Amer. J . Orthopsychiat. 48(4), October 1978
COMMUNITY MENTAL HEALTH IDEOLOGY: A Problematic Model for Rural Areas Bonnie Berry, B.A., and Ann
E. Davis, M.S.S.W., Ph.D.
The prevailing model for mental health services is found to be inappropriate with respect to many of the needs of rural communities. Special problems of rural areas are identified, and suggestions are offered for revision of mental health concepts and practice that might result in a better fit between professional ideology and rural reality.
he ideology underlying community
T mental health services suggests that the use of community-based program-
ming will reduce the occurrence of stigma from mental hospitalizations, help clients maintain contact with their families, and, by making services locally available, facilitate the treatment and prevention of emotional problems. From the practitioner’s vantage point, community-based services tare expected to improve the quality of treatment by enhancing the professionals’ understanding of the clients and their milieu and by encouraging the development of preventive programming. Also implicit is the belief that community services will be less costly than hospital-based programs, given that communities become involved in and assume local responsibility for mental health services.
A close examination of the realities of rural community mental health services leads the authors of this paper to believe that clinics located in rural areas have problems that differ from those of urban centers and that these problems require a reexamination of what has previously been the fairly uniform application of community mental health ideology to all areas of our society. Social factors peculiar to the rural areas have not been adequately taken into account in the process of developing services. The difficulty is, broadly, twofold: first there is the problem of the rural population’s lack of education about emotional disorders and psychiatric care; second, there is the problem of the urban-born and trained mental health professional’s ability to be responsive to the culture of a rural area.
Submitted to the Journal in September 1977. Authors are at: Ohio State University (Berry); and Miami University, Oxford, Ohio (Davis).
673
674
Inabilities to confront misconceptions directly in these sectors impede the process and effectiveness of community mental health services. IDEOLOGICAL MISFITS
Community mental health centers were conceived by professionals from urban communities who were primarily concerned with urban services; this provides the basis for understanding many difficulties. One of the first problems involves the concept of community. “Rural” has meant country or farmland to many, but in actuality a rural community is often best described as a small town or towns plus the surrounding farming region. The boundaries of a rural community are often diffuse; as an entity, it therefore differs socially and physically from urban catchment areas. The implication for service is that miany rural areas contain a number of politically separate towns, which compete with one another for prestige and resources. A single clinic serving a number of such towns has difficulty establishing an identity as the resource for all of them. The location of the clinic in one town may automatically alienate community leaders in adjacent towns. A second problem is presented by the contemporary psychiatric concept that espouses family involvement as a desired aspect of care. In ‘any setting, when the family is hostile, apathetic, or absent there are difficulties. But with rural clientele the problems are exacerbated. Rural clients are more directly dependent on their families because they have fewer acceptable alternatives, life styles, or job opportunities to allow independence; it is therefore more difficult to encourage autonomy in a rural client with an uncooperative family.
