mental health counselors - The Professional Counselor

Rising From the Ashes: Voices of Rural Counselors During the Coronavirus (COVID-19) Pandemic

Aug 26, 2025 | Volume 15 - Issue 3

Brandi M. Sawyer, Edith Gonzalez

The global health and economic disaster caused by the coronavirus (COVID-19) pandemic has intensified mental health needs and subsequent demands on helping professionals. Counselors, in general, are at risk of experiencing both shared traumatic realities with clients and exacerbation of occupational stressors. For rural mental health counselors, who already face enhanced stressors related to rural service provision, the impact of COVID-19 is generally unknown. Through transcendental phenomenology, this study explores the experiences of 11 rural mental health counselors practicing in Texas during the COVID-19 pandemic. Two themes emerged, revealing experiences of systemic limitations as well as counselor growth and resilience. Findings provide implications for mental health counselor training, clinical practice, and advocacy.

Keywords: COVID-19 pandemic, rural, mental health counselors, transcendental phenomenology, resilience

With over a million deaths in the United States alone (Centers for Disease Control and Prevention [CDC], n.d.) the novel coronavirus (COVID-19) pandemic created a mental health crisis that includes long-term fear, trauma, grief, isolation, and negative social patterns (Czeisler et al., 2020; Eisma et al., 2021; Elbogen et al., 2021; Prati & Mancini, 2021). The influx of mental health needs meant that practitioners had to meet the demand of providing quality counseling services for those struggling with COVID-19 pandemic–related symptoms. Mental health counselors and related professionals experienced significant increases in caseloads and the clinical severity of presenting symptoms (Czeisler et al., 2020) that added increased pressure to workload, risk of burnout, and compassion fatigue, all of which are natural occupational hazards even under typical circumstances (Litam et al., 2021; Posluns & Gall, 2020; Sprang et al., 2007).

Increases in service demand were especially problematic when considering the vast preexisting shortage of mental health service availability worldwide (Wainberg et al., 2017). For rural mental health counselors, who ordinarily experience increased mental health service shortages (Breen & Drew, 2012; Slama, 2004), these demands and lack of resources were likely more intensely highlighted as lockdowns and shelter-in-place orders further reduced service access while simultaneously increasing the need for it (Panchal et al., 2023; Prati & Mancini, 2021). Mental health professionals were suddenly forced to transition to teletherapy services, a modality not frequently used prior to the COVID-19 pandemic (Burgoyne & Cohn, 2020; Pierce et al., 2021).

Teletherapy completely reshaped the provision of counseling services and required practitioners to consider and navigate various concerns, including accessibility and advocacy issues for vulnerable populations, quality of therapeutic engagement, ethical and legal matters, financial issues, treatment effectiveness, experience limitations, and training limitations (Maurya et al., 2020). This was likely a greater adjustment for rural practitioners, as they were less likely to use this modality than their urban counterparts prior to the COVID-19 pandemic (Pierce et al., 2020). Teletherapy has its disadvantages and advantages. The disadvantages include increased complexity of ethical issues such as privacy, information security, and maintaining a professional environment and professional relationships (Burgoyne & Cohn; Pierce et al., 2021). However, teletherapy provides client accessibility to services, overcoming the most notable barrier of local practitioner shortages experienced more often by rural residents (Tarlow et al., 2020). Through teletherapy, rural residents can connect to counselors in larger populated areas, but internet connectivity to do so has been a challenge historically (Handley et al., 2014).

Rural Mental Health

Practice and clinical topics related to rural populations are relatively sparse in empirical counseling literature, and this is especially true regarding rural mental health counselors during the COVID-19 pandemic. Existing research has established the enhanced hardships faced by rural populations, including more significant mental health presentations caused by mental health stigma (Slama, 2004) and a significant lack of mental health, medical, and transportation resources (Breen & Drew, 2012; Pullen & Oser, 2014; Slama, 2004). For rural counselors, this often means bulging caseloads, professional isolation, and more complicated cases than their urban counterparts.

Although not specific to COVID-19, Fruetel et al. (2022) documented the experiences of school and clinical mental health counselors responding to crises in rural areas. Findings indicated significant hardships such as isolation and lack of crisis stabilization resources. This highlights the fact that rural counselors continue to face significant mental health challenges in the community with limited institutional and professional support, placing further demands on existing providers and thereby increasing the risk of burnout and attrition (Litam et al., 2021; Sprang et al., 2007). To further complicate matters, the COVID-19 pandemic has exacerbated practitioner experiences of vicarious trauma, fatigue, and emotional disconnection as well as feelings of incompetence (Aafjes-van Doorn et al., 2020), which likely has a compounded effect for rural mental health counselors, who face additional geographic and cultural stressors (Breen & Drew, 2012; Pullen & Oser, 2014; Slama, 2004).

Trauma and Resilience
For many counselors involved in trauma and crisis work, occupational hazards such as burnout, compassion fatigue, and vicarious trauma have been documented (Posluns & Gall, 2020; Sprang et al., 2007), but less is known about the complexities of sharing trauma and crisis simultaneously with clients. Bell and Robinson (2013) posited that such experiences evolve into a compounded experience for counselors, in which the interplay between both vicarious and direct trauma—known as shared traumatic reality—enhances the post-traumatic exposure counselors experience. The shared traumatic reality of the COVID-19 pandemic has likely intensified existing occupational hazards of stress, burnout, and compassion fatigue (Litam et al., 2021; Posluns & Gall, 2020; Sprang et al., 2007).

Examining only the negative experiences associated with long-term trauma and crisis work would be unidimensional, inaccurate, and ignoring the potential value in such meaningful work. Additionally, this one-sided position ignores the presence and value of resilience among practicing counselors. Resilience has been represented as the ability to adapt and maintain well-being during unfavorable conditions (Clauss-Ehlers, 2008) and more specifically, taking deliberate actions to sustain health during hardship (Litam et al., 2021). Fostering resilience is imperative for mental health counselors who often face vicarious trauma. Without self-care and the ability to cope positively, these professionals risk burnout and impairment (Posluns & Gall, 2020), the latter of which has strong ethical implications because it poses an emotional risk to clients (Bell & Robinson, 2013).

Lambert and Lawson (2013), who studied counselors providing services during Hurricanes Katrina and Rita, found that counselors treating survivors of those disasters experienced compassion fatigue and burnout at no greater rates than counselors in general. Interestingly, those counselors who were both survivors and treatment providers experienced compassion satisfaction and post-traumatic growth, positive counterparts to compassion fatigue and post-traumatic stress, respectively. Similarly, Litam et al. (2021) found comparable results for counselors during the COVID-19 pandemic. Although occupational hazards such as compassion fatigue, vicarious trauma, and burnout were apparent for counselors in the sample, resiliency was a positive mitigating factor. It is important to note, however, that neither study examined multicultural issues as variables, and Litam et al. noted the absence of rural counselors as a significant limitation of their study.

Although not a study conducted with counselors, Wang et al. (2021) compared coping and adjustment in rural and urban individuals in North America. Despite adverse experiences among both groups, Wang et al. found several strengths in rural populations that were undetected in their urban counterparts, including enhanced coping and adjustment. These findings imply a cultural element to trauma and disaster response. In studies specific to counselors, Crumb et al. (2021) found strengths among rural school counselors providing disaster mental health services that included deepened empathy because of co-experience; Imig (2014) also found that despite difficulties, rural counselors found meaning in difficult work.

At the time of this study, we did not find additional research examining stress, resilience, or other quantitative or qualitative inquiries of rural mental health counselors’ experiences during the COVID-19 pandemic. This paucity of literature necessitates our study, which aims to fill a gap in understanding the interplay of rural mental health constraints and COVID-19 response. Learning how rural mental health counselors manage the complexities of limited mental health and medical resources, increased service demand, and vicarious trauma is imperative to better prepare for future mass disasters while maintaining the health and well-being of practitioners. Additionally, this study provides a much-needed voice for rural counselors and can further advocacy efforts for rural communities.

