opening plenary

According to the American Heritage Dictionary, “policy” is a plan or course of action adopted by a government or business organization designed to influence and determine decisions, actions, and other matters. Rural mental health is primarily affected by public policy enacted by state governments or the federal government and by policy adopted by funding sources such as insurance companies and managed care organizations (MCOs). There are, however, many other entities whose policy decisions have an impact on rural mental health. Universities in their mental health training programs and accrediting organizations such as the Joint Commission on Accreditation of Healthcare Organizations make policy decisions that directly impact rural mental health. Private foundations, such as Robert Wood Johnson, make policy decisions that either enhance or reduce the opportunities for rural mental health programs to access their resources and support. National mental health advocacy organizations, such as the National Mental Health Association and National Alliance for the Mentally Ill, make policy decisions which either promote or ignore the rural mental health concerns. Rural mental health providers and practitioners deliver services and rural consumers have their needs responded to within policy determined frameworks. These frameworks are the funding requirements and opportunities, regulations, standards, and a whole host of other factors that serve to either constrain or promote rural mental health. There are two primary areas of interest when reflecting on how policy affects rural mental health. The first of these areas relates to the “policy dilemmas” that rural mental health poses to policy makers. In other words, the essential question of “if or how rural should be taken into account in mental health policy.” The second area relates to the ways in which “urban models and mind sets” bias mental health policy and result in the imposition of inappropriate and unrealistic constraints and demands on rural mental health practice.

Policy Dilemmas

The first “dilemma” facing mental health policy makers is whether rural should be taken into account in policy at all. Does “rural” present sufficient special conditions or circumstances that warrant “special consideration” in policy? While most rural mental health practitioners would likely argue that “rural” does warrant special consideration, there is certainly not universal agreement on that. Most mental health policy is made without consideration of its impact on rural consumers, families, providers, or practitioners and rural mental health is rarely a key policy consideration. Ahr and Holcomb (1985) found that rural mental health services were close to the bottom in a ranking of priorities of state mental health program directors. Kimmel (1992), in a surveying the same group, found that there were few state mental health staff with full time responsibility for rural issues and that state mental health agencies were rarely asked to address rural issues in a direct and sustained way.

If mental health policy makers are open to “taking rural into account” there are two broad areas of consideration: (1) making general mental health policy “rural friendly” and (2) developing mental health policy that specifically addresses the needs of rural mental health. The first issue asks the question: “will what we are trying to do in mental health in general harm or unfairly disadvantage rural mental health practice?” The second issue is more a question of “what can we do to specifically respond to the problems facing rural mental health?”

Making Mental Health Policy “Rural Friendly”

Making mental health policy “rural friendly” is primarily an exercise in sensitivity and involvement. There are essentially two approaches to this dilemma: (1) mental health policy impact assessment and modification and (2) participation by rural mental health representatives in mental health policy development. These approaches are not mutually exclusive and can be integrated in a unified approach. For example, the Federal Office of Rural Health Policy (ORHP) has as one of its missions the review and assessment of the potential negative impact of Health and Human Services Policy on rural populations and the making recommendations for modifications that create a more “rural friendly” health policy. ORHP also sponsors a national advisory group composed of rural health experts and rural persons whose mission is to provide recommendations to the Secretary of Health and Human Services on health policy. While very few policy making entities go to the extent of creating a function like ORHP, there are attempts to include rural representation in planning and mental health policy development and to seek rural input. Unfortunately, these attempts are not the norm. When these opportunities do occur it is not unusual to find a single (token) rural representative who is regularly “out voted” by a mass of urban constituents. Without (and even with) a commitment to make mental health policy “rural friendly” there is the very high risk that mental health policy will be urban biased (see the section on urban bias).

Rural participation in the policy development process is a dilemma for the policy maker. The two primary mental health reasons for this is cost and time. It is often expensive to “travel” rural representatives to participate in policy discussions and frequently less time consuming to check things out informally with local (urban) contacts. It is difficult for rural mental health providers to get away on short notice due to lack of backup coverage and as a consequence their involvement requires more planing and formality (it can’t be spur of the moment). Faced with scarce resources (time & money) mental health policy makers find it easier to engage local (urban) input informally. It is simply more likely for mental health policy makers to have personal relationships with urban-based mental health practitioners. In addition it is often easier for urban mental health providers to access policy makers. Urban mental health practitioners may reside in the same city where mental health policy is made or they may have the resources (time, money & backup) to travel to where the policy is being made. They often can afford to dedicate staff for periods of time to participate in policy development groups.