MODEL FOR RURAL AREAS Similarly, there are special problems involved in encouraging the discharged hospital patient to become ‘a self-supporting and contributing member of society in a rural area. If patients are to become independent, the community must provide some of the supports previously offered by hospital programs, such as access to social welfare funding, half-way iacili,ties, medical care services, recreation, vocational reeducation, and job referrals. Although lack of community resources is a pervasive problem in all mental health programming, the relatively poorer predicament of the rural community is seldom taken into account. Studies that include careful measures of the indirect financial costs of adding such supportive community facilities are also lacking. As importantly, follow-up studies have not shown that discharged hospital patients in the ccmmunity are, in fact, independent. Empirical information, where available, suggests that the former hospital patient is actually a continuing financially dependent member of the community. When community resources are lacking, the most obvious question is: Are such clients better off in the community, especially in the rural community? SERVICE DELIVERY PROBLEMS
Our population’s need for services is uncertain. Findings from epidemiological studies are difficult to apply because there are few agreed-upon criteria or measurements for defining mental disorders; there are few studies to document the prevalence of disorders, and even fewer to determine the need for services, especially among rural populations. To complicate the issue, rural cultures may define behavior differently l4 and the psychiatric criteria used
BERRY AND DAVIS
to assess symptoms may not be relevant to rural people. As yet, the extent and nature of their clinical disorders and the differences in this regard between rural and urban populations have not been established. It is obvious that rural existence is not necessarily idyllic, and rural people do have disorders. But the lack of research and contradictions in available studies leave us uncertain about many aspects of rural mental health needs and rural service delivery. Acceptance of Care
Veverka and Goldman l6 maintained that rural people will accept and use mental health services, especially if located in their own community. However, a significant source of resistance is fear of the unknown, which has been correlated with a reluctance to use mental health services.l Major problems in delivering services to rural areas have been identified as: lack of adequate resources, distance, population dispersal, and entry of mental health personnel into the community.e Other important barriers are the people's llack of knowledge about existing mental health services and about what constitutes a problem for which care should be sought.' Rural community mental health centers have other special problems, which include professional isolation of the workers, lack of transportation for clients, and communication breakdowns in remote areas, as well as outreach education problems to sparsely populated areasx2 Mental health workers often encounter fear, mistrust, hostility, land apathy on the part of rural people. One mental health education experiment ' found that the people were at first friendly
675
to the researchers but later became apathetic, withdrawn, hostile, and finally no longer wanted to be lassociated with the project. It is possible that small communities want to appear progressive and helpful, but only up to a point. They also become recalcitrant when confronted with programs that bring change that threatens the status quo. Yet ,another difficulty concerns trust between local community professionals and mental health personnel. Carver noted a defensiveness toward one another on the part of teachers and mental health workers. Physicians may be friendly yet often aloof from and suspicious of psychologists and other therapists because the latter are salaried and are seen as quasi-governmental employees. Mental health workers discover that they must play the game the rural community's way, and that it takes a while, as outsiders, to gain the trust of rural people. Mental health personnel must learn to handle the initial conservative uncertainty from local officials and the populace at large by clearly demonstrating the value of their services.l0 Visibility: A Special Rural Problem
Rural persons affected by mental disorders seek no help 50% of the time. Most of those who do seek help see physicians, a few go to mental health professionals, and the rest see ministers, friends, police, lawyers, welfare workers, and public health officials. Fear of being identified as mentally ill acts as an effective barrier to help-seeking. All psychiatric practitioners desire to give the assurance of confidentiality to clients, but the issue of visibility in a rural area is a major problem. Because of the smaller number of persons in
