In rural areas, mental health issues loom

Rural communities in the Northwest are facing a shortage of people who can help them with mental health challenges.

According to the Department of Health and Human Services, roughly one-third of the U.S population lives in an area short on mental health providers. Of that group, over two-thirds are in rural or partially rural places.

Alyssa Robinson is a therapist in St. Maries, Idaho, which has a population of around 2,500. She said it’s especially difficult to find providers who take Medicaid.

Her clinic is one of just three in the town and one of the few in that area to take Medicaid. As a counselor, she said, there isn’t much financial incentive to take Medicaid, which is why providers who do are harder to come by.

“They’re the ones that have the most hoops to jump through and the lowest reimbursement,” she said. “You’re doing more work for less pay.”

Robinson has some clients drive from as far away as Post Falls and Coeur d’Alene — well over an hour in the winter — simply because she takes Medicaid.

She says for some rural patients, telehealth services can help bridge the gap. But internet access isn’t always reliable in remote areas, and some patients don’t want to seek therapy over a video call.

“I don’t know if this is across all rural communities or just here, but a lot of them prefer in person,” she said.

In addition to a preference for in-person appointments, Robinson said, she’s seen more patients who struggle with stigma surrounding mental health challenges while working in a rural community.

“While the stigma is definitely decreasing compared to what it used to be even 10 years ago, I think in the rural communities, it takes longer for that to recede compared to, like, Portland or Boise,” Robinson said. “I still have clients whose husbands aren’t on board with them coming to session, or whose families are really confused why they would need therapy.”

Nichole Konen Giraldo lives in Walla Walla, Wash., a town of about 30,000. This past summer, she lost her husband.

“You’re struggling, you’re sad, you’re depressed, you’re suicidal,” she said. “I mean, you have all these things going through your brain and you just need someone to talk to.”

Giraldo has been searching for a long-term grief counselor for five months. She’s called every therapist she can think of. Most don’t even call her back.

“You’re left to basically just sink or swim,” Giraldo said.

Denise Metzger is a social worker in Coeur d’ Alene. She said even though her part of the state isn’t rural, it’s still underserved. All the good therapists usually have wait lists, and that’s not counting those who serve clients with specialized needs or limited insurance.

“If you have Medicaid or Medicare, then the amount of people that you can see are very limited. I give out the same names and same numbers to pretty much a lot of the people,” she said. “In terms of children’s therapies, that’s pretty limited as well.”

The challenges can be even greater for immigrant populations, who may experience a range of cultural and structural barriers, including language, stigma and cost, according to a systemic analysis published in the Psychiatry Online.

A shortage of counselors also ends up putting more strain on emergency rooms, providers say.

As the Lewiston Tribune reported in 2022, staff at Pullman Regional Hospital’s emergency room noted that psychiatric services were one of the fastest-growing needs in the past decade.

Nurses at the time noted they often ended up with more than one psychiatric patient, necessitating the use of rooms not specifically designed for psychiatric care within eyesight of the nurses’ station.

Though the need is clear, the solutions are less so. Some strategies focus on reducing paperwork and increasing reimbursement for providers.

Others focus on simply getting more people into the field.

And that’s no easy hurdle: While the median pay for physicians or surgeons is more than twice that of behavioral health care providers, according to the Bureau of Labor Statistics, many behavioral health care positions still require advanced degrees. And then there’s the issue of burnout.

“There’s always been tremendous need and it’s a challenging field,” said Teresa Claycamp, who works at Washington’s Health Care Authority. “The pandemic really greatly exacerbated the workforce shortage.”

Robinson said many counselors end up burning out before they’ve had a chance to pay off student loans. Repayment plans are available for people working at federally qualified health centers, or FQHCs, but those same health centers often have a high workload that can lead to burnout, she said.

“I think if (loan repayment) was more accessible to all types of agencies in rural health communities, or people doing private practice, that might help draw people in because the student loan stuff is a really big piece of it.”

Another Washington state initiative helps pay for master’s programs for aspiring therapists and social workers. After graduating, students in the program must spend three years working at select community agencies or tribal health centers. In Walla Walla County, for instance, there are three agencies that would qualify.

Some programs, like Project ECHO through the University of Washington’s WWAMI Medical Education program, which collaborates with universities including the University of Idaho, support clinicians in rural and underserved communities by providing workforce training and a chance to consult with other professionals.

“For me, it feels like, sometimes, a lifeline,” said Metzger, the social worker in Coeur d’Alene. “I have presented cases for feedback from other professionals. And that has been really helpful, even if it’s just to get some validation, like, ‘Yep, that one’s a really hard one.’ ”

To pull more providers into the field, Claycamp’s agency launched a public awareness campaign in 2021.

It highlights behavioral health careers that don’t require graduate degrees, such as substance use disorder professionals and peer counselors. It aims to attract providers who otherwise might not have considered jobs in mental health. Washington has also introduced a behavioral health apprenticeship program.

“There’s lots of different pathways in,” Claycamp said. “It’s not just this cookie cutter way of getting to a career.”

Sun may be contacted at rsun@lmtribune.com or on Twitter at @Rachel_M_Sun. This report is made in partnership with Northwest Public Broadcasting, the Lewiston Tribune and the Moscow-Pullman Daily News. NWPB's Susan Shain contributed to this report

If you or someone you know is struggling with mental health, support is available by calling or texting the national Suicide and Crisis Lifeline at 9-8-8.