One of the central dilemmas in making mental health policy “rural friendly” is whether rural mental health should be held to the same standards and requirements as their urban-based counterparts. This debate focuses around attempts by policy makers to ensure quality or protect the public (e.g., standards for licensure, certification, and/or accreditation of providers and practitioners) and accountability (e.g. performance and outcome standards). There are generally two arguments against allowing rural mental health providers and practitioners to be held to different standards or to be “excused” from compliance with certain standards. Both these arguments center on fairness and equity. The first argument states that it is not fair or just to have a lower standard of quality for rural residents; that would be treating them as second class citizens. The second argument states it would be unfair to other mental health providers to allow rural mental health providers and practitioners to operate at a “lower” standard. The argument for special consideration is that rural mental health providers and practitioners face unique and different circumstances and that warrants different standards. There are a number of problems with the argument that rural providers must be treated the same as all other mental health providers. First, most standards are not direct measures of quality or performance but rather are indicators or proxy measures. These indicators or proxy measures have been developed almost totally in reference to urban populations and services. Second, the connection between these standards and what they claim to measure maybe spurious. Most of these standards on based upon theoretical notions or correlation studies. There is little evidence that performance related to these standards produces quality. In fact, most of these standards are measurements of process rather than outcomes. Third, even if these standards were valid, the consequences of rigorously applying these standards may be to further reduce the availability of mental health services to an already severely underserved rural population.

Directly Addressing Rural Mental Health Needs

When seeking to directly address the needs of rural mental health policy makers are faced with the dilemma of choosing a single or multifaceted approach. They must answer the question of whether to have a single policy strategy to address rural mental health problems or employ multiple strategies or create some sort of flexible approach that allows for tailoring solutions to unique local needs. In the vast majority of cases where policies are developed specifically to address rural mental health they are “single” solution approaches. Rarely do policy makers appreciate the tremendous variation that exists in the circumstances of rural mental health consumers and providers or the heterogeneity of rural America. In order words, it is one thing for rural mental health advocates to get the attention of policy makers; it is quite another thing for them to hold that attention long enough for those policy makers to truly understand the complexity of rural mental health needs and fashion a flexible policy response.

The next policy dilemma in seeking to directly address the needs of rural mental health is whether to seek a “system” or “symbolic” solution to the problems. A system solution provides a permanent change to the basic infrastructure that supports rural mental health services. A “symbolic” solution provides either a temporary (time limited) fix or a fix that only certain parts of the rural mental health community have access to. Demonstration grants, model program support, grace periods for getting into compliance with standards, and the like are typical examples of symbolic solutions. Unfortunately, there have been very few attempts to provide system solutions to rural mental health problems. Most of the policy attempts have been symbolic, resulting in a kind of “boom and bust” cycle for some rural mental health programs.

The preeminent policy dilemma in directly addressing rural mental health needs is one of subsidization. In many rural areas there is simply not a sufficient economic base to support “market driven” services. This is true not only in mental health but also in areas ranging from utility construction to transportation. In rural mental health the traditional public subsidy of mental health services must not only address the issue of financial accessibility but also the problems of geographic availability. The policy dilemma related to rural mental health is whether rural mental health services should be subsidized at a greater rate than other mental health services. With very few exceptions, there has not been special subsidization of rural mental health services above and beyond the traditional public subsidization related to making services accessible to people who do not have the ability to pay.

Urban Bias

Urban models and minds sets are the “yoke” of rural mental health. While most mental health providers complain of “cookie-cutter” approaches imposed by centralized bureaucracies, rural mental health is at a particular disadvantage. Even the “hallowed” community mental health center model of the 1970s has been characterized as an “urban model” antithetical to the social structure of rural communities (Berry & Davis, 1978). Through regulation, financing mechanisms, and standards the urban world is imposed upon rural mental health practitioners and programs (Sawyer, 1998). These constraints are a major barrier to effective service delivery and program operation. The “mental models” (Senge, 1990) of urban based policy makers fail to “take into account” the realities of rural mental health practice. These taken-for-granted assumptions about the world and how it works find their way into funding requirements, requests for proposals, regulations, licensing or credentialing standards, policy directives, practice guidelines, training materials and programs, ethical standards, funding decisions, etc. This results in rural mental health providers having to operate under bureaucratic conditions that often are at odds with the world within which they must deliver services. The classic, but by no means only, example of this is the situation that comes up regularly is where someone wants to establish a policy which prohibits “dual relationships” (where the mental health professional has an additional relationship with a client other than the one of therapist-client). However desirable such a policy is, it is clearly unworkable in rural communities where “everybody knows everybody” and people would be denied needed services. Table 1 summarizes some of the more predominate urban, “taken-for-granted,” assumptions about mental health practice and the corresponding rural realities. These differences have important policy implications for today’s world of managed care. Urban based models assume a world dominated by duplication of services, adequate (if used correctly) resources, over abundance of specialized mental health professionals and providers, over utilization of services, the cost-effectiveness of specialization, and an obligation to clients that is narrowly focused on “treating a mental disorder.” In contrast, rural practice assumes a lack of availability of services, scarcity of resources, severe shortages of specialized mental health practitioners and providers, the under utilization of services, the impracticality of specialization, and a recognition that to be effective clients must be supported beyond the narrow range of “medically necessary” specialized mental health services. A set of “managed care” policies based upon the assumptions of the “urban model” can have devastating effects in rural areas as mechanisms are put in place that seek to reduce utilization, narrow the scope of services provided, require specialization, etc. As more and more decision making and control is centralized in urban (or out-of-state) based “corporate” or government offices, there is an increased risk not only to the accessibility and quality of rural mental health care but also to the very existence of the fragile rural mental health care infrastructure (New York Rural Health Research Center, 1997).