MODEL FOR RURAL AREAS rural areas, all or most of the people the income, and the larger the size of have access to only one mental health the farm, the less the wife becomes incenter. In small towns, people know volved in decision-making. Such nonegalitarian interaction affects quite well what others are doing and there is a high probability that a person the prospects for effective individual visiting the center will be recognized and family therapy. Fathers and husand talked about by acquaintances. For bands may forbid their children or similar reasons, group therapy efforts wives to visit the mental health center, may be hampered because clients are fearing that practitioners will undermine unwilling to have others who know their authority; often these men will not them, and may gossip about them, learn personally participate in any form of in detail about their problems. Consid- therapy . ering the difficulty of maintaining anoEven though sexism is widespread in nymity, in conjunction with their rela- the rural setting, rural women are betive lack of sophistication in regard to coming aware of women’s liberation mental health services and the fear of through the mass media. Those who are stigmatization, the reluctance of rural becoming assertive are encountering repeople to seek care from mental health sistance both from men and from other women. Many rural women continue centers is understandable. patterns of submission because they seem a safer course; for those willing to A uthoritarianism try liberation, divorce, job loss, and an Another hindrance to rural mental increase in tensions with friends are health service has to do with sexism likely outcomes. Divorce is a difficult and authoritarianism in the rural com- alternative in a rural area, where munity and family. Authoritarianism is women’s opportunities for employment more pronounced in the country; there and means of support for themselves is stronger adherence to religiosity, and their children are still very few. stronger dependence on family, and stronger respect for government.I6 In Locating the “Right” Professionals a rural family, the fathers and husbands Of major importance to mental health exercise authority over their children and their wives, as well as over females service in rural areas are the professional workers in the clinics. The rural in general. In a study of rural families, Sawer l 3 setting demands special skills and qualidemonstrated that husbands tend to as- ties of mental health personnel, such as sume the major role in decision-making knowledge of rural politics and power concerning farm matters. The number structures, and the ability to develop of children the couple has is negatively informal patterns of communication correlated with the wife’s involvement with key community officials.6 Staff in general and with the adoption of members also must be familiar with and joint decision-making; income and farm sympathetic to the local cultural values, size are also negatively associated with norms, and socioeconomic arrangements the wife’s decision-making. Thus, the of the community. Pentlarge l 1 sugmore children in the family, the higher gested that the rural psychiatrist not
BERRY AND DAVIS adopt too colorful a style, but that a somewhat bland, professional, and benign manner may be requisite. According to Buxton,2 a social worker in a rural mental health setting may be set ‘apart by age, dress, education, and value system from others in the community. There is an effective word-ofmouth network among rural citizenry that reports all the activities of the mental health worker.*O Rural people are well-informed on matters concerning the worker’s life, such as marital status, family stability, drinking habits, where clothes are purchased and their cost, kind of car driven, recreational habits, religious participation, and residence. Rural mental health professionals must be concerned about their image in the community because local people will judge them on the basis of the personal factors noted above, and this judgment will color their response to the professionals’ services. The rural mental health worker must be a practitioner-generalist, able to handle a variety of problems, because the rural community cannot afford a large selection of specialists or referral resources. Mayer ti described the personal and professional rewards available to the rural worker as limited. The demands and responsibilities are enormous at times and can be somewhat of a trial. The clinician must also provide a continuity of care which, in larger centers, is often compartmentalized. On the positive side, rural mental health work may be satisfying and challenging for a number of reasons, including the status acquired through being one of the few professionals in the community. The worker’s background can be an important factor, since the community may well be wary of any newcomer,
677
especially an urban practitioner from a widely disparate area of the country. If the worker comes from another, somewhat similar, rural area, an understanding of the needs of the community may be facilitated. The professional who is indigenous to the area is a specialand rare-case. Few country boys or girls who go off to study in urban tenters choose to return home to practice; for them, professional training often represents an escape from the “restrictive” rural milieu. Equally important is the question of whether clients will accept their own prior acquaintances as therapists; again, community closeness may prove to be detrimental to confidentiality. CONCLUSIONS AND IMPLICATIONS
