Small but Mighty: Perspectives of Rural Mental Health Counselors

Anastasia Imig

Limited research is available on the experiences of rural mental health counselors. The following is a phenomenological study grounded in critical theory. Four practicing licensed professional counselors currently working in rural settings in the Midwest region of the United States were interviewed to elicit stories regarding rural counseling, supervision and professional development experiences. The participants’ responses included the following themes: (a) need for flexibility, (b) resource availability, (c) isolation, (d) ethical dilemmas and (e) finding meaning in one’s work. The results contribute to a small but growing body of research about rural counselors, who are often misunderstood in the context of mental health.

 

Keywords: rural counseling, rural mental health, ethical dilemmas, phenomenological, professional development

 

 

No common culture for the rural United States is absolute. Rural communities range according to geographic location, diversity of inhabitants, social and economic factors, problems and resources available (Bushy & Carty, 1994). As such, counselors-in-training often lack critical background information to competently and ethically serve traditionally underserved clientele (Smalley et al., 2010); in addition, counselors often lack the professionalism necessary for dealing with the profusion of unique issues in rural settings. Authors have documented studies related to rural school counseling, rural marriage and family therapy, rural mental health practitioners, rural clinical psychology, and rural healthcare and education (Bambling et al., 2007; Boyd et al., 2007; Curtin & Hargrove, 2010; Curtis, Waters, & Brindis, 2011; Ellis, Konrad, Thomas, & Morrissey, 2009; Endacott et al., 2006; Hartley, Loux, Gale, Lambert, & Yousefian, 2010; Lockhart, 2006; McCord et al., 2011; Morris, 2006; Murry, Heflinger, Suiter, & Brody, 2011; Owens, Richerson, Murphy, Jageleweski, & Rossi, 2007; Smalley et al., 2010). There is a noticeable gap in the literature, however, related to rural mental health counseling experiences.

The many definitions of rural reflect the complexity and dynamism of this elusive concept. In one scenario, population density may be the focus of the definition, whereas in other cases, geographic isolation may take precedence. For example, the U.S. Census Bureau (2013) uses the urban-rural classification system to distinguish between two types of urban areas: (a) urban communities of 50,000 or more people and (b) urban clusters of between 2,500 and 50,000 people. Rural thereby encompasses all population, housing and territory not included within an urban area (U.S. Census Bureau, 2013). However, the U.S. Department of Agriculture uses a regional-economic concept as defined by the Office of Management and Budget, which distinguishes metropolitan areas as broad labor-market areas that include (a) central counties with one or more urbanized areas (densely populated areas with more than 50,000 people), and (b) outlying counties that are economically tied to the core counties as evidenced by labor-force commuting (U.S. Department of Agriculture, 2013). Nonmetropolitan areas are therefore those outside these metropolitan areas (U.S. Department of Agriculture, 2013). For the purposes of this article, rural is defined according to the Office of Management and Budget geographic isolation definition, with rural counties constituting those with fewer than 50,000 people as well as counties not economically tied to densely populated counties.

Bushy and Carty (1994) authored one of two articles specifically devoted to rural mental health counseling. The authors provided a solid foundation of rural mental health considerations, outlining the availability, accessibility and acceptability of services. The authors also described rural culture and its intersection with mental health, stating that utilization patterns are typically characterized by informal support systems versus social services. When rural residents do seek help, it is often because of crisis with higher associated incidents of depression, alcohol abuse, domestic violence, and child abuse and neglect.

Erickson (2001) defined the multiple relationships inherent in rural counseling. She explored various problems with regard to dual relationships in rural settings, as well as an ethical decision-making model for use in such instances. Through a case study, Erickson applied her decision-making model and promoted adherence to ethical guidelines in spite of multiple relationship occurrence.

The Council for Accreditation of Counseling and Related Educational Programs (CACREP) provides accreditation standards for licensed professional counselors. With CACREP as the industry hallmark for promoting competence through properly trained counselors, practitioners and leaders in the mental health field must take note of the lack of research and training for rural mental health counselors. The purpose of this qualitative phenomenological study was to identify the counseling experiences of licensed professional counselors working in rural settings in the Midwest region of the United States. From a critical theory perspective, this study asked the global question, “What is the experience of rural mental health counselors?” Three subquestions included the following: (a) How does the experience of working in a rural setting impact the counselor’s roles? (b) What are the contextual factors impacting counseling supervision in rural areas? and (c) What is the essence of the professional development of supervisors and supervisees providing counseling services in rural areas?