Method

The purpose of this study was to explore the experiences of rural mental health counselors during the COVID-19 pandemic and to develop a distinct picture of this population during long-term stress and disaster. We utilized a postpositivism paradigm, which allows for the acknowledgement of multiple perspectives while also striving for empirical rigor, to explore the universal experience of rural counselors during the COVID-19 pandemic (Guba & Lincoln, 1994; Hoshmand, 1996). To facilitate this exploration, we utilized a transcendental phenomenological methodology to capture the essence or true meaning of the phenomena of interest, the overall experiences, and the responses of the sample who share elements of an identity under similar conditions (Moustakas, 1994). Although postpositivism and transcendental phenomenology originate from different epistemological assumptions, one that emphasizes a reality that can be approximated through empirical observation and the other focusing on the essence of lived experience through subjective exploration, this study intentionally combined both to balance rigor and depth. Transcendental phenomenology and postpositivism have been found to complement each other through acknowledging multiple perspectives and having a top-down approach to research (Henderson, 2011; Hoshmand, 1996; Moustakas, 1994), and additional studies have utilized this paradigm and methodology (Eryaman et al., 2013; Hall et al., 2016). Nevertheless, to address potential incongruences, we utilized bracketing techniques to mitigate researcher bias and to ensure that the participants’ experiences remained central to the study. In alignment with transcendental phenomenology, we aimed to explore the lived experiences of rural mental health counselors during the COVID-19 pandemic, focusing on the perceived impacts and responses. The research questions guiding this exploration were:

RQ1: What were the experiences of rural mental health counselors during the COVID-19 pandemic?
RQ2: What impacts, if any, did COVID-19 have on the lives of rural mental health counselors?
RQ3: How did rural mental health counselors respond, if at all, to the COVID-19 pandemic?

Site and Sample Selection
The sample criteria included Licensed Professional Counselors of all rankings—Licensed Professional Counselor-Associates (LPC-As), Licensed Professional Counselors (LPCs), and Licensed Professional Counselor-Supervisors (LPC-Ss)—who provided mental health counseling services in rural regions of Texas between March and December 2020. Texas was selected as a matter of convenience sampling (both Brandi M. Sawyer and Edith Gonzalez reside in Texas and are familiar with public license information) and because 76% of the state is considered fully rural. Additionally, Texas, like most other states, experienced government-mandated lockdowns, restricted social gatherings, and shuttered schools for most of 2020 (Friend, 2021; Limón, 2020), indicating that Texans experienced significant adversity from the pandemic. The criteria for rural regions were determined by the fiscal year 2022 definitions set forth by the Federal Office of Rural Health Policy (Health Resources and Services Administration, Federal Office of Rural Health Policy [FORHP], 2025).

Following approval for this study by the IRB, we obtained a list from the FORHP (2025) of counties in Texas with a completely rural status for fiscal year 2022 as an initial guide for sampling. Once the counties were identified, we used the Texas Behavioral Health Executive Council’s online search tool to obtain the names of eligible participants. This information was then used in a Google search to find addresses and emails for potential participants. In sum, we compiled a list of LPCs from 198 of 200 counties. Two counties were eliminated, as Sawyer had worked extensively in these rural counties and the likelihood that she knew potential participants was significantly increased. Email addresses, when available, were the first method of contact for recruiting participants. When not available, paper flyers were mailed to available addresses. Participants who completed the study and the final member-checking procedure received a $50 Amazon gift card. All participant recruitment and data collection took place in August and September of 2022.

Participants
Following recruitment procedures, 12 individuals volunteered to participate in this study, 11 of whom completed individual interviews. Saturation of data, when no new themes emerged during interviews and analysis (Ando et al., 2014), was reached within the 11 participants; no additional participants were needed. Eight participants identified as female, two participants identified as male, and one participant identified as transgender male. Eight participants identified as White and three identified as Hispanic or Latino. Nine of the 11 participants had master’s degrees and two held doctoral-level degrees. Years in counseling practice ranged from 1.5–30. Years in rural counseling practice also ranged from 1.5–30. Working environments varied across the 11 participants and included seven in group and private practice, three in agency and nonprofit settings, and one in an educational setting fulfilling a mental health counseling role. The sample consisted of the following current license categories: nine LPCs, one LPC-A, and one LPC-S.

Data Collection
Exploratory questions were designed to holistically capture the perceived impact of the COVID-19 pandemic, including the related thoughts, emotions, and behavioral responses as they align with the research questions exploring general experience, impact, and response. Participants chose personalized pseudonyms for anonymity and engaged in a 45–60-minute semi-structured, open-ended interview exploring their experiences working during the COVID-19 pandemic. The interview protocol included the following questions:

What was it like to provide rural mental health counseling during the COVID-19 pandemic?
How did you respond to the COVID-19 pandemic?
What feelings do you experience about providing rural counseling during the COVID-19 pandemic?
How did the COVID-19 pandemic impact your personal life?
How did the COVID-19 pandemic impact your professional life?
What was it like providing teletherapy during the COVID-19 pandemic?
What is it currently like providing teletherapy?
What is your perception of rural mental health counseling during the COVID-19 pandemic?
How do you see your rural mental health work in the future following the COVID-19 pandemic?

Interviews were conducted and recorded via Zoom. Transcripts were first generated through a transcription application, Otter, and then verified for accuracy.

Data Analysis Procedures
Following the procedures set forth by Moustakas (1994), we used thematic analysis to evaluate data using two cycles of inductive coding. Engaging in multiple levels of inductive coding allowed us to explore themes within participant experiences while minimizing preconceived biases, a process known as epoche. The steps of coding and analysis first included preliminary horizontalization, which involved reducing narrative data into smaller units but not yet grouping data based on shared meanings. Using a spreadsheet, we achieved this by taking participant transcripts line by line, summarizing them, and placing them into columns. The next step in analysis, phenomenological reduction, involved clustering data relevant to the research questions into categories of corresponding themes and considering these from a variety of perspectives. Clustering data was done first to efficiently manage the data in order to better recognize recurring themes. We evaluated the horizontal data in the spreadsheet and clustered data from textural descriptions in various statements until no new groupings emerged. Ancillary information irrelevant to the research questions was eliminated from further coding. The final coding procedure generated the broadest themes, which were grouped based on shared meaning derived from phenomenological reduction using imaginative variation. We evaluated and interpreted the context of all codes achieved in reduction until the final themes emerged.

Strategies for Establishing Trustworthiness
We took steps to ensure trustworthiness of the findings according to Lincoln and Guba’s (1985) five tenets of trustworthiness: credibility, authenticity, transferability, dependability, and confirmability. Credibility and authenticity were achieved through in vivo and post-interview member checking to ensure accurate understanding or credibility of participant reports and by using two methods, providing ample opportunities for clarification. Another credibility validation tool, prolonged engagement, was achieved by having Sawyer interview, transcribe, check for accuracy, and conduct analysis, resulting in heightened awareness and understanding of the data. Triangulation with Gonzalez, who has different professional and personal identities, aided in furthering the inductive and methodological nature consistent with transcendental phenomenology (Moustakas, 1994).

Transferability was achieved through inductive procedures and obtaining rich details about study findings. Dependability was achieved through a rigorous methodology as outlined in Moustakas’s (1994) framework, which lends itself to examining multiple realities from an objective position. Multiple coding cycles additionally aided in dependability because they reduce abstract and biased findings. These same procedures also helped to achieve confirmability, enhancing objectivity in this qualitative research. We reduced researcher bias in interviewing and analysis through multiple coding cycles with rigorous methodology and triangulation (Lincoln & Guba, 1985).

Reflexivity
Bracketing was used to achieve reflexivity as a means to isolate and understand participant experiences apart from existing presuppositions. Sawyer has a professional identification aligning with that of rural mental health counselors. For 14 years, she has practiced mental health counseling in rural Texas, and since the onset of the COVID-19 pandemic, has provided teletherapy. She is an LPC-S and National Certified Counselor (NCC) who lives in Texas and has roots in rural Texas. Sawyer led all aspects of the research study. Gonzalez served as an external auditor for data analysis and assisted with manuscript writing. She is a counselor educator, researcher, and LPC with extensive experience in qualitative research and previous teaching experience in a rural setting. Based on Sawyer’s positionality, there were some apparent internal assumptions existing prior to the study. We assumed, based on personal and professional experiences, that participants would likely identify some hardships with rural service provision. Based on Sawyer’s work with often resilient rural clients during the last 14 years, we assumed some strengths related to rural populations would likely be identified.

In addition to bracketing, Sawyer reviewed interview questions and reflected on their cognitive reactions to the questions prior to conducting the interviews in an attempt to be aware of and set aside suppositions about the topic. Following each interview, Sawyer again reflected on personal cognitive responses to the topics, making notes as needed, and regularly reflecting on potential biases and enhancing trustworthiness with Gonzalez to counter them. As a result of such reflection, during thematic analysis, we did line-by-line coding to minimize interpretive assumptions, yielding the most objective view of sample experiences possible.