Some suggestions can be made regarding the improvement of mental health services to rural people. Lee, Gianturco and Eisdorfer demonstrated a need for long-term community education, the desirability of using indigenous workers, and the importance of using the “back-up” services of local physicians. Systematic mental health education can help community members to feel less threatened by change as it is represented in services provided by the mental health practitioner, and changes brought about by influences such as women’s liberation, In addition to traditional community education, there must be efforts to involve and train local citizens to assist the mental health professionals. Local volunteers can be used as aides in developing recreational programs, making “concerned” home visits, running educational workshops, and developing employment possibilities. To facilitate entry into a rural corn-
MODEL FOR RURAL AREAS
678
munity, mental health professionals to work with a wide range of people must begin contacts with other local and problems, and be able to use a professionals on a specific and concrete number of different therapies and reproblem-solving basis; help must be of- sources effectively. They should also be fered to ‘the courts, schools, and other able to handle the greater visibility of agencies on their long-standing psychi- their personal lives and the inevitable atric problem cases. Rural leaders will, judgments that will be made about them when convinced of the concrete service by community members. Perhaps of potential of mental health professionals, greatest importance is the recognition respond with cooperation. The problem that treatment personnel with a rural cases, as defined by the community, background, familiar with similar culconstitute the starting point for service tures, may be able to maintain a lower contact. This is a simple restatement of personal profile and encounter less paa basic social service principle, but one tient resistance. Finally, we agree with Mermelstein too often ignored in this age of ideological model building: “One starts where and Sundet that the professional role in rural community mental health should the client is.” In order to deal with the special prob- be determined by the phenomena adlems of visibility and client confiden- dressed, not by imposition of the pretiality in the rural area, it may be possi- vailing professional methodology or ble to locate the mental health center ideology. We need a model designed for in a setting or building that minimizes rural mental health services by profespublic exposure. It may also be possible sionals who are knowledgeable about to locate a secondary and smaller men- and sensitive to rural people, a model tal health center in a neighboring town that is responsive to the particular milieu or create a one-worker office in the of the rural area. This paper has atnearby community to afford anonymity tempted to offer some perspectives defor each population. Clients can com- signed to stimulate development of a remute short distances when visibility vised ideology, one that would more or embarrassment is an issue. Mental closely correspond to rural realities. health staff can also visit homes of clients who need and want assistance but REFERENCES 1. BUTTEWEG, M. 1974. Mental health attiare afraid to come to the center for tudes in the small community. Smith Coltreatment. This would be particularly lege Studies in SOC.Wk. 45:64. beneficial for families in which unco~.BWXTON, E. 1973. Delivering social services in rural areas. Pub. Welfare 31: operative spouses or parents refuse to provide transportation to the clinic. All 3. J. 1972. Multi-county mental of this implies aggressive outreach, health center school consultation. Ment. skills, and sensitivity to legalities as yet Hlth. Learning 49-53. underdefined and poorly explored by E. AND CUMMINC, J. 1957. Closed Ranks. Harvard University Press, the typical outpatient clinical model of Cambridge, Mass. service.6 5. DAMS. A., DINITZ, S. AND PASAMANICK, B. 1975: Schizophrenics in the New CUSThe careful selection of professionals todial Community. Ohio State University for rural areas is also important. They press, Columbus, Ohio. should be generalists, have the capacity ~ . G E R T Z , B., MEIDER, J . AND PLUCKHAN, M.
,;::;:A
4.CUMM1NG9
BERRY AND DAVIS 1975. A survey of rural community mental health needs and resources. Hosp. Comm. Psychiat. 26:816-819. 7. LEE, S., GIANTURCO, D. AND EISDORFER, C. 1974. Community mental health center accessibility: a survey of the rural poor. Arch. Gen. Psychiat. 31 :335-339. 8. MAYER, W. 1972. Treasure and trials of the complete community psychiatrist. Exchange 1:7-8. 9.MERMELSTEIN, J. AND SUNDET, P. 1973. . Community control and the determination of professional role in rural mental health. J. Operational Psychiat. 5 ( 1) :3-12. J. 1972. Mental health in rural ~O.O’NEILL, areas. Exchange 1:9-11. 11. PENTLARGE, V. 1975. Psychiatry in a small
679 town. Massachusetts J. Ment. Hlth. 5 : 14-17. 12. Rural roundup: space divided by people= problems. 1974. Innovations 1: 12-16. ~ ~ . S A W EB.R ,1973. Predictors of the farm wife’s involvement in general management and adoption decisions. Rural Sociol. 38: 412-426. 14.SUMMERS, G., SEILER, L. AND HOUGH, R. 197 1. Psychiatric symptoms: cross-validation with a rural sample. Rural Sociol. 36:367-378. 15. VEVERKA, J. AND GOLDMAN, J. 1973. Rural family counseling. J. Iowa Med. Society 63 :395-398. 16. YOUMANS, E. 1973. Age stratification and value orientations. Aging and Human Develpm. 4:53-65.