 

Method

 

Participants

Participants were recruited via network selection or “snowballing” (Creswell, 2007), in which participants and other field contacts make referrals for participation. Participants were four women who met the following research criteria: They were licensed professional counselors (LPC) currently working in the counseling field in a rural setting as defined by the U.S. Department of Agriculture (2013). Participants lived in the Midwest region of the United States at the time of the interviews, recruited from Nebraska and South Dakota. All four women were Caucasian; three were in their mid-30s and one was in her mid-50s. Each participant’s amount of experience at her current work setting fell between 2 months and 10 years. Two participants had additional credentials in either art or equine-assisted therapy (see Table 1 for a demographic summarization of participants).

 

Procedure

The author and other doctoral students participating in a graduate-level qualitative research course developed 13 interview questions. Interviews were based on research questions and semistructured, allowing for both interviewees and the interviewer to spontaneously elaborate and provide further questions and information when necessary. The author conducted the interviews face-to-face with three participants; she conducted the fourth interview over the phone. The author used two digital recorders to audiotape all four interviews, which ranged in length from 45 minutes to 1.5 hours. The author also conducted transcription of the audiotapes. She stored data in a locked drawer to ensure participant confidentiality, and used coding for participant identification to further protect anonymity. Prior to investigation, the author wrote an epoch (Moustakas, 1994) in which she identified her own experiences with rural culture in order to suspend previous understandings and to gain a fresh perspective. Such bracketing of the author’s experiences was used during and after the interviews and data analysis to further assess for and reduce potential bias.

 

Table 1

 

Participant Demographics

 

Participant

Age

Credentials

CACREP

Years

in field

Current setting

Years at current setting

Super Nanny

35

LPC, Equine-assisted therapy

No

2

Home-based, community health

.16

The Pastor’s Wife

36

LPC

Yes

10

Children’s services, outpatient

5.5

Putting Out Fires

34

LPC,

Art therapy

No

10.66

Outpatient, American Indian reservation

2.33

All Things Rural

56

LPC

Yes

10

Nonprofit, outpatient

10

 

 

 

Analysis

The author first read all transcripts in order to become familiar with the data, and then read the transcripts a second time with a subsequent data analysis, following the phenomenological approach that Creswell prescribed (2007). The current author categorized individual statements into specific codes closely resembling the participants’ statements. She clustered the codes according to their subject, with similar codes combined into units of meaning in order to better manage the data, and then she labeled each unit of meaning in a theme. From key sentiments that each participant expressed, the author developed a pseudonym to reflect her unique perspectives. Using member checking (Creswell, 2007), the author restated and summarized information, and then questioned each participant to determine accuracy throughout the interview. The author emailed both transcripts of the interviews and analyzed data to the participants so each could either agree or disagree that her experiences, views and feelings were represented accurately and completely. The author additionally utilized peer and expert audit reviews (including her doctoral classmates and class instructor) to ensure credibility of the overall findings.

 

Results

 

The author identified the following themes: (a) need for flexibility, (b) resource availability, (c) isolation, (d) ethical dilemmas and (e) finding meaning in one’s work.

 

Need for Flexibility

 One of the dominant themes of the interviews was the need for rural mental health counselors to be flexible. All participants noted having to be flexible in order to accommodate changing schedules, multiple roles and responsibilities, working in a variety of different settings, and driving long distances. For example, The Pastor’s Wife explained her struggle with flexibility when she is in a town only once a week: “Scheduling is hard. . . . And so if a kid can only be seen after school . . . at a certain time . . . I’m only in [town] one day a week. That’s a challenge.”

 

Super Nanny explained driving as part of rural life: “I mean, where I grew up, you just have to drive everywhere. To get groceries, to get a job, you have to drive at least half an hour.” For this participant, it was therefore not challenging to commute: “It’s about an hour drive from my home to visit with my supervisor.” Putting Out Fires, on the other hand, described struggles with driving: “The hardest part for me is the drive. I drive 45 minutes one way. I just hate that. For me, that’s the most frustrating.” The Pastor’s Wife had a different problem with driving: “The thing that gets me . . . is cost. . . . It costs a lot for travel. . . . With budget cuts, they cut back on that kind of stuff. So, to get creative, [I] carpool to different trainings.”