Findings

Thematic analysis rendered two themes as distinctly capturing the rural mental health counselor experience: systemic limitations and counselor growth and resilience. The codes within these themes had a 100% endorsement from the sample.

Systemic Limitations
The theme of systemic limitations was defined by participants as resource limitations within their rural communities, including significant shortages of mental health and medical services as well as services for basic needs such as food, housing, and financial assistance. Furthermore, a large majority of these clients characterized resource limitations as being both preexisting as well as exacerbated by the pandemic. For many participants, COVID-19 conditions greatly impacted their ability to provide face-to-face counseling in already resource-limited communities. Internet connectivity deficits in rural communities, which are already dealing with limited resources, were also included in this theme.

Mental health care prioritization and a lack of mental health care availability for rural clients were among the most prominent topics in participant reports. Participants shared the idea that because basic health care and other needs remained unmet in their communities, mental health care was a lower-ranking priority during the COVID-19 pandemic. One noted that “mental health had to take a second seat because their basic needs were not being met.” Another described that although mental health “maybe needed more,” other responsibilities took priority because the “importance of [mental health] was not there.” Additionally, one participant further addressed not just the need for mental health counseling services but the impact of the loss of services during the COVID-19 pandemic. She emphasized that these impacts were “more keenly” felt in rural areas due to baseline counseling resource limitations. Furthermore, one participant shared this perspective by noting the need for financial support for ongoing focus on parity in rural mental health care. Although this participant acknowledged the attention garnered by the COVID-19 pandemic for rural communities, she worried that the focus was waning too quickly.

In addition to mental health shortages, medical shortages were also prominent with rural clients. One participant, whose caseload was heavily comprised of transgender individuals, compared his experiences between metropolitan and rural areas, emphasizing the rural-specific difficulties for his clients. He went on to describe how the COVID-19 pandemic shutdowns led to a temporary loss of gender-affirming care in his community. He identified this experience as “particularly rough” for his clients who were “dealing with worrying about whether they would ever be able to access their gender-affirming health care or [have] it delayed a long time.” Limitations in resources for basic survival were also impacted during the COVID-19 pandemic, as one participant described the deepened scarcity of financial and housing assistance as well as food bank supplies. He went on to describe his community as “one of the poorest in Texas, where poverty is pronounced,” to emphasize the impact these resource shortages made in rural communities during this time.

In addition to health and other wellness services, internet connectivity deficits greatly impacted the ability for rural counselors to reach and provide services to rural clients. Nearly all participants identified geographical and/or financial barriers in rural communities obtaining internet connectivity necessary for everyday life during the COVID-19 pandemic. For those who could afford internet service, rural geography made consistent connectivity difficult. Some participants had to resort to primarily phone usage early in the COVID-19 pandemic. It was also noted that difficulties in connectivity impacted “already thin” mental health resources in rural communities and that “Wi-Fi is not as fast as it is in metro areas.” Even when some counselors attempted to have face-to-face services, they were met with difficulties in sustainability. In describing the changes to her private counseling practice, one participant described having to shutter her face-to-face business, which never rebounded after the period of shutdown between March and June 2020, and begin providing teletherapy only. This meant that there was one less in-person practice operating in a rural area where mental health resources were already limited.

Counselor Growth and Resilience
The theme of counselor growth and resilience was defined as rural counselors’ abilities to overcome significant adversities related to COVID-19 pandemic conditions in the context of their rural identification. Specifically, growth was defined as the ability to not only manage difficult circumstances but also to experience a change in themselves as an outcome of that experience. Resilience was defined as an ability to rebound or cope quickly in the face of adversity and, in the case of the COVID-19 pandemic, traumatic circumstances. Among the 11 participants, over half detailed a clear alignment between rural-specific deficits, as noted in the theme of systemic limitations, and the need to respond in resilient ways. Two participants, for example, adjusted quickly to phone counseling without face-to-face contact when rural internet connectivity and Wi-Fi availability fell short. Relatedly, another provided face-to-face services throughout the COVID-19 pandemic as the only practitioner in her area who could meet this need.

All participants described significant adverse experiences, up to and including vicarious trauma, but also an ability to cope with or make meaning of the circumstance. Collectively, participants leaned into their challenges, and many described a sense of empowerment in meeting them. For example, one participant, like most other counselors in this study, struggled significantly with the idea of teletherapy service delivery. She had difficulty adjusting treatment for her caseload, which included children coping with trauma and their families. Despite the stress described, she grew to enjoy meeting these new demands. She not only described that she “likes a challenge” but also discussed a process of using cognitive flexibility in providing herself “grace” and coping with the sudden need to learn a new skill set.

Although the ability to pivot typical practice styles during desperate times was a notable element of rural counselor growth and resiliency during the COVID-19 pandemic, so was the ability to alter beliefs and personal philosophies in order to adapt to changing times. Participants described a shift in viewpoints and flexibility to teletherapy as a modality. Although initially and fundamentally opposed to the practice, one participant reflected on the ability of professionals to shift their views. In speaking on the revolution of teletherapy in counseling, she stated that an in-person counseling modality is “not the only practice . . . we have to be flexible . . . we can’t be as old school anymore.” Similarly, another participant, also speaking on behalf of himself and rural mental health counselors, described a positive component of the pandemic: trying new things and learning that they are beneficial. He illustrated this by describing his “work–life balance” since his employers retained remote working allowances initially issued during lockdown and stay-at-home orders.

Participants illustrated cognitive flexibility in response to changes within their working world, but cognitive flexibility only represented part of the growth and resiliency among this sample. As depicted in the theme of systemic limitations, most participants provided services to clients with intensely limited resources, which naturally impacted how they typically provide counseling. In efforts to be therapeutic for his often crisis-affected clients, a participant noted that most of his work in the early months of the COVID-19 pandemic was “just letting people know that however they’re feeling is okay,” and further described, “I am good at remaining calm when the person in front of me is not . . . and appear to have at least a reasonably soothing presence.” Another participant closely mirrored these concepts in her statement that “it was, for me, a lot of just providing this space for people to have whatever feelings they had about it. And for that to be okay.” Additionally, two more participants reflected the change in focusing on immediate needs versus long-term or abstract concepts in counseling. Both described staying abreast of current events to help clients process their concerns.

As mentioned earlier, a majority of the participants noted a direct connection between rural-specific resource deprivation and the need to respond with resilience. Consequently, many participants found themselves becoming an integral part of resource seeking and attainment, which was described as a notable deviation from their typical counseling role. One participant described responding by actively providing help to clients who needed food when there were shortages due to already limited resource closures. She described this process as case management and assumed an active role in ensuring resources were obtained, including “trying to find people that could go pick up groceries and drop off at their porches.” Another similarly reflected that she did “a lot more social work . . . more connecting people with resources and that sort of thing.” She went on to note that as she adjusted her typical role from mental health counseling, the clients felt “cared for” and subsequently experienced a renewed encouragement to keep moving forward with counseling. Another participant additionally noted that gender-affirming care was already “quite difficult to find” in his rural community but became even more difficult to access due to the COVID-19 pandemic. In response, he sought out “updates through newsletters and Facebook connections with professionals” to ensure clients that the medical community was working to resolve the deficit. Collectively, these participant reports indicated that this sample of rural mental health counselors possessed the ability to shift their work and adapt to rapidly changing circumstances during the COVID-19 pandemic.

Discussion

The study explored the experiences of rural mental health counselors during the COVID-19 pandemic, revealing that participants experienced both preexisting and exacerbated systematic limitations in addition to growth and resilience during the early and more impactful phases. Systemic limitations identified by participants spanned the spectrum of human needs from food, financial, medical, transportation, and housing resources to a near absence of mental health services in their respective rural communities. Unique to rural counseling, the mass implementation of teletherapy was met with limitations involving lack of connectivity and financial means to remain online. For many participants, connectivity concerns have persisted. Unfortunately, the dearth of services for basic needs also meant an increase in the need for mental health services to cope with those hardships.

