Published August 25th, 2021 at 6:00 AM
A couple of years ago, Jason Medows, a farmer and pharmacist who works in Rolla, Missouri, was desperate for mental health care.
Finding that care was nearly impossible.
“I called not one, not two, not three providers in Rolla, but four and was not able to be seen,” he said.
Two of the lines he called were even disconnected.
“I’m a health care worker. I understand (the system) and I was frustrated,” he said. “So I could not imagine what it would be like for someone who is not in my shoes, who doesn’t have an understanding of the system, how they would be discouraged.”
Ask someone in rural America what the biggest challenge is to mental health care and they’ll most likely say “access.” Not only is there a lack of mental health professionals in rural communities, experts say, but people often have to travel long distances to find those professionals. Even then, there are issues with getting it covered by insurance.
According to the University of Missouri Extension, all of the 99 rural counties in Missouri have a shortage of mental health professionals. In 57 of those counties there are no mental health professionals.
This isn’t just a rural problem, either. Less than 6% of mental health needs are met in Missouri, according to a 2021 report by the Bureau of Health Workforce, Health Resources and Services Administration and the U.S. Department of Health & Human Services.
That’s less than any other state. In Kansas, about 32% of needs are met.
Garret Hawkins, president of the Missouri Farm Bureau, said the first obstacle to mental health care for farmers is acknowledging its need.
As a farmer himself, Hawkins said he knows the physically demanding lifestyle of a farmer or rancher encourages a do-it-yourself mentality. And not in a Pinterest, make-your-own-coffee-table type of way, but in a way that stigmatizes asking for help.
“We’re known for being tough and resilient, yet at the same time, we’re not always the best about asking for help when we need it,” Hawkins said. “And so one of the roles that we have taken on as the state’s largest farm organization is to work with others to tear down the stigma, to let our members know it’s okay to not be okay.”
Hawkins said Missouri Farm Bureau has been working with the University of Missouri and other partners to normalize conversations around mental health amongst its members.
While others might be able to admit they need help, they might feel a social stigma around entering a mental health care facility or trying to seek help.
Kansas Farm Bureau (KFB) and K-State Research and Extension for Farm Stress are also working on bringing more mental health awareness in rural Kansas. Erin Petersilie, assistant director of health plans at KFB, said in a town where common knowledge travels fast it can be uncomfortable to seek care.
“We also need to think about the fact that there is still very much a stigma surrounding mental health and it is very hard in those small towns when we think about how everybody knows everybody,” Petersilie said. “So the last thing people want to have happen is to have a vehicle parked in front of a mental health office, because they are going to get talked about.”
KFB and K-State Research and Extension have teamed up to provide more education on mental health warning signs and different numbers and hotlines people can call if they need help.
Amy May, clinical director at North Central Missouri Mental Health, said her rural offices have typically only dealt with severe mental health illnesses like schizophrenia or bipolar disorder. But in the past year or so she’s seen more patients dealing with suicide and depression.
Despite the increase in patients, May said many still feel uncomfortable in seeking mental health care.
“I still feel like there is this stigma of we still just don’t want to talk about it; or we don’t want people to know we’re getting services, especially here,” May said. “I feel like our offices are kind of in outlying locations and yet I still have clients … they’ll drive to another office just because they don’t want, and they flat out said, ‘I don’t want people to see my car in your parking lot.’ ”
Even at the school level, Polo R-VII school counselor Rebecca Chambers-Arway said the invisible illness can be hard for her students to take seriously.
She worked with a student for a while who said her friends would make jokes about her counseling sessions. Chambers-Arway’s advice was to remind them that mental well-being is a serious health issue even though it’s not always visible.
Someone goes to the doctor for a broken bone, Chambers-Arway noted. How is it any different to seek help for a broken spirit?
“It’s hard because I still think kids think that a mental illness is a weakness, but so many of us deal with it on a daily basis,” Chambers-Arway said. “It’s just (that) it’s hidden. You can’t see it.”
Chambers-Arway said she works to simplify complex emotions, like anxiety, and instead helps children to recognize the things they are worried about. Those simplified conversations can evolve as the students age to better understand the way they are feeling.
“I think so many times those feelings aren’t normalized when they’re little, so that’s what they grow up learning,” Chambers-Arway said.
It’s not an issue that can be solved or normalized overnight. Chambers-Arway said she hopes to see more involvement with mental health first aid training both at school and in the community.
These sessions can help instructors and parents to recognize signs of mental health issues and know how to intervene, but she said the response in Polo hasn’t been huge.
“I think it’s just going to be a constant battle until people, not people, society, embraces it and recognizes that it is something that needs to be addressed,” Chambers-Arway said.
In the same vein, Hawkins said the Missouri Farm Bureau is working to teach people the warning signs of mental illness.
In early 2020, the bureau was part of a study noting the effect of economic changes, congressional action and severe weather conditions on the mental well-being of Missouri agriculture producers.
Since then, Hawkins said the COVID-19 pandemic exacerbated mental health conditions as supply chain disruptions and increased isolation caused more stress to farmers.
“Just knowing that family and friends are facing issues makes it even more imperative that maybe we do check-ins more frequently, just to see how folks are doing,” Hawkins said, “Just asking the question, ‘How are you doing?’ It’s really that simple.”
Thankfully, as studies emerge about this issue, Hawkins said more resources have been made available through the University of Missouri Extension and through the USDA’s Farm and Ranch Stress Assistance Network.
After someone in a rural area has identified the signs of mental illness and decided to seek help, where do they turn? Hawkins serves on his local hospital board and said the number one issue it is currently faced with, and doesn’t provide, is mental health counseling.
