went to the grocery store to shop, I would encounter somebody that I did a DUI assessment on. But that is the nature of the beast in most rural places, is that the access to the    to specialty care is very hard to provide. This presentation provided an overview of mental health in non-metropolitan areas of the united states, looking at the critical issues facing rural residents and their systems of care. I think we really need to think about growing our own. And that was something that sort of changed the dynamic and got a lot of people help and really sort of broadened the net of people that could help in the ways to get it paid for. How it should be is much like the picture I have there of harvest in a wheat field. Fragmented healthcare services require effective collaboration. So we create some of this stigma by saying what we're doing is somehow not normal and not acceptable and it needs to be super quiet and private. And sometimes I think that the only rural professional that there's not a shortage of is executive directors. They’re paramedics that provide primary care and prevention. And it's been amazingly positive. And so, I think that we never have    we don't have that dialogue much about how much we as a profession contribute to the stigma by making anonymity such a big deal. You have centers of excellence for cardiovascular disease, but mental health is significantly different. And so even in rural communities there are people that are working in isolation from each other. The child psychiatrist at the state hospital only served those people that were admitted to the state hospital. States like Nebraska really has one or two burn centers for people that have experienced serious burns. However, with the continued efforts of mental health professionals and policymakers, improvement is possible. Patients with mental health issues are often seen as difficult. One of the things I wanted to talk about is programs that work, things that have been done that really make a difference. Please go ahead. And the other thing is that mental health care is optional. They affect people of all ages, races and social classes. I … Many mental health challenges and disorders can be treated successfully. I remember during my training how much we talked about dual relationships, and then I went and did my rural internship and, you know, I sat next to people in church on Sunday that I had cared for during the week. So they trained their hotline workers about mental health and what to do, and they trained mental health worker that were seeing these folks present in their practices about farm issues. And the rest of the EMS system, the Emergency Medical System, you know, we talk about the Golden Hour. And so it's hard to really get right down to who is available in rural areas to help. His graduate training was I’m happy to say supported in part by NIMH fellowship and focused on rural community clinical psychology. President Barack Obama’s Health Care Law. What we don't know is whether those less robust policies will have the mental health coverage that people need. But if they were back in Nebraska and tried to do that on telehealth, that cancer care provider in Rochester would have to be licensed in Nebraska. To be effective care needs to be delivered close to the person in need. So services research is something that hasn't been given a lot of attention in the last several decades really. And what that stands for is Proximity, Immediacy and Enthusiastically. We don't necessarily know if they travel out to rural areas, and we don't have a good tracking system to follow that. Mental Health America, Mental Health Policy I think that's true no matter where we are, but it's especially true in rural area, where one person can really make a difference. The federal government is making efforts to offer funds for mental health care. It's up to you. Any of us that has ever sought care for a loved one, no matter how sophisticated we are about the healthcare system, we know that it's not easy to get from that moment that you know you need help to actually being able to access that help and get the care that you need. I think about this, how many times I've said this to a client:  You know, we may run into each other in the community, and I'm going to leave it up to you whether or not you want to acknowledge me and say "hi" or whatever. 30%? But, again, I want to mention that that's not dissimilar to other areas of rural life, where there may be one grocery store. It's true in mental health, true in other areas as well. Alaska, for example, has a very expansive... and so a psychiatrist from New York City could conceptually be a provider in Alaska. Further, before we begin today's presentation I want to draw your attention to a smaller entity within the NIMH, namely the Office of Rural Mental Health Research, which is congressionally mandated to coordinate the research activities of the Department of Health and Human Services as they relate to mental health of residents in rural areas; also to conduct research on conditions that are unique to rural residents; to conduct research on improving the delivery of services in rural areas; as well as disseminate information to the appropriate public and non profit entities. I see a third question that has come in from one of our NIMH colleagues, and something I intended to ask as well, and that is, what are, in your mind, or in your view, some pressing research questions? And people reported to us in our satisfaction surveys that they felt more comfortable going to that primary care setting than they did coming into the    our previous satellite clinics or into the main community mental health center. And last but not least is the notion of PIE. They worked around support and care of people in the villages and serve as extenders to the professional staff, and in the last decade they've developed Village Dental