The descriptions of rural resource and funding deprivation extend and support the findings of the rural counselor hardships from other qualitative studies (Breen & Drew, 2012; Imig, 2014). The findings from this study show that despite nearly a decade, systemic changes that would otherwise bolster the quality of life or resource availability in rural communities have not been actualized. Naturally, this has created enhanced stressors for this sample of rural mental health counselors who perceived these otherwise typical limitations in their work as being grossly exacerbated during the COVID-19 pandemic.

The findings related to growth and resiliency in this study align with previous findings on counselors’ work in mass disasters (Lambert & Lawson, 2013). Most recently, Litam et al. (2021) found that counselor resiliency was associated with post-traumatic growth and compassion satisfaction, states that are in contrast with post-traumatic stress and compassion fatigue, which cause burnout. We suggest that finding one’s purpose is critical for growth, which aligns with the descriptions provided by this sample of participants. Much like the rural counselors in this study, Posluns and Gall (2020) found that maintaining awareness, finding balance, and having a flexible coping style were key to overcoming hardship. Additionally, Pow and Cashwell (2017) found that emotion-focused coping skills such as mindfulness and emotional regulation techniques were effective at mitigating the traumagenic effects of disaster work among a sample of disaster mental health counselors. The findings, combined with those on resilience practices in the current study, strongly support counselors and clients emphasizing a greater role in resilience and positive coping during disasters.

Participants also described resilience in the form of strong personal and professional support from family, friends, and colleagues, which validated findings that both personal and professional support were important for coping with adverse conditions and experiences during the COVID-19 pandemic (Aafjes-van Doorn et al., 2020). This finding is interesting in light of prior research showing that rural counselors experience isolation (Breen & Drew, 2012; Imig, 2014). They are, however, consistent with the findings of Wang et al. (2021), which showed that social connections helped rural individuals cope better than their urban counterparts during COVID-19, and Crumb et al. (2021), which indicated that social connection and rural community collaboration are helpful in coping after disaster.

Though not a theme that is uniquely tied to the rurality of the mental health counselor sample, it was evident that participants experienced intense levels of negative affect vicariously with their clients, especially during the earlier and more impactful parts of the COVID-19 pandemic. Such experiences included anxiety, uncertainty, depression, trauma, and helplessness. Findings from this study included echoes of prior research related to broader populations (Czeisler et al., 2020; Eisma et al., 2021; Elbogen et al., 2021; Prati & Mancini, 2021). In our study, these vicarious experiences intensified the natural occupational hazards (Lambert & Lawson, 2013; Litam et al., 2021) associated with professional health counseling practice and created a shared traumatic reality caused by mass disaster (Bell & Robinson, 2013). Additionally, uniquely rural hardships such as immense systemic limitations no doubt exacerbated these pandemic-related stressors as described by nearly all participants. This in turn necessitated the growth and resilience demonstrated by most of this sample in their descriptions of responding in creative and resilient ways.

Implications
Exploring the experiences of rural counselors during the COVID-19 pandemic reveals important training, clinical, and advocacy implications to consider. The findings emphasize the need for rural mental health counselors to adopt a more comprehensive approach that extends beyond traditional counseling roles. To effectively respond to sudden mass disasters or crises, like the COVID-19 pandemic, counselors must develop enhanced skills in case management, crisis intervention, referral coordination, and social service networking. Given the compounded challenges in rural settings, cultural competency training is vital for addressing the unique needs of these populations.

Mental health counselors should proactively familiarize themselves with available community resources and remain adaptable to extending services beyond conventional counseling modalities during crises. Counselors may consider expanding their training by attending workshops on advocacy and referral strategies and being more involved in networking with non-counseling resources within their clients’ communities. For those providing teletherapy services across their state or in several states, there are a few issues to consider. In addition to consulting and abiding by state laws related to interstate practice, mental health counselors should consider the location of their remote clients and at least generally link them to resources in their own communities.

Although teletherapy has proven beneficial, relying solely on virtual services is not a comprehensive solution for rural communities that lack consistent broadband access. Federal funding for increasing rural internet connectivity has been explored, as the National Telecommunication and Information Administration (n.d.) has allocated over a quarter of a million dollars to aid in increasing broadband accessibility in rural areas. However, until broadband for all is an established reality, continued advocacy is necessary to ensure rural connectivity remains a national priority.

Rural mental health counselors can further support rural clients by promoting culturally relevant resilience practices that emphasize mindfulness and emotional regulation (Pow & Cashwell, 2017) as well as self-awareness, balance, and cognitive flexibility (Posluns & Gall, 2020). For rural clients, aiding in establishing social support may better foster resilience development. Counselors can help rural clients explore, develop, and strengthen their involvement across multiple systems, including family, church, school, and the broader community to increase their capacity to cope with adversity. Further, counselors can help rural clients identify and leverage existing community strengths to mitigate the impact of resource limitations.

Advocacy and leadership are needed for promoting systemic change to drive policy and clinical practice shifts in the counseling profession (Lee & Rodgers, 2009). Advocacy efforts should prioritize systemic changes at local, state, and national levels that target funding allocations, service accessibility, and infrastructure development in rural areas. Addressing chronic resource limitations in rural areas involves advocating for increased mental health and medical funding, expanding access to basic needs, and sustaining broadband infrastructure initiatives. Prioritizing mental health care includes boosting resources, reducing stigma, and ensuring that mental health services are affordable and accessible. In these efforts, counselors can collaborate with community leaders, social service agencies, and advocacy organizations to elevate rural mental health priorities within broader policy discussions.

Finally, rural mental health counselors should recognize and enhance personal cultural strengths to overcome natural occupational hazards associated with counseling work as well as the enhanced challenges that coincide with rural practice. To maintain their own well-being amid ongoing crises, rural counselors should also engage in professional development that fosters their resilience. Implementing peer support programs, attending networking events, and participating in supervision groups can provide essential emotional support and guidance. Additionally, involvement in local, regional, and state counseling associations can further reinforce counselors’ sense of connection and reduce the isolation often associated with rural practice. This comprehensive approach will empower rural mental health counselors to better navigate the challenges they face and enhance their ability to support their clients.

Limitations and Future Research
Despite providing rich phenomenological data to understand the experiences of this sample during the COVID-19 pandemic and contributing to a relative paucity of research on this population, this study was not without limitations. Defining rurality is complex with no single definition capturing the multifaceted nature of such a culturally intricate group (Imig, 2014), and our study is no exception. For the purpose of generating accurate findings, a categorical and geographically based definition was selected. While the FORHP’s (2025) fiscal year 2022 classifications were used and represented an enhanced and more accurate definition of rural areas compared to previous definitions, it neglected to consider the descriptive or cultural aspects of rurality. Defining COVID-19 and its parameters was also a limitation. Participants, much like society, have navigated the uncertain, mutating, and episodic nature of viral outbreaks; therefore, it is difficult to define as either a historical or current event 4 years later. At the time of the study, however, participants largely viewed the most impactful degree of the COVID-19 pandemic as having occurred in earlier phases, which is helpful in ameliorating this limitation. Conversely, the length of time between the identified impactful phases in 2020 and interview time in 2022 is an additional limitation. With the passing of nearly 2 years, retrospective reflections may impact the accuracy of participants’ accounts of their experiences.

This study brings about several recommendations for future research. Future studies should continue to explore counselor experiences during mass and prolonged disasters. Despite being several years removed from the devastation of the COVID-19 pandemic, lessons of preparation and adaptability linger. In the last year, the United States has experienced Hurricane Helene in North Carolina and the Los Angeles wildfires, among hundreds of other disaster declarations (Federal Emergency Management Agency, n.d.). It is important to understand how counselors can care for their clients and themselves while navigating shared traumatic realities. Learning ways to foster resilience and post-traumatic growth is necessary to prevent counselor burnout and, ultimately, improve client care. For rural research specifically, replications of this study and related inquiries should continue to seek the most robust definition of culture; developing mixed methods approaches to capturing rurality would most likely overcome some limitations present herein. Rural cultural resilience should be a continued exploration, as much research has highlighted primarily barriers and challenges with less emphasis on resilience (Fruetel et al., 2022; Imig, 2014; Pullen & Oser, 2014; Slama, 2004; Sprang et al., 2007). Lastly, comparative analyses should be done in the future to further determine the uniqueness of rural counselor growth and resilience, as identified as a theme in this study.