The increasing call for “best practices,” “service protocols,” and “practice guidelines” are new areas of risk where urban models are likely to be imposed on rural mental health practice with serious consequences. For example, a study of the implications of implementing “practice guidelines” for the care of people with non-insulin dependent diabetes projected dramatically increased rural health work force resource demands. Focusing on the rural Medicare population the study by the Minnesota Rural Health Research Center (1997) concluded, “When all the additional recommended laboratory tests, procedures and visits are taken into account, we estimate that treating diabetes alone would require the full-time attention of twenty additional primary care physicians and fourteen additional ophthalmologists in the rural regions of Minnesota.

Conclusions

Danbom (1995) argues that rural Americans have declined “from majority, to minority, to curiosity.” Rural residents are not only declining in number, they are also rapidly losing political power and influence and, consequently, policy influence. As Dyer (1997) recently reported, “Rural people feel powerless and disenfranchised because they are powerless and disenfranchised”. Ginsberg (1977) notes that rural populations suffer from an “auditory gap” in that they have a problem in simply being heard. As Stock (1996) suggests, “...most Americans have only the remotest connections with the day-to-day realities of rural America and most frequently idealize its value while passing through on summer vacation orflying over in a transcontinental jet.” This problem is not new. Rural Americans have always suffered from the tendency for policy makers to base their actions on a rather narrow range of personal experience which is urban and “east coast” based (Stock, 1996).

Increasingly, however, people in positions of power and influence have no experience with or realistic knowledge about rural realities, resulting in either massive indifference or gross naivete. It used to be that a majority of policy makers had some rural connection. Perhaps they were one generation removed from the farm or maybe they’d spent a summer on an uncle’s farm or had friends who lived in the country. Today that is not the case. Today there is a new generation of mental health policy makers with almost no rural connections or experience. Today’s policy maker’s ideas about rural come mostly from the urban-based and biased media and/or advocacy (often environmental) organizations whose mission is to preserve the rural environment (for urban constituents) often at the expense of rural populations. Rural people are perceived as either quaint, unsophisticated “good souls” or dangerous, bigoted, backward “rednecks.” This political disenfranchisement of rural Americans is reflected in the lack of policy attention rural mental health receives.

The essential question in addressing “rural” in mental health policy is one of “special consideration.” The argument being that the unique realities of rural mental health practice require some form of consideration not given to the “average” mental health program. Mostly the neglect of rural policy issues and the imposition of “urban models” is either a function of ignorance or expediency or reluctance to incur the cost. There is, however, an attitude that rural areas and populations do not warrant any special consideration. In a curious kind of reasoning it is assumed that to “take rural into account” in mental health policy would somehow be unfair to others while forcing rural mental health practitioners to operate under conditions designed for urban populations and areas is considered equitable. Rural residents and rural mental health practitioners may need to take the route of other disenfranchised minority groups and seek protection and relief from the courts and through legislation.

Scroll to see Table 1.

References

Ahr, P.R. and Holcomb, W.R. (1985) State mental health directors’ priorities for mental health care. Hospital and Community Psychiatry, 36, 39-45.

Berry, B. & Davis, A.E. (1978) Community mental health ideology: A problematic model for rural areas. American Journal of Orthopsychiatry 48(October), 673-679.

Danbom, David (1995) Born in the country: a history of rural America, Johns Hopkins University Press.

Dyer, Joel (1997) Harvest of Rage, Westview Press.

Ginsberg, L. (1977) Social work in rural areas. In R.K. Green and S.A. Webster (Eds.) Social Work in Rural Areas: Preparation and Practice, University of Tennessee School of Social Work.

Kimmel, W.A. (1992). Rural Mental Health Policy Issues for Research: A Pilot Exploration. Paper published by the Office of Rural Mental Health Research, National Institute of Mental Health, Rockville, MD.

Minnesota Rural Health Research Center (1997) Will Guidelines Implementation Increase Rural Health Care Work Force Demand? The Case of Diabetes Mellitus, Working Paper #20, School of Public Health, University of Minnesota.

New York Rural Health Research Center (1997, May) Introducing Medicaid Managed Care in Rural Communities: Guidelines for Policy Makers, Planners, and State Administrators. National Rural Health Association.

Sawyer, D.S. (1998) A perspective from the other side of the adirondacks. Rural Community Mental Health, 24(4).

Senge, P.M. (1990) The Fifth Discipline, Doubleday.

Stock, C.M. (1996) Rural Radicals, Penguin Books.