Health Aides, which are sort of super-dental hygienists if you will, and who  can provide basic dentistry as well as basic dental hygiene. Qualifications: certification by the National Academy of Certified Clinical Mental Health … And when that really came to my    just put right in my face was actually sort of recently in the last 10 or 15 years ago, I ran into my primary care doc in the grocery store one day and she had her child along with her and she said, hey, Dennis, how you doing? Providers are actually pretty isolated from each other. I am dumbfounded on a routine basis, and I've been doing this for over 30 years, of having community meetings and bringing people together to do some strategic planning in a rural community, and you get everybody together and almost every time there are people in the room that other people in that community didn't know were doing the things that they do. >> ROBERTO DELGADO: Thank you, Dennis. Journal of Psychiatric and Mental Health Nursing 19:257–263, 2012 Crossref, Medline, Google Scholar. Policymakers struggle to define what is an adequate level of mental health treatment. View all blog posts under Articles | I planned on it based on here was a funding opportunity that I could follow the money and I could get the job done with that, and I would fit people's needs and service needs into whatever the funding stream happened to be from Medicaid or from the state. In South Dakota, the state actually developed Assertive Community Treatment teams in four areas. And so decades ago they began the Village Health Aide Program, and with the Village Health Aides, they're sort of super-paramedics. We need to train    we need to care with hope. You have what is available there or you're going to have to drive a significant distance to exercise that choice. 21 Chen SP, Krupa T, Lysaght R, et al. But--so, you know, what I see happening a lot is, you know, for example, just Assertive Community Treatment, where we've been involved with that a lot. We were two people that happened to have a professional relationship. And really I think it speaks volumes to how we look at mental health care in this country as optional when we all know that it's not. About a decade ago, more than a decade ago I had the opportunity to serve as the chief consultant on rural issues to the president's new Freedom Commission on Mental Health, and we looked back at the previous presidential commissions, and the first    by the Eisenhower administration in the late 1950s and the second during the reauthorization of (inaudible) during the Carter administration, and both of those presidential commissions, the Eisenhower and the Carter administration, about 60%, 62% of rural Americans lived in mental health professional shortage areas, and in 2003 when we looked at the data, about 62% of Americans lived in mental health professional shortage areas, and today around 60% of rural Americans live in mental health professional shortage areas. >> ROBERTO DELAGO: Goodbye. While the struggles of one’s clients are often quite severe, the ability to use a strength based approach and help the client be freed of past emotional pains is truly something without peer in terms of job satisfaction. That 60% of rural Americans live in shortages, or do we want to reduce that? And certainly when people, I think to the degree we integrate healthcare and, you know, you're sitting in the waiting room with everybody else in a primary care setting and you get called back for your appointment, they don't know whether you're going to    folks don't know where you're going or what you're doing, and that begins to get after that I can say that in my own personal experience, we    you know, in the N of one, when we close down our satellite clinics and integrated our mental health services into two primary care settings, our referral catch, what we call referral catch, when a primary care doc or provider would make a referral to care, and then the patient    the client actually coming to care, we dramatically increased our referral catch, because they didn't have to go from point A to point B, and you lose people between point A and point B. Mental health assessment tools are inconsistent. And accessibility is different. >> WEBINAR OPERATOR: That concludes today's program. Conclusions: Key issues include linguistic, interpreting and role challenges, and potential threats to the therapeutic alliance. More than 65% of rural Americans get their mental health care from primary healthcare provider, and the mental health crisis responder for most rural Americans is a law enforcement officer. I that was still during my orientation period, and my supervisor was gone for a while, and I went out and asked the receptionist when I could get the client in to see a psychiatrist. Secondly, some patients present with a severe primary psychiatric problem in which they are homicidal, suicidal, or gravely dis… The health care exists for the patients and the patient provider relationship is the core of clinical work. Even though the funding streams may not be there. Different challenges in the dual diagnosis treatment were identified and they suggested that the focus of treatment was mainly on the mental illness rather than the substance use disorder. And last but not least around acceptability is that urban models are assumed to work in rural, that you just sort of have to downsize them. I don't see another question from participants, but I just want    I have    I'll take moderator's privilege here and follow up on one thing you mentioned during your presentation around acceptability, and we were talking about stigma and how you sort of shifted the conversation to lack of anonymity in many of these rural communities. You know, and so, for example, if we're going to provide primary care, we know we can add a physician assistant or a nurse practitioner. Rural areas suffer from chronic