Conclusion

The COVID-19 pandemic intensified mental health challenges in the United States, further straining an already overburdened health care system. Rural communities, which already experience fundamental disparities in resources and mental health care, were no exception. This study revealed both the struggles and resilience of rural mental health counselors in navigating the impacts of the COVID-19 pandemic in their communities. Identifying both exacerbated resource limitations and the need to cope and adapt with creativity and strength provides lessons for all counselors in the face of inevitable mass disasters. The findings underscore the importance of self-care, resilience-building, and leveraging community support during crises. Counselors should be well-versed in local resources and adopt broader roles. Given persistent disparities in rural health care access, ongoing advocacy remains essential.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Brandi M. Sawyer, PhD, NCC, LPC-S, is an assistant professor at Bellevue University. Edith Gonzalez, PhD, NCC, LPC, is an associate professor at the Hazelden Betty Ford Graduate School. Correspondence may be addressed to Brandi M. Sawyer, 1000 Galvin Rd. S., Bellevue, NE 68005, bsawyer@bellevue.edu.

Mental Health Counselors’ Perceptions of Rural Women Clients

Feb 26, 2021 | Volume 11 - Issue 1

Lisbeth A. Leagjeld, Phillip L. Waalkes, Maribeth F. Jorgensen

Researchers have frequently described rural women as invisible, yet at 28 million, they represent over half of the rural population in the United States. We conducted a transcendental phenomenological study using semi-structured interviews and artifacts to explore 12 Midwestern rural-based mental health counselors’ experiences counseling rural women through a feminist lens. Overall, we found eight themes organized under two main categories: (a) perceptions of work with rural women (e.g., counselors’ sense of purpose, a rural heritage, a lack of training for work with rural women, and the need for additional research); and (b) perceptions of rural women and mental health (e.g., challenges, resiliency, protective factors, and barriers to mental health services for rural women). We offer specific implications for counselors to address the unique mental health needs of rural women, including hearing their stories through their personal lenses and offering them opportunities for empowerment at their own pace.

Keywords: rural women, mental health counselors, feminist, perceptions, phenomenological

More than 28 million women, ages 18 and older, live in rural America and represent over half of the rural population in the United States (Bennett et al., 2013; U.S. Census Bureau, 2010). Researchers have discussed women’s issues as a distinct category within counseling for over 50 years, yet few counseling programs offer training specific to counseling women (American Psychological Association [APA], 2018; Broverman et al., 1970; Enns, 2017). Rural women have garnered even less attention within counseling literature and training over time (Bennett et al., 2013; Fifield & Oliver, 2016). In addition, rural mental health researchers have focused on rural populations in general, encapsulating women under the entire family unit (U.S. Department of Agriculture, 2015). However, in all environments, women experience mental health needs in unique ways (Mulder & Lambert, 2006; Wong, 2017). Although government agencies have increased efforts to alleviate mental health disparities in rural areas, there is limited research available on rural women’s mental health to guide these efforts (Carlton & Simmons, 2011; Hill et al., 2016). Thus, more studies focused on rural women can assist in comprehensive data-based decision-making efforts of federal, state, and local policymakers (Van Montfoort & Glasser, 2020). Mental health counselors who work with rural women have a unique perspective in understanding the needs of rural women and the disparities they face.

The Invisibility of Rural Women’s Mental Health
Researchers have described rural women as invisible within the mental health literature. Specifically, they have used words such as “unnoticed,” “lack of recognition,” “overlooked,” and “no voice and no choice,” which may illuminate why rural women have less access to appropriate mental health services and may underlie the noticeable absence of rural women as participants within research (Mulder & Lambert, 2006; Weeks et al., 2016). Members of rural communities have traditionally seen women as an extension of their nuclear and extended families and as responsible for involvement in community and church activities (Mulder & Lambert, 2006). Rural women, as a population with unique mental health needs, may need help (i.e., representation in research) getting their voices heard on a more macro level to promote systemic changes (Van Montfoort & Glasser, 2020). A research approach based in feminist theory may amplify the voices of rural women (Schwarz, 2017).

Feminism is a theoretical approach that evolved following the women’s movement in the 1960s, and grew to effect change in social, political, and cultural beliefs about women’s roles (Evans et al., 2005). Many of the early feminist writers spoke of women as “oppressed” and “having no voice” (Evans et al., 2005). Those words have been similarly found throughout the literature on rural women (Weeks et al., 2016). Feminist theory has traditionally challenged the status quo of the patriarchy by working to reduce the invisibility of women’s experiences (Evans et al., 2005; Schwarz, 2017). Further, feminist theory has evolved to amplify voices of all oppressed and marginalized individuals and to promote recognition of the intersectionality of identity. The feminist perspective can facilitate insight into the context of rural women’s experiences (Wong, 2017).

Challenges Faced by Rural Women
The definition of rural areas has historically been based on population size (U.S. Census Bureau, 2010). Some consider rurality a more accurate term than rural, as it may include population density, economic concerns, travel distances to providers, religion, agricultural heritage, behavioral norms, a shared history, and geographical location (Smalley & Warren, 2014). Rural women face unique needs related to the intersection of gender with race, ethnicity, age, and sexual orientation (Barefoot et al., 2015). Rural women have less access to educational opportunities, are often the head of household, and are more likely to live in poverty than urban women (Watson, 2019). Lesbian and bisexual rural women face challenges of bias, lack of support, and increased victimization (Barefoot et al., 2015). Although urban women also experience mental health issues related to motherhood, rural women often must travel long distances to services and have limited access to postpartum care (Radunovich et al., 2017). Residents in many rural communities experience food insecurity and related disordered eating with less proximity to grocery stores and limited food choices (Doudna et al., 2015). Isolation also creates a greater risk for partner abuse that is complicated by long distances to shelters, lack of anonymity, and a widely held view of traditional gender roles (Weeks et al., 2016). The lack of research regarding rural women and mental health compromises the efforts of rural counselors to provide care that is culturally responsive and efficacious (Imig, 2014). In addition, the recognized barriers of accessibility, availability, and acceptability of mental health services in rural areas disproportionally affect rural women (Radunovich et al., 2017).

Barriers to Mental Health Services
A lack of professionals, limited training for work in rural areas, high rates of turnover of mental health professionals, and limited research about rural demographics can negatively impact the quality of services (Smalley & Warren, 2014). In addition, rural residents may experience barriers such as long distances to services, adverse weather conditions, affordability of services, and a lack of insurance coverage (Smalley & Warren, 2014). Rural women may also feel reluctant to seek out mental health services for fear of loss of anonymity and the stigma attached to seeking mental health services in rural areas (Snell-Rood et al., 2019). Approximately 40% of rural residents with mental health issues opt to seek treatment from primary care physicians (PCPs), as these professionals may represent the only health care provider in the area (Snell-Rood et al., 2017). However, these professionals often have limited expertise in diagnosing and treating mental health issues (Hill et al., 2016).

Currently, the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) does not specify rurality or other cultural identities when referencing cultural competence within required curriculum. This omission may contribute to minimal specialized training, in addition to the limited research for mental health counselors to use as a guide for understanding the unique needs of rural women (Watson, 2019). Additionally, agencies have difficulty recruiting mental health counselors because of isolation from colleagues and supervisors, lower salaries, limited social and cultural opportunities, and few training opportunities specific to rural mental health (Fifield & Oliver, 2016).

Addressing Mental Health Needs of Rural Women
Given the limited research about rural women and their unique mental health needs, rural counselors are left with few evidence-based practices to utilize when working with this population (Imig, 2014). Historically, counseling researchers have equated “mentally healthy adults” with “mentally healthy adult males,” resulting in literature that is focused on best practices more appropriate for men (Broverman et al., 1970), and potentially upholding sex-role stereotypes within the fields of psychology, social work, medicine, and mental health counseling (APA, 2018; Schwarz, 2017). More recent researchers have demonstrated the efficacy of gender-specific counseling approaches (Enns, 2017). However, the approaches often do not consider the additional barriers to services that rural women may face, such as long distances to services, limited availability of mental health professionals, and the stigma of seeking services in a rural area (Hill et al., 2016).

In this transcendental phenomenological study, we sought to explore the lived experiences of licensed professional counselors (LPCs) who work with rural women in terms of their perceptions of rural Midwestern women’s mental health, and the academic training they received to prepare them for working with rural women. The study sought to answer the following research questions: (a) What are the lived experiences of LPCs who work with rural women?; (b) What are the challenges and benefits of working with rural women?; (c) How are mental health services perceived by those working with rural women?; and (d) What training, if any, did the participants receive that was specific to work with rural women?