For reprints: Dr. Ann E. Davis, Sociology Department, Miami University, Oxford, Ohio 45056
COMMUNITY MENTAL HEALTH IDEOLOGY: A Problematic Model for Rural Areas Bonnie Berry, B.A., and Ann
E. Davis, M.S.S.W., Ph.D.
The prevailing model for mental health services is found to be inappropriate with respect to many of the needs of rural communities. Special problems of rural areas are identified, and suggestions are offered for revision of mental health concepts and practice that might result in a better fit between professional ideology and rural reality.
he ideology underlying community
T mental health services suggests that the use of community-based program-
ming will reduce the occurrence of stigma from mental hospitalizations, help clients maintain contact with their families, and, by making services locally available, facilitate the treatment and prevention of emotional problems. From the practitioner’s vantage point, community-based services tare expected to improve the quality of treatment by enhancing the professionals’ understanding of the clients and their milieu and by encouraging the development of preventive programming. Also implicit is the belief that community services will be less costly than hospital-based programs, given that communities become involved in and assume local responsibility for mental health services.
A close examination of the realities of rural community mental health services leads the authors of this paper to believe that clinics located in rural areas have problems that differ from those of urban centers and that these problems require a reexamination of what has previously been the fairly uniform application of community mental health ideology to all areas of our society. Social factors peculiar to the rural areas have not been adequately taken into account in the process of developing services. The difficulty is, broadly, twofold: first there is the problem of the rural population’s lack of education about emotional disorders and psychiatric care; second, there is the problem of the urban-born and trained mental health professional’s ability to be responsive to the culture of a rural area.
Submitted to the Journal in September 1977. Authors are at: Ohio State University (Berry); and Miami University, Oxford, Ohio (Davis).
673
674
Inabilities to confront misconceptions directly in these sectors impede the process and effectiveness of community mental health services. IDEOLOGICAL MISFITS
Community mental health centers were conceived by professionals from urban communities who were primarily concerned with urban services; this provides the basis for understanding many difficulties. One of the first problems involves the concept of community. “Rural” has meant country or farmland to many, but in actuality a rural community is often best described as a small town or towns plus the surrounding farming region. The boundaries of a rural community are often diffuse; as an entity, it therefore differs socially and physically from urban catchment areas. The implication for service is that miany rural areas contain a number of politically separate towns, which compete with one another for prestige and resources. A single clinic serving a number of such towns has difficulty establishing an identity as the resource for all of them. The location of the clinic in one town may automatically alienate community leaders in adjacent towns. A second problem is presented by the contemporary psychiatric concept that espouses family involvement as a desired aspect of care. In ‘any setting, when the family is hostile, apathetic, or absent there are difficulties. But with rural clientele the problems are exacerbated. Rural clients are more directly dependent on their families because they have fewer acceptable alternatives, life styles, or job opportunities to allow independence; it is therefore more difficult to encourage autonomy in a rural client with an uncooperative family.