 

To help close the distance typically found in rural areas, participants met with clientele in a variety of untraditional settings to lessen the physical gap between counselors’ offices and clients’ homes. Settings included town libraries, churches, schools and funeral homes. Putting Out Fires candidly remarked, “I even go to their work. It’s approved by their boss that I meet them. I do that every week.” Even in her office space located in a church, All Things Rural must be flexible with the comings and goings of congregation members.

 

We’re very respectful of the church people and they are very respectful of us. If they know we have something going on, they stay away. Like [if] we have someone in the family room, they’ll go somewhere else. It’s wonderful.

 

In addition to juggling different settings, participants juggled many roles in their positions as well. Whether it was the role of teacher, case manager, secretary, grant writer, administrator, supervisor or advocate, all four participants acknowledged that an essential part of being a rural counselor entailed wearing many hats. All Things Rural commented, “So, we do everything: phones, insurance, make our own appointments, case notes. We make our own grants. It is very all encompassing.” Similarly, Putting Out Fires admitted, “I do trainings with the pre-natal classes. . . . I do a lot of community activities. I do a lot of prevention. [When] they have community activities, like National AIDS Awareness Day, we’ll have a booth.” Of course, Super Nanny described her teaching responsibilities accordingly: “I do a lot of Super Nanny type stuff . . . a lot of hands on, experiential, teaching type stuff. Like taking advantage of teachable moments. So I’m teaching.”

 

Flexibility also resulted in fewer people doing more jobs in the community as a whole. For example, doubling of other roles also occurred. All Things Rural explained, “The church secretary also double-times as our treasurer.” Putting Out Fires echoed a similar example: “They were without a social worker for a while. So they had a nurse trying.” And if roles are not filled, then it is the community that must go without.

 

Resources

Another dominant theme was resources in rural communities. All Things Rural described the affordability of counseling for community members: “We can see people who for any reason aren’t having their mental health or counseling needs met, we never refuse anyone for inability to pay.” Putting Out Fires mentioned the availability of transportation for clients: “I really do not have very many no-shows because we provide transportation. So we even go to the houses and pick them up.” For those individuals initiating services, culturally diverse staff is available, according to Super Nanny:

 

At the agency that I work, they have at least two licensed therapists that, one of them is actually from Somalia and the other one is kind of like an expert in that area . . . really knows a lot of the culture and all that stuff. . . . I’m impressed with that in where I’m working now. There’s also a large Hispanic culture and at least half of all the staff, the family service workers, as well as the therapists, are bilingual.

 

Despite being in rural locations, participants had access to other professionals and trainings. One of the benefits of working for an American Indian/Native Alaska tribe, confided Putting Out Fires, was that “there’s lots of funds. When it comes to CEUs [continuing education units], trainings, I am very spoiled. They pay for all of that. That’s a huge benefit. It’s huge.” Although the other participants did not have comparable financial backing for professional development, The Pastor’s Wife commented on local trainings: “I think that there are some local things that are available. There’s been some . . . workshops at the hospital . . . which has been nice. And they’re free. So that’s good.” All Things Rural similarly described a local conference: “Here in [town] there is an annual Mental Wellness Conference.”

 

All four participants identified local availability for interacting with other rural mental health counselors. Whether through staff meetings, informal office drop-ins or contact with other area personnel, all have been able to find resources nearby. All Things Rural stated, “I always have people I can talk to.” Super Nanny described a similar experience: “And then . . . if I don’t know about something, I access the person that does within the agency.” Furthermore, the Internet has proven helpful for participants when asking questions over e-mail, finding information or materials online, or utilizing telesupervision. Putting Out Fires explained, “The big thing now is telesupervision. And even using Skype. I actually went to a seminar at the last art therapy conference, and it was all about telesupervision. Because I even had supervised somebody through Skype.”

 

On the other hand, participants also had experiences where wait lists formed due to high need and not enough local professional staff available. The Pastor’s Wife said, “I’m the only QMHP [qualified mental health professional] in [town] on Fridays.” Putting Out Fires also complained about the lack of professionally qualified area staff: “Their CPS [Child Protective Services] workers don’t have to have a college education. . . . I’m not sure what their requirements are. So they may not necessarily even be trained.”