“One of the challenges that we have as a critical access hospital is how to provide all the services that are needed in our community and the outlying rural areas for our farm and ranch families,” Hawkins said.
Telehealth presents itself as a golden solution to reaching rural communities, but access to strong internet connection remains an obstacle.
“In my hometown of Appleton City, we have the technology to do telehealth, but we don’t have strong enough bandwidth to provide telehealth on a consistent basis that is adequate for the provider, as well as the patient,” Hawkins said.
Because Missouri has such a shortage of mental health professionals, Hawkins said telehealth is logistically the best way to reach communities far and wide.
“If we have that physical shortage it only makes sense that opportunities provided with telehealth allow us to cast a wider net to try to reach more providers to improve accessibility for farm, ranch and rural families,” Hawkins said.
Medows is a big proponent for telehealth counseling.
After his unsuccessful search for in-person care, Medows went online, where he was finally able to get help. He now uses a virtual service called Better Health, which allows him to instant message and video conference with licensed professionals.
Medows is fortunate because he has access to high-speed internet, but that’s not the case for many in rural communities.
According to the Federal Communications Commission (FCC), just one-fourth of the rural population in America has broadband access. But even this data has been criticized for not being granular enough, meaning that ratio is likely even smaller.
“There is no such thing as affordable high speed internet out here,” Medows said. “I mean, that’s like a unicorn, as far as I’m concerned. We’re fortunate to where we can afford it, but even what we afford isn’t very good. We pay $190 a month for internet and it’s not even that good.”
Petersilie of KFB said that the bureau has some initiatives to improve broadband access and stressed the importance of making care as accessible as possible.
“How do farmers access this system?” Petersilie said. “We also need to look at the flip side of that point. How does that system access the farmers?”
Elaine Johannes of K-State Research and Extension for Farm Stress said not only does there need to be more telehealth options, but quality therapists who understand the unique stressors of rural America and farming.
“We need to talk about telehealth,” she said. “We need top talent. We need to have people understand that therapies can be done online, they can even be done through a cell phone. Now, that doesn’t replace the human and the interaction between folks. But again, we need to understand what’s going on with mental health care in the United States and especially in rural areas, so we could be allies with it.”
Schools are typically reliable locations with stable internet in rural areas, meaning it could be possible to have students take telehealth counseling from the building. Chambers-Arway said her district has started a program like this.
“(Telehealth therapy) would be an ideal situation. It’s just, I feel like sometimes the insurance hoops are harder to get through than the parents and students agreeing to the support,” Chambers-Arway said.
Insurance hoops were a barrier to students even when the school had an in-person therapist. This program, through Northwest Behavioral Health, designated a therapist to split time between Gallatin, Polo and Hamilton school districts each week.
Chambers-Arway said the program was successful and generated a lot of interest, but because it was free to the school and paid for by a student’s insurance, the enrollment paperwork was immense.
It sounds like a small inconvenience to fill out the forms and meet with the therapist, but Chambers-Arway said it meant a day off from work and a lot of parents in Polo couldn’t afford that time.
“As soon as we got that going we had students coming in, and parents, to us and asking, ‘Okay, can we get ours set up with her?’” Chambers-Arway said.
When the therapist left Northwest Behavioral, Gallatin and Polo were without a replacement, but a well-established need. Chambers-Arway said she tried to get a different person to come to the school, but said it never reached fruition.
“In my opinion, that’s the only way we’ll be able to secure some mental health support, outside of what I can do as a (school) counselor,” Chambers-Arway said. “I can’t do some of that deep-seeded counseling in a school setting.”
Jennifer Kline, program manager at Northwest Behavioral, said all of the school outreach programs like this have ended because of a shortage in behavioral health providers.
“It’s challenging for us to fill vacancies and meet the demand even in urban areas across the board,” Kline said. “It’s just not enough people to go around and fill all of the positions.”
Providers in rural areas, and especially those working in schools, require specialized knowledge in aiding those populations, making their roles especially difficult to fill.
Local behavioral and mental health facilities like Northwest and North Central Missouri Mental Health are stretched thin, serving four and nine counties, respectively, with outreach offices.
Even with these local offices, that leaves a lot unreached or with a significant drive to reach care. A map by the University of Missouri Extension shows all of the mental health facilities in the state. Many counties are left with just one facility and others are completely barren.
May said she sees transportation as a major issue to clients seeking mental health care.
“Transportation is a huge barrier for our clients,” May said. “We do have a lot of satellite offices. However, for prescribers and therapists, they may not be able to get to all the offices. So the clients have to travel to a certain office location to get to our services.”
Getting care is important, but Medows said for many farmers who work with the daylight, an hour and half trip can be too much time away.
“Double that drive time and whatever time that you’re there and that’s all time that is lost in whatever else you want to do, working a job, spending time with the family,” Medows said.
His passion for mental health awareness led Medows to create his podcast, “Ag State of Mind.” For Medows, it’s important to have farmers and ranchers talking about mental health so others struggling with the same problems know they’re not alone.
“There needs to be more real people talking about it; more people sharing their own experience with it and not having the fear of ridicule,” Medows said.
By “real people” Medows means the people living with feelings of independence and isolation often associated with rural life.
“People who are residents of the rural community. People like me who live in the rural community and share their certain experience in the challenges and are relatable. People who just as easily could be their neighbor, people who people could see being their neighbor.”
Marissa Plescia is a Dow Jones summer intern at Kansas City PBS. Vicky Diaz-Camacho covers community affairs for Kansas City PBS. Cami Koons covers rural affairs for Kansas City PBS in cooperation with Report for America.