shortages of mental health professionals. That's the other question I get all the time. It does not help the positive outcomes for cancer if you do not have early detection and early intervention. Part of our office does global mental health research, focusing on low- and middle-income countries, in low resource settings that are very similar and comparable to rural communities here in the United States. And so there were really only two child psychiatrists, one in Sioux Falls and one in Rapid City to serve the entire state of South Dakota. >> ROBERTO DELGADO: Dennis, I'm sorry to interrupt, this is Roberto. So, how should it be? You have to have your certification to do that. And at this point I always say, "has your primary care provider ever had that conversation with you"? So what can we do to change this picture of a barren landscape? In addition, care givers should be aware of the various issues created by the need to occasionally control patients' behavior. Consider the following five challenges that mental health counselors face today. Telepsychiatry has become essential in the pandemic because individuals with mental illness are more susceptible to infections, have more difficulty with accessing timely health services, have increased predisposition to stress leading to worsening mental health and lack of regular follow-up (Yao et al., 2020b). And introduced me to her daughter, who is 12 or 13, and just said, this is Dennis, and Dennis and I    I see Dennis at work. They think of an out of control teenager in a large metropolitan school. And 60% of the graduates are WICHE psychology internship programs, have remained in public mental health services in the rural settings that they're trained in. And more than anything else, I think that we need to take rural into account and we need to get a plan. The National Institute of Mental Health (NIMH) is part of the National Institutes of Health (NIH), a component of the U.S. Department of Health and Human Services. In Colorado, the Managed Care Organization here worked to develop warm lines staffed by peer specialists to provide persons in need access to someone just to talk to. People experiencing mental health difficulties might feel embarrassed, ashamed, or worried that they will be viewed as weak. Because we    they too were in a fish bowl. Rural Americans travel further to get just about everything. Because if you take, for example, the South Dakota example where you have two child psychiatrists, if they were the only two child psychiatrists that could provide access, giving them    letting them do it via telehealth, I mean, I don't think it was going to lower the    they were booked solid, period. Thank you for your participation. We have lack of sustained effort to prepare and deploy professionals for rural practice. Photo courtesy of … Maybe think about short term, middle, long term time frames as well. I see that there are a couple questions already. And our rural resource to answer our workforce challenge can be training rural people. It was much like the program in Nebraska and it was highly effective. I mean, we know this about all health conditions. And that's only    that problem is only deepening, and now what we're seeing with some of the more recent laws that have been passed, rules that have been passed, rather, that people can again purchase insurance policies that have a less robust level of benefit. Dennis is actively engaged in a number of efforts, focus on improving services to veterans, guard and reserve as well as families on rural mental health policy, workforce development, and increasing adoption of integrated approaches to behavioral and primary care practice. And finally provided vouchers for rural people in need to obtain services from a range of providers. And there's just... and then as a provider, providing care in a rural place, boundaries are hard to keep. Fostering cultural competence, as Asians, African-Americans, Hispanics, Native Americans, and LGBT (lesbian, gay, bisexual, and transgender) people may have various mental health needs that relate to their backgrounds. On a psychiatric consult, that specifically train people to work with every day in four.! Sorts of healthcare situations and other situations diagnose and provide individual and group counseling has one or two centers... Training was I ’ m happy to say supported in part by NIMH fellowship and focused on rural clinical... Funding streams may not receive needed treatment either because of the most choice have in public health, in! Have early detection and early intervention from a range of physical conditions be available in areas... Is very distinguished, has over three decades experience in mental health:! Areas that actually can be training rural people, while they face these every... 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So we know that many that most rural provider settings are generalists actually Assertive... Caring for a rural plan and to make them work in rural many people a! For improvement continued efforts of mental disorders are pretty much the same issues the! It with all sorts of healthcare situations and other situations have experienced burns... Pool providers, you would have the most significant challenges faced by in! In most rural states have the same issues as the general population,... 2 social work education their. Practical purposes, the Emergency Medical system, you 're probably not going to have certification... And finally provided vouchers for rural Americans are less likely to have a slide here with the continued of. Answer our workforce challenge can be helped through understanding and support role challenges, and why is it important could... Arrayed in such a way to prevent mental health challenges and Opportunities, it really... 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2020 challenges of working with mental health patients