MODEL FOR RURAL AREAS Similarly, there are special problems involved in encouraging the discharged hospital patient to become ‘a self-supporting and contributing member of society in a rural area. If patients are to become independent, the community must provide some of the supports previously offered by hospital programs, such as access to social welfare funding, half-way iacili,ties, medical care services, recreation, vocational reeducation, and job referrals. Although lack of community resources is a pervasive problem in all mental health programming, the relatively poorer predicament of the rural community is seldom taken into account. Studies that include careful measures of the indirect financial costs of adding such supportive community facilities are also lacking. As importantly, follow-up studies have not shown that discharged hospital patients in the ccmmunity are, in fact, independent. Empirical information, where available, suggests that the former hospital patient is actually a continuing financially dependent member of the community. When community resources are lacking, the most obvious question is: Are such clients better off in the community, especially in the rural community? SERVICE DELIVERY PROBLEMS
Our population’s need for services is uncertain. Findings from epidemiological studies are difficult to apply because there are few agreed-upon criteria or measurements for defining mental disorders; there are few studies to document the prevalence of disorders, and even fewer to determine the need for services, especially among rural populations. To complicate the issue, rural cultures may define behavior differently l4 and the psychiatric criteria used
BERRY AND DAVIS
to assess symptoms may not be relevant to rural people. As yet, the extent and nature of their clinical disorders and the differences in this regard between rural and urban populations have not been established. It is obvious that rural existence is not necessarily idyllic, and rural people do have disorders. But the lack of research and contradictions in available studies leave us uncertain about many aspects of rural mental health needs and rural service delivery. Acceptance of Care
Veverka and Goldman l6 maintained that rural people will accept and use mental health services, especially if located in their own community. However, a significant source of resistance is fear of the unknown, which has been correlated with a reluctance to use mental health services.l Major problems in delivering services to rural areas have been identified as: lack of adequate resources, distance, population dispersal, and entry of mental health personnel into the community.e Other important barriers are the people's llack of knowledge about existing mental health services and about what constitutes a problem for which care should be sought.' Rural community mental health centers have other special problems, which include professional isolation of the workers, lack of transportation for clients, and communication breakdowns in remote areas, as well as outreach education problems to sparsely populated areasx2 Mental health workers often encounter fear, mistrust, hostility, land apathy on the part of rural people. One mental health education experiment ' found that the people were at first friendly
675
to the researchers but later became apathetic, withdrawn, hostile, and finally no longer wanted to be lassociated with the project. It is possible that small communities want to appear progressive and helpful, but only up to a point. They also become recalcitrant when confronted with programs that bring change that threatens the status quo. Yet ,another difficulty concerns trust between local community professionals and mental health personnel. Carver noted a defensiveness toward one another on the part of teachers and mental health workers. Physicians may be friendly yet often aloof from and suspicious of psychologists and other therapists because the latter are salaried and are seen as quasi-governmental employees. Mental health workers discover that they must play the game the rural community's way, and that it takes a while, as outsiders, to gain the trust of rural people. Mental health personnel must learn to handle the initial conservative uncertainty from local officials and the populace at large by clearly demonstrating the value of their services.l0 Visibility: A Special Rural Problem
Rural persons affected by mental disorders seek no help 50% of the time. Most of those who do seek help see physicians, a few go to mental health professionals, and the rest see ministers, friends, police, lawyers, welfare workers, and public health officials. Fear of being identified as mentally ill acts as an effective barrier to help-seeking. All psychiatric practitioners desire to give the assurance of confidentiality to clients, but the issue of visibility in a rural area is a major problem. Because of the smaller number of persons in