Method

Qualitative research, by its very nature, validates individuals who may be disempowered (Morrow, 2007; Ponterotto, 2010). Phenomenology is a qualitative method that helps researchers describe the common meaning of participants’ lived experiences specific to a particular phenomenon (Creswell & Poth, 2018). In this study, the phenomenon was the lived experiences of LPCs who worked with rural women. Transcendental phenomenology (Moustakas, 1994) provided a framework for the study that began with epoché, a process of bracketing the researchers’ experiences and biases, and the collection of participant stories (Creswell & Poth, 2018). For this study, postpositivist elements of transcendental phenomenology (e.g., bracketing and data analysis) were utilized to reduce researcher biases (Moustakas, 1994). Specifically, we viewed bracketing as essential because participants might not share the feminist viewpoint of the researchers. The infusion of feminism into the study came from a constructivist/interpretivist standpoint as I (i.e., first author and lead researcher) believed—based on literature—the stories of rural women were not being heard and, thus, designed the study to help illuminate the experiences, mental health needs, and resiliency of rural women (Morrow, 2007).

Participants
For this study, participants were recruited using criterion and snowball sampling. Criterion sampling involved selecting individuals on the basis of their shared experiences and their abilities to articulate those experiences (Heppner et al., 2016). Snowball sampling allowed for selecting participants who previously had a demonstrated interest in this area of research based on their connection to other participants. Criteria for participation included a degree from a CACREP-accredited counseling program, licensure within their jurisdiction, current practice, and clinical work that included rural women. To recruit participants, we collected names and emails from a Midwestern state counseling association; however, this method produced only two responses. So, we utilized snowball sampling by asking participants to refer us to others who met our eligibility criteria (Creswell & Poth, 2018). We determined the number of LPCs needed to describe the phenomena by achieving saturation of the data collected (Heppner et al., 2016). This saturation was reflected by eventual redundancy in participant responses.

Following approval from the appropriate IRB, an invitation to participate was emailed to potential participants and included a link to a demographic form and informed consent for those who met the criteria and wished to participate. Rural areas were defined as those geographic areas containing counties with populations of less than 50,000, a definition that did not include population density but was appropriate for the Midwestern areas included in the study (Smalley & Warren, 2014). Twelve mental health counselors met the eligibility criteria for participation and enrolled in the study.

All participants had graduated from a CACREP-accredited counseling program, were licensed to practice within their jurisdiction, were currently practicing privately or in an agency, and had a clinical caseload that included rural women. The designation of LPC was used throughout the study and included all levels of licensure within the various jurisdictions. All of the LPCs reported working with a wide variety of mental health issues; three of the LPCs had addiction counseling credentials. Eleven participants self-identified as female and one self-identified as non-binary. Eleven participants self-identified as Caucasian, and one self-identified as Native American. Years of experience working as a mental health professional ranged from 4 years to 27 years, with an average of approximately 12 years. All participants reported working with both urban and rural clients, and one participant listed a reservation as the primary location for her work. LPCs’ clients included adult rural women from the upper Midwest. The rural women were single or married with children, working or unemployed, Caucasian or Native American. In addition, all the participants expressed a connection to rural areas, either through personal experience of growing up in a rural area or through connections with extended family. Each participant chose a pseudonym that is referred to throughout the manuscript.

Data Collection
We collected data through individual semi-structured interviews and participant artifacts. The semi-structured interview format allowed for more collaboration and interaction between interviewer and interviewee (Creswell & Poth, 2018). In this way, the interview format aligned with a feminist research approach and helped eliminate a power differential between researcher and participant (Heppner et al., 2016). There were 12 interview questions aimed at exploring participants’ work with rural women, participants’ perceptions of the unique mental health needs of rural women, the influence of participants’ rural heritage on their work with rural women, challenges and benefits of participants’ work with rural women, and participants’ training specific to work with rural women (see Appendix for all 12 interview questions). As lead researcher, I conducted all 12 interviews in order to maximize consistency in employing the interview protocol while allowing participants to elaborate on responses. Interviews ranged from 30–45 minutes. All research documents, such as informed consents, demographic questionnaires, and transcriptions, were securely stored on a password-protected device.

Participants were invited to share artifacts that represented their work with rural women. Artifacts could include personal letters, poems, artwork, and photos (Heppner et al., 2016). The artifacts in this study provided an opportunity for broader expression of the counselors’ experiences as well as understanding their connection to rural life. Seven artifacts were pictures of objects or individuals that inspired participants’ work with rural women, two were stories about experiences of rural women, and one was an original poem entitled “Rural Woman.”

Data Analysis
Brown and Gilligan’s (1992) research of young women and relationships utilized a Listener’s Guide for analyzing data. This guide is feminist and relational and allows researchers to pay attention to unheard voices. The Listening Guide is considered a psychological method that reflects the “social and cultural frameworks that affect what can and cannot be spoken or heard” (Gilligan & Eddy, 2017, p. 76). The method included three successive “listenings”—one for plot, one for “I” statements, and one for the individual in relationship to others (Brown & Gilligan, 1992). Throughout the listening process, I looked for and highlighted significant statements the participants made during the interview process that reflected the experiences of the phenomenon. I organized information via a phenomenological template under the heading “Essence of the Phenomenon” and included personal bracketing (epoché), significant statements, meaning units, and textural and structural descriptions (Creswell & Poth, 2018). Although a transcription service was utilized to transcribe the interviews, I read through the transcripts several times and coded data into categories or themes, which emerged organically from the transcripts. An independent peer reviewer then examined the transcriptions and helped to develop the codes and themes. We developed clusters of meaning from the significant statements into themes, followed by a textural and structural description that encompassed the significant statements and related themes. The rich and thick descriptions became the essence of the phenomenon enhanced by continual review of the interview tapes, journal notes, artifacts, and other data collected (Morrow, 2005).

Epoché
The epoché section was written from my perspective as the primary researcher and first author. I was responsible for designing the study, collecting and analyzing data, and writing the manuscript. My co-authors served as consultants in designing the study and helped to write and edit the manuscript. As the primary researcher, I sought to see the lived experiences of participants from a perspective that was free from my assumptions (Creswell & Poth, 2018). I grew up in a Midwestern rural area, steeped in traditional gender roles, while witnessing significant change for all women in expectations and opportunities. During the process of the study, it became apparent that my perceptions of rural women as stay-at-home farmwives have changed to reflect a population more diverse in ethnicity, family structure, and socioeconomic status; however, the traditional patriarchal expectations have not changed. My work as a mental health professional shaped my desire to explore the perceptions of other LPCs’ experiences of their work with rural women. Prior to the data analysis, I bracketed my personal and professional rural experiences about power differentials within rural areas.

Trustworthiness
To promote trustworthiness, I utilized self-reflective journaling, member checks, the achievement of data saturation, independent peer review, and an external audit. I kept a journal and made notes throughout the data collection process to facilitate an awareness of biases and/or assumptions that emerged during the process (Heppner et al., 2016; Morrow, 2005). I also conducted member checks, asking all participants to review and provide feedback via email on descriptions or themes (Creswell & Poth, 2018; Morrow, 2005). Frequently, participants would elaborate on themes by adding clarification to their responses to the interview questions. The “prolonged interaction” (Ponterotto, 2010, p. 583) with participants was significant for developing an egalitarian and unbiased relationship between researcher and participant. This strategy was congruent with feminist theory because it acknowledged the subjectivity of the researcher within the study and facilitated a collaborative relationship between researcher and participant (Morrow, 2007).

Coding the data into categories or themes helped arrange the large amount of data that was collected. The process was made easier by taking notes, or “memoing,” when reading through the information. The peer reviewer evaluated potential researcher bias by checking the coding against all transcripts, serving as a “mirror” that reflected my responses to the research process (Morrow, 2005, p. 254). Next, we discussed possible themes that emerged from the data (Heppner et al., 2016). I also utilized an external auditor to aid in establishing confirmability of the results rather than objectivity (Morrow, 2005). The auditor examined the entire process and determined whether the data supported my interpretations (Creswell & Poth, 2018). Both individuals had participated in phenomenological research and were not authors of this article.