 

Because there are few professionals serving a small population, there is often a lack of clinician anonymity. Super Nanny described the challenge of maintaining a private life while out in public: “Is it somebody I’m working with? Is it somebody I’m going to work with possibly in the future? . . . What are they seeing? What opinions are they forming?” Super Nanny expressed similar concern: “It’s just [that you’re] always having to represent yourself in a professional manner whether you’re at work or not at work.” All Things Rural summarized, “You run into your clients more in a rural setting than you would otherwise.”

 

Isolation

Not surprisingly, another aspect of being a rural counselor involved experiences with wide, open spaces. The Pastor’s Wife elaborated on the complications as a result of unavailable cell signals:

 

If I have a question, or something, and I need to call back, at times there’s trouble with reception. . . . Like down in [town] . . . you have to go to . . . the top of this hill to get cell reception. . . . In somebody’s house, there’s no cell reception.

 

Super Nanny struggled with a different piece:

 

I miss the office interaction, though. That’s where you do a lot of the collaborating. A lot of consultation . . . a lot of ideas are generated. “I’m struggling with a client, what do you do?” Just, you know, passing in the hall. Or, when you have a 10-minute break and you’re in someone else’s office. “I’ve got a quick question for you. I’m struggling with . . . What advice do you have?” I miss that.

 

Ethical Dilemmas

Dual relationships abound in rural communities. Putting Out Fires explained, “It’s so small in the community, you become friends, then . . . you see their kid.” She further detailed, “And we don’t have an EAP [Employee Assistance] program. So we’ve seen co-workers. That’s really hard.” The Pastor’s Wife added, “And also I see a few of the kids of staff, of my co-workers. . . . I haven’t had any issues, but it’s . . . a whole different situation I guess. Because you’re coworkers and a client.” The Pastor’s Wife also explained the intersection of her personal and professional lives:

 

Well, I’ve run into some difficulties with my husband being a pastor at the church. . . . I’ve had some clients that have also been parishioners, and so with the confidentiality, I can’t talk to my husband about things. But he also has confidentiality about things, being a pastor. And he can’t talk to me about things. But there have been times that I’ve been on-call, and he has gotten a call from a parishioner, that he has had to encourage to call the crisis line, then I answer the crisis line. And it’s just . . . it hasn’t caused any problems, but the uncomfortableness [sic] is there. And, so that has been difficult at times.

 

In addition to dual relationships, participants cited concerns regarding other rural professionals’ multicultural competency. The Pastor’s Wife described several colleagues’ biases:

 

I know that there is natural stereotypes, of you know, this kid’s a Native American kid versus a White kid. So the Native American kid is gonna be, you know, have more problem behaviors. I think there’s stereotypes for sure.

 

Putting Out Fires had a similar experience: “The thing that is really frustrating . . . there are teachers in the schools that are really racist.” In addition to advocating for clients while on the job, she stresses the importance of doing so while interacting with family and friends. Putting Out Fires explains, “Oh, I say stuff” to combat stereotypes and injustices.

 

Finding Meaning in One’s Work

In spite of the obstacles of rural mental health counseling, all four participants identified sources of job satisfaction. Putting Out Fires remarked about her American Indian clients, “They’re so resilient. And you know, they’re strong. They adapt to the circumstances.” The Pastor’s Wife reflected on her multiple responsibilities by saying, “There’s some benefits in working in rural areas, too. I think . . . it can be more rewarding because you feel you’re doing more. You have to.” Super Nanny was proud to be giving back to her childhood community: “I feel that it’s very rewarding to work in the communities . . . that I grew up in and to be able to actually help the people I work with.” Super Nanny also added the following:

 

And within small communities, the chances that I’m going to run into them in the future are very high. . . . And I have had that experience where I do run into people from the past and I see them doing very well . . . to me [this] is very rewarding.

 

All Things Rural stated, “We have a wonderful staff and we’re very happy.” To reiterate, she said, “I love my work. I love my work.” All Things Rural summarized her rural mental health counseling experiences by saying, “We are small, but mighty.”