MODEL FOR RURAL AREAS rural areas, all or most of the people the income, and the larger the size of have access to only one mental health the farm, the less the wife becomes incenter. In small towns, people know volved in decision-making. Such nonegalitarian interaction affects quite well what others are doing and there is a high probability that a person the prospects for effective individual visiting the center will be recognized and family therapy. Fathers and husand talked about by acquaintances. For bands may forbid their children or similar reasons, group therapy efforts wives to visit the mental health center, may be hampered because clients are fearing that practitioners will undermine unwilling to have others who know their authority; often these men will not them, and may gossip about them, learn personally participate in any form of in detail about their problems. Consid- therapy . ering the difficulty of maintaining anoEven though sexism is widespread in nymity, in conjunction with their rela- the rural setting, rural women are betive lack of sophistication in regard to coming aware of women’s liberation mental health services and the fear of through the mass media. Those who are stigmatization, the reluctance of rural becoming assertive are encountering repeople to seek care from mental health sistance both from men and from other women. Many rural women continue centers is understandable. patterns of submission because they seem a safer course; for those willing to A uthoritarianism try liberation, divorce, job loss, and an Another hindrance to rural mental increase in tensions with friends are health service has to do with sexism likely outcomes. Divorce is a difficult and authoritarianism in the rural com- alternative in a rural area, where munity and family. Authoritarianism is women’s opportunities for employment more pronounced in the country; there and means of support for themselves is stronger adherence to religiosity, and their children are still very few. stronger dependence on family, and stronger respect for government.I6 In Locating the “Right” Professionals a rural family, the fathers and husbands Of major importance to mental health exercise authority over their children and their wives, as well as over females service in rural areas are the professional workers in the clinics. The rural in general. In a study of rural families, Sawer l 3 setting demands special skills and qualidemonstrated that husbands tend to as- ties of mental health personnel, such as sume the major role in decision-making knowledge of rural politics and power concerning farm matters. The number structures, and the ability to develop of children the couple has is negatively informal patterns of communication correlated with the wife’s involvement with key community officials.6 Staff in general and with the adoption of members also must be familiar with and joint decision-making; income and farm sympathetic to the local cultural values, size are also negatively associated with norms, and socioeconomic arrangements the wife’s decision-making. Thus, the of the community. Pentlarge l 1 sugmore children in the family, the higher gested that the rural psychiatrist not
BERRY AND DAVIS adopt too colorful a style, but that a somewhat bland, professional, and benign manner may be requisite. According to Buxton,2 a social worker in a rural mental health setting may be set ‘apart by age, dress, education, and value system from others in the community. There is an effective word-ofmouth network among rural citizenry that reports all the activities of the mental health worker.*O Rural people are well-informed on matters concerning the worker’s life, such as marital status, family stability, drinking habits, where clothes are purchased and their cost, kind of car driven, recreational habits, religious participation, and residence. Rural mental health professionals must be concerned about their image in the community because local people will judge them on the basis of the personal factors noted above, and this judgment will color their response to the professionals’ services. The rural mental health worker must be a practitioner-generalist, able to handle a variety of problems, because the rural community cannot afford a large selection of specialists or referral resources. Mayer ti described the personal and professional rewards available to the rural worker as limited. The demands and responsibilities are enormous at times and can be somewhat of a trial. The clinician must also provide a continuity of care which, in larger centers, is often compartmentalized. On the positive side, rural mental health work may be satisfying and challenging for a number of reasons, including the status acquired through being one of the few professionals in the community. The worker’s background can be an important factor, since the community may well be wary of any newcomer,
677
especially an urban practitioner from a widely disparate area of the country. If the worker comes from another, somewhat similar, rural area, an understanding of the needs of the community may be facilitated. The professional who is indigenous to the area is a specialand rare-case. Few country boys or girls who go off to study in urban tenters choose to return home to practice; for them, professional training often represents an escape from the “restrictive” rural milieu. Equally important is the question of whether clients will accept their own prior acquaintances as therapists; again, community closeness may prove to be detrimental to confidentiality. CONCLUSIONS AND IMPLICATIONS