Results

Analysis of the interview transcripts, the artifacts, and the journal reflections resulted in eight themes, organized into two categories. I further categorized each theme as: 1) textural, a subjective experience of the LPC’s experience with rural women; or 2) structural, the context of the experience. According to Moustakas (1994), the textural themes represent phenomenological reduction, a way of understanding that includes an external and internal experience; the structural themes represent imaginative variation, the context of the experience. One of the themes, counselor experience, fit the description of both textural and structural. The categories represented two distinct dimensions of the phenomenon: (a) LPCs’ perceptions of their work with rural women, and (b) LPCs’ perceptions of rural women and issues related to mental health.

Dimension 1: LPCs’ Perceptions of Their Work With Rural Women
Five textural themes emerged from the coding process; I took the names of three of these verbatim from the interviews. The textural themes included 20 codes that represented the subjective experiences of LPCs’ work with rural women. The participants’ pseudonyms were inserted into the direct quotes included in theme descriptions. Artifacts offered by participants were also included.

Bootstraps
Rooted in the familiar saying of “pull yourself up by your bootstraps,” this theme included codes of resilient, stoic, self-sufficient, and independent. According to LPCs’ perceptions of rural women, bootstraps described an acceptance of the current conditions of rural life and a reliance on past experiences for guidance. Many of the LPCs believed that rural women came to counseling with a skill set that, as Nancy said, “can teach us and others about how to be resilient.” Fave commented that working with rural women also required patience:

It’s this sense of “I can do this.” There are more demands with farming, and rural women still believe they should be able to do it all. When they come into counseling it can be difficult because they have worked hard to sort of protect this thing and keep it close to them because they’re pretty sure they can figure it out themselves.

Courtney shared a story about a ranch woman who was grieving the loss of her husband and was struggling with family issues. She remarked in one session, “Today I decided it was time to put on my red cowboy boots.” For Courtney, this represented her client’s resiliency and stoicism—“I’ve got this, and I’ve got my red boots on to prove it.”

Trailblazer
Trailblazer included pioneer, open-minded, resourceful, educated, and empowered; these words described LPCs’ perceptions of rural women’s abilities to move past accepting the realities of rural living and work toward change for improving themselves, their families, and their communities. According to the LPCs, this theme is distinct from bootstraps in that it is future-oriented rather than past-oriented. Elsie first referred to trailblazer when she told a story about a client who began recycling in the early 1980s: “She had bins and bins of recycling because she said, ‘I’m gonna leave this planet in a different shape than I found it.’ Rural women very much can be trailblazers.” The LPCs’ perceptions represented a new perspective that reflected resourceful change-makers, educated and empowered to challenge the status quo.

As one of her artifacts, Courtney offered a story about one woman’s determination to make Christmas special even though there were no resources for gifts and decorations. The woman found a large tumbleweed, covered it with lights and decorations, and declared it beautiful. Courtney said, “She was not just making do, but making things better.”

Challenges of Rural Women
LPCs observed multiple challenges for rural women including isolation, poverty/financial insecurity, role overload, grief, and generational trauma. Layla talked about the complex grief that was experienced by Native American women. She commented that “the death of a family member can mean losing someone from three or four generations. There is grief from loss of jobs, moving from the reservation, and loss of culture.” LPCs cited role overload as one of the most common experiences among rural women. Many rural women worked full-time jobs in addition to caring for family members while contributing to the farm/ranch operation. Jean observed that rural women “are responsible for everyone’s emotions in the family, sometimes leaving them isolated within the family.” LPCs believed that the isolation contributed to vulnerability. Rural women faced domestic violence, anxiety, depression, and addictions, exacerbated by having no one to talk with and long distances to services. Jean noted that resistance to change was perpetuated by the fear and control inherent in domestic abuse for many of her clients and led to complacency in reporting. The challenges of rural women described by participants defined the issues that LPCs faced when working in rural areas and increased their awareness of the critical needs of rural women.

Protective Factors
Protective factors included a sense of identity and the strong support systems of families and community that gave rural women “a lot of people that you can draw upon to help you through hard times,” according to Nancy. Her clients valued the easy access to nature and the opportunity to “immerse yourself in something bigger than yourself. It’s a way to build resilience and find meaning and joy spending time outside.” Layla found a strong sense of identity evident in rural Native women as central to the ability to teach their children cultural beliefs—a protective factor for future generations.

Nancy shared a picture of a family moving their 100-year-old home to a new location as her artifact. Her description of the house and rural heritage symbolized part of what she believed was important for rural women—the connection to family and heritage along with a sense of purpose in maintaining family culture. She said, “It’s a good way to pass down the family stories and even the family culture.”

Counselor Experience
Counselor experience (textural) included the reasons why participants chose to become LPCs. These included the motivations that sustained their work and advice for new counselors. Assumptions about diversity, a sense of purpose, listening, and connections to resources encapsulated this theme.

Layla became a counselor because she wanted “to give back to my Native people.” Nancy believed that the work with rural women helped her build a rural counselor identity. Woods’ early experience with rural women felt profound because of the chaos she observed in the lives of her clients, many of them impoverished single mothers struggling to survive. She was given a sense of purpose in her work saying, “These women are burned into my head.”

When asked about advice for new counselors who anticipate working with rural women, participants offered the following brief statements:

“Don’t make assumptions.” (Courtney)
“Ask to be taught.” (Marie)
“Hear their story without filtering through your own personal lens.” (Nancy)
“There is a difference in working in rural areas—a conservative mind-set, practicality—and you need to meet people where they are.” (Kay)
“Listen more than you talk.” (Suzie)
“Have respect for their culture.” (Layla)

LPCs’ Perceptions of Rural Women and Issues Related to Mental Health
Three structural themes represented what Moustakas (1994) termed imaginative variation, the acknowledgment of the context of multiple perspectives. The themes were derived from nine codes that provided a vital aspect of further describing the phenomenon. The theme descriptions included participants’ quotes and artifacts.

Perceptions of Rural Heritage
This theme represented LPCs’ view of rural life, including traditional values, heritage, and expectations/perfectionism. According to participants, many of the rural women embraced the traditional values of their rural heritage, and the roles of rural life; this theme honors that perspective. Fave talked about the expectations that rural women often have of themselves: “It’s a perfectionist perspective, meaning they can do it all.” Even in light of the increased demands on rural women’s time and energy, Marie found that rural women were often hesitant to seek outside professional mental health counseling, choosing instead to rely on family and community.

Barriers to Mental Health Services
The barriers included codes of lack of resources, stigma, and invisibility. All LPCs felt concerned about the lack of resources for rural women. Suzie talked about the dearth of women’s shelters on the reservation and resources for women who are victims of domestic violence. Suzie said, “They often stay because there are no resources for them to leave, and they can’t afford it.” Woods noted the lack of daycare providers and the fact that many rural women cannot afford these services and depend on family members for childcare. According to several LPCs, rural women do not prioritize their mental health needs, possibly because of the many demands on them.

Kay and Marie practiced in an urban area but saw many rural women who chose to travel long distances for mental health services because it gave them a sense of anonymity. Kay said, “They know if their car is parked at the counselor’s office, it won’t be recognized by everyone in town.” Rural women also feared exposing family secrets if they disclosed something to a counselor who lived in the same area.

Poignantly, LPCs acknowledged the invisibility and minimization of rural women’s mental health needs. The following comments by participants exemplified the rural woman’s experiences of being unnoticed or dismissed. Elsie stated, “Even if rural women are speaking, they don’t have the platform like urban women do, and they feel like nobody gets this life.” Kay stated, “Everything is fine, everything’s great and we’re not going to talk about the fact that Grandma is crying all the time and wearing sunglasses.”

The statements of the participants provided powerful examples of the ramifications of the silencing imposed on rural women through traditional or cultural norms. The stigma of accessing mental health services created a loss of connection between the rural women who needed the services and their community. In addition, rural women often felt selfish in seeking services just for themselves. The consensus among LPCs was that rural women suffer to a greater extent than other rural populations because their needs are minimized or not recognized. Elsie remarked that rural women do not often see their stories in mainstream media, leading them to believe “I’m living this experience that nobody else lives.”

The description of the artifact contributed for this theme may further elucidate the invisibility of rural women. Woods’ artifact was a picture of two locally designed sculptures of women. Woods said, “They are so rooted and earthy.” One sculpture had no arms or legs and, for Woods, that “speaks to the limited access to needed supports and the lack of voice.”

Counselor Experience
Counselor experience (structural) described how LPCs provide mental health services to rural women and included connection to rural life, distances and dual relationships, and lack of academic training/postgraduate training. Although not all the participants grew up in rural areas, many had rural ties through extended family. Marie’s upbringing on a ranch influenced her understanding of rural women: “There is a more intense work ethic; women are very strong and independent and hardworking.”