 

Discussion

 

This study demonstrates many aspects of rural mental health counseling and answers the research question related to rural counselors’ various roles and supervision and professional development experiences. Given the extra roles that participants take on and the multiple settings in which they practice, the findings of this study are similar to those of Bushy and Carty (1994). This study further highlights the ambiguous nature of availability and accessibility of rural mental health resources. In some instances, participants described ample collegial accessibility. Putting Out Fires said, “I feel supervision-wise, I get a lot of good support.” All Things Rural concurred: “I know a lot of my colleagues in the area. And that’s helpful.” In other instances, participants bemoaned a lack of resources. Putting Out Fires replied, “You have to work your butt off. We have scraped. We have scraped.” Super Nanny responded, “They’re there. You just have to look for them.” With such contradictions occurring within the context of the four interviews, the complexity of rural mental health counseling is apparent. Hard work is expected. Putting Out Fires explained, “If you’re going to be successful, you’re going to have to work at it.”

 

By using a qualitative design, the author was able to gain insight into the nature of rural mental health counseling experiences that she could not study easily through quantitative methods. Allowing participants to speak candidly about their experiences in a semistructured interview format provided an increased understanding of rural mental health counseling experiences, supervision and professional development. The participants also represented a variety of service venues, including outpatient services on an American Indian reservation.

 

One limitation of the study relates to the questionable reliability of self-reports. Some participants may have felt political or internal pressure to portray their geographic location or job in a positive light. The author’s presence during data collection may similarly have impacted participants’ responses. An obvious limitation is the narrow demographic representation and sample size. Although the participants represented a variety of community mental health settings, all the participants were Caucasian females. Having more substantive demographic differences (e.g., age, race, gender, years in the field) and a larger sample size could have further enriched the findings.

 

Implications for Clinical Practice, Counselor Education and Future Research

 

It remains clear that certain personal qualities and professional skills can lead to increased rural mental health job satisfaction and success. For example, knowing how to adapt to ever-changing situations, be they role or setting related, is important. Whether being prepared to help a community sandbag for an approaching flood, anticipating loss of cell phone reception or writing one’s own grants, flexibility becomes key. As All Things Rural said, “You just have to be very versatile.”

 

The current study reinforced findings from previous rural mental health research. Working in isolation is a hard truth for rural mental health counselors (Curtin & Hargrove, 2010). All Things Rural said, “Smaller communities . . . don’t have services.” The Pastor’s Wife expanded on the dilemma: “And the resources out there are even . . . less than here, so it was really important to have those credentials.” Obtaining additional credentials may not only help advance one’s career goals, but in rural mental health counseling, it can become a function of survival.

 

Smalley et al. (2010) further suggested anticipation of ethical dilemmas. Participants in this study recognized the coping skills necessary for dealing with concerns surrounding confidentiality, dual relationships and discrimination. Super Nanny used deflection and planned ignoring. All Things Rural used humor. Putting Out Fires and The Pastor’s Wife used limit setting. While Curtin and Hargrove (2010) promoted overall administrative and supervisory support for rural mental health professionals, it is the current author’s belief that such encouragement can prove additionally important regarding ethical concerns. Furthermore, Endacott et al. (2006) advocated that licensing boards differentiate between acceptable and unacceptable boundary crossings for rural mental health counselors and develop corresponding guidelines for protection when such occurrences happen.

 

Bushy and Carty (1994) found limited training regarding rural mental health practice. Inevitably, counseling training programs have an urban orientation toward the counseling profession (Bushy & Carty, 1994). Ellis et al. (2009) recommend specialized training to meet the unique needs of rural mental health counselors. Training areas of particular importance include telesupervision, social justice advocacy, and managing inevitable dual relationships and breaches in confidentiality.

 

In light of this study’s findings, optimism remains for this growing area of mental health counseling. All four participants were able to glean meaning despite extra responsibilities, isolation, ethical hardships and unavailable resources. It is clear these four rural mental health counselors are able to transcend tremendous obstacles. Indeed, “small but mighty” is a fitting description for this specialized group of mental health professionals.

 

 

 

 

 

References

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Anastasia Imig is a doctoral candidate at the University of South Dakota. Correspondence can be addressed to University of South Dakota, Room #210 Delzell, 414 E. Clark St., Vermillion, SD 57069, anastasi.imig@usd.edu.