Some suggestions can be made regarding the improvement of mental health services to rural people. Lee, Gianturco and Eisdorfer demonstrated a need for long-term community education, the desirability of using indigenous workers, and the importance of using the “back-up” services of local physicians. Systematic mental health education can help community members to feel less threatened by change as it is represented in services provided by the mental health practitioner, and changes brought about by influences such as women’s liberation, In addition to traditional community education, there must be efforts to involve and train local citizens to assist the mental health professionals. Local volunteers can be used as aides in developing recreational programs, making “concerned” home visits, running educational workshops, and developing employment possibilities. To facilitate entry into a rural corn-
MODEL FOR RURAL AREAS
678
munity, mental health professionals to work with a wide range of people must begin contacts with other local and problems, and be able to use a professionals on a specific and concrete number of different therapies and reproblem-solving basis; help must be of- sources effectively. They should also be fered to ‘the courts, schools, and other able to handle the greater visibility of agencies on their long-standing psychi- their personal lives and the inevitable atric problem cases. Rural leaders will, judgments that will be made about them when convinced of the concrete service by community members. Perhaps of potential of mental health professionals, greatest importance is the recognition respond with cooperation. The problem that treatment personnel with a rural cases, as defined by the community, background, familiar with similar culconstitute the starting point for service tures, may be able to maintain a lower contact. This is a simple restatement of personal profile and encounter less paa basic social service principle, but one tient resistance. Finally, we agree with Mermelstein too often ignored in this age of ideological model building: “One starts where and Sundet that the professional role in rural community mental health should the client is.” In order to deal with the special prob- be determined by the phenomena adlems of visibility and client confiden- dressed, not by imposition of the pretiality in the rural area, it may be possi- vailing professional methodology or ble to locate the mental health center ideology. We need a model designed for in a setting or building that minimizes rural mental health services by profespublic exposure. It may also be possible sionals who are knowledgeable about to locate a secondary and smaller men- and sensitive to rural people, a model tal health center in a neighboring town that is responsive to the particular milieu or create a one-worker office in the of the rural area. This paper has atnearby community to afford anonymity tempted to offer some perspectives defor each population. Clients can com- signed to stimulate development of a remute short distances when visibility vised ideology, one that would more or embarrassment is an issue. Mental closely correspond to rural realities. health staff can also visit homes of clients who need and want assistance but REFERENCES 1. BUTTEWEG, M. 1974. Mental health attiare afraid to come to the center for tudes in the small community. Smith Coltreatment. This would be particularly lege Studies in SOC.Wk. 45:64. beneficial for families in which unco~.BWXTON, E. 1973. Delivering social services in rural areas. Pub. Welfare 31: operative spouses or parents refuse to provide transportation to the clinic. All 3. J. 1972. Multi-county mental of this implies aggressive outreach, health center school consultation. Ment. skills, and sensitivity to legalities as yet Hlth. Learning 49-53. underdefined and poorly explored by E. AND CUMMINC, J. 1957. Closed Ranks. Harvard University Press, the typical outpatient clinical model of Cambridge, Mass. service.6 5. DAMS. A., DINITZ, S. AND PASAMANICK, B. 1975: Schizophrenics in the New CUSThe careful selection of professionals todial Community. Ohio State University for rural areas is also important. They press, Columbus, Ohio. should be generalists, have the capacity ~ . G E R T Z , B., MEIDER, J . AND PLUCKHAN, M.
,;::;:A
4.CUMM1NG9
BERRY AND DAVIS 1975. A survey of rural community mental health needs and resources. Hosp. Comm. Psychiat. 26:816-819. 7. LEE, S., GIANTURCO, D. AND EISDORFER, C. 1974. Community mental health center accessibility: a survey of the rural poor. Arch. Gen. Psychiat. 31 :335-339. 8. MAYER, W. 1972. Treasure and trials of the complete community psychiatrist. Exchange 1:7-8. 9.MERMELSTEIN, J. AND SUNDET, P. 1973. . Community control and the determination of professional role in rural mental health. J. Operational Psychiat. 5 ( 1) :3-12. J. 1972. Mental health in rural ~O.O’NEILL, areas. Exchange 1:9-11. 11. PENTLARGE, V. 1975. Psychiatry in a small
679 town. Massachusetts J. Ment. Hlth. 5 : 14-17. 12. Rural roundup: space divided by people= problems. 1974. Innovations 1: 12-16. ~ ~ . S A W EB.R ,1973. Predictors of the farm wife’s involvement in general management and adoption decisions. Rural Sociol. 38: 412-426. 14.SUMMERS, G., SEILER, L. AND HOUGH, R. 197 1. Psychiatric symptoms: cross-validation with a rural sample. Rural Sociol. 36:367-378. 15. VEVERKA, J. AND GOLDMAN, J. 1973. Rural family counseling. J. Iowa Med. Society 63 :395-398. 16. YOUMANS, E. 1973. Age stratification and value orientations. Aging and Human Develpm. 4:53-65.
For reprints: Dr. Ann E. Davis, Sociology Department, Miami University, Oxford, Ohio 45056