The LPCs seemed to feel a strong sense of purpose in their work; some of them chose to become counselors and returned to their home communities to work. They discovered that the connections of shared experiences fostered trust in the counseling relationship and process. Most felt that they were helping to make positive change. Although all participants believed the connection to a rural heritage was critical in their work with rural women, some LPCs did not live and work in the same location, saying it helped to reduce the possibility of multiple relationships. Nancy commuted almost an hour to her work “because you really want to have the counseling relationship be through your therapeutic lens and not through the community lens.”

None of the participants recalled receiving academic training specific to rural areas; however, all participants agreed on the need for academic training focused on rural areas and rural women. Elsie believed that textbooks should “include women’s voices and rural voices.” Jean expressed her concern that “We don’t necessarily address rural women or what they need from the communities around them or even what their typical experience is. I think that’s a disservice to our counseling students.”

Two artifacts aligned with this theme: Marie’s picture of a young girl, dressed in overalls, pitching hay, and Mae’s great-grandmother’s writing desk (see Figure 1). Marie’s artifact exemplified the family’s connection to rural life and the physical strength of rural women that she observed in her work. Mae now uses the writing desk in her practice and feels it gives her a strong connection to her rural heritage.

Figure 1

Mae’s Great-Grandmother’s Writing Desk

Note. Mae presented this picture of her great-grandma’s writing desk when asked to provide
an artifact that demonstrated her work with rural women.

Discussion

LPCs described rural women as strong, independent, resourceful, and resilient. However, this image of rural women was not corroborated within the research literature. An APA report on the behavioral health care needs of rural women (Mulder et al., 2000) did not mention resiliency as a coping strategy; however, in 2006, the report’s lead author recognized the need for additional research about resiliency in rural women, saying it would offer “significant potential benefit to rural women” (Mulder & Lambert, 2006, p. 15). In the present study, LPCs’ perceptions of rural women as resilient called attention to the innate strengths of rural women that developed out of necessity, cultivated by connections with family, community, and earth.

Rural heritage represented a dichotomy of rural tradition. From a positive perspective, participants believed the traditional roles of rural women provided a sense of identity and belonging. From a negative perspective, the traditional patriarchy evident in many rural areas dictated social and cultural norms, leaving rural women with the expectation that they should be able to “do it all.” Both perspectives defined a critical aspect of LPCs’ understanding of rural women. Even though many of the rural women participants described worked full-time to contribute to household income and health insurance (in addition to caretaker responsibilities), they faced gender inequities in income, employment, and educational opportunities (Watson, 2019). In addition, rural women have had little political power to effect needed policy changes for better access to care (Van Montfoort & Glasser, 2020).

LPCs highlighted multiple challenges that rural women experience: isolation, poverty, grief, role overload, and generational trauma. Barriers to obtaining services included stigma of mental health issues, loss of anonymity, a lack of resources, invisibility, and minimization of mental health issues. The general population also faces barriers of accessibility, acceptability, and availability of counseling services (Smalley & Warren, 2014); however, there were fewer references to the mental health barriers and challenges specific to rural women (Van Montfoort & Glasser, 2020). This is surprising given that the population of rural women exceeds that of any other population group in rural areas (Bennett et al., 2013). Rural women experience higher risks of depression, domestic violence, and poverty (Snell-Rood et al., 2019). The mental health services available in rural areas, often described as “loosely organized, of uneven quality, and low in resources” (Snell-Rood et al., 2019, p. 63), compound the challenges for rural women.

As evident in the themes of assumptions and diversity, rural women represent a unique population who deserve mental health services that reflect their specific needs. Rural communities and rural women are more diverse than once believed. LPCs’ observations are corroborated by research that acknowledged differences among rural women in socioeconomic status, family structure, age, sexual identity, ethnicity, education, and geographical location (Barefoot et al., 2015). In addition, there remains a misconception that the mental health needs of urban and rural women are the same; in fact, much of the literature about women and mental health is based on an urban context (Weaver & Gjesfjeld, 2014). The findings of the current study support the lack of recognition of the context of rural women’s issues and their status as an invisible population (Bender, 2016). Two LPCs’ observations of the isolation felt by rural women reinforced previous research of the invisibility of rural women. Elsie said, “Rural women don’t see their story a lot,” and Fave shared that “a lot of the women I work with don’t feel like they’re heard.”

None of the participants recalled academic training or postgraduate opportunities specific to work in rural areas or with rural women. Even though rural areas represent the largest population subgroup in the United States (Smalley & Warren, 2014), this study suggests that new counselors may not feel prepared to meet the needs of this underserved population. The shortage of mental health professionals working in rural areas and the lack of counselors who have training specific to rural mental health care suggest a need for rural-based training that might include an elective course in rural mental health and rural internships (Fifield & Oliver, 2016).

Implications

The recognition of the challenges and benefits of working with rural women may validate rural LPCs’ experiences, promote their professional identity as rural counselors, and potentially decrease the isolation felt when working in rural areas. Protective factors, including connections to family, community, and nature, may be critical for building resiliency in both rural women and rural LPCs. The increasing diversity of rural women is often contrary to the traditional stereotype of a stay-at-home farmwife (Carpenter-Song & Snell-Rood, 2017); diverse rural women may face unique barriers to accessing culturally relevant mental health services. In addition, many rural women experience role overload from working full-time and caring for families while contributing to the farm/ranch operation. Counselors should avoid interacting with rural women clients in ways that limit their identities based on stereotypes and work to make their services accessible for all women.

The study results also have implications for counselor educators. Rural-based counselors in this study did not report being taught how to work with rural women. A review of the 2016 CACREP programs found few gender-based counseling courses and none that addressed rural mental health. Programs could offer electives on counseling in rural areas, incorporate the context of gender and rural mental health into current curricula, and encourage rural internships. Collaborating with other rural health professionals may provide more informed approaches to working in rural areas. Rural residents may see their PCPs for mental health–related treatment, as PCPs may be the only health care provider in rural areas (Snell-Rood et al., 2017). Lloyd-Hazlett et al. (2020) suggested creating additional training for LPCs who choose to work in settings offering integrated care. Incorporating LPCs who have the appropriate training and skills into rural medical settings may offer mental health services in a familiar clinical context and one that does not broadcast engagement in mental health care. The collaboration may also provide more awareness of the mental health needs of rural women.

Limitations

The study has several limitations. Although I took measures to reduce any personal bias as a non-traditional rural woman, I do not believe it is possible to eliminate all biases. Many of the participants talked about empowering rural women and working toward making their clients’ voices heard, both tenets of feminist theory (Evans et al., 2005); however, participants rarely used the language of feminism. Several of the participants related personal stories of their connections with rurality and, often, their stories of rural women were from decades ago. Their stories may not have represented the current generation of rural women. Another limitation relates to the demographics of LPCs because a majority of participants self-identified as Caucasian and female and represented rural areas in the Midwest. LPCs working in other areas of the United States may encounter different demographics of rural women, mental health challenges specific to region, and unique intersections of their clients’ identities. Finally, the experiences of rural women were heard through LPCs and not from rural women clients themselves.

Directions for Future Research

This study included a sample of rural LPCs who were primarily Caucasian females from the Midwestern United States; future researchers may seek professional perspectives from participants who represent a blend of race, ethnicities, gender identities, and geographical locations. Research with rural women as participants themselves is also an important opportunity. Based on findings from this study, future researchers might also explore training needs related to work with rural women and rural populations. Studying counselor educators who teach in counseling programs based in rural areas could also offer unique insights. This may reveal information about ways educators currently infuse rural culture and work with rural women into the curriculum. Future researchers may study counselors, health care providers, and rural women in finding ways to integrate health care services in rural areas to provide better access to services and reduce the stigma often associated with mental health. Finally, additional studies about working with rural PCPs may highlight issues (e.g., intimate partner violence) that could benefit from early screening of symptoms.

Conclusion

Gilligan offers these words: “To have something to say is to be a person. But speaking depends on listening and being heard; it is an intensely relational act” (1982/1993, p. xvi). As indicated in our findings, rural women are too often invisible and unheard. This study represents a first step in amplifying the voices of rural women regarding their specific mental health needs. The experiences of the LPCs in this study have illuminated ways to connect with rural women, listen to their stories, and validate unique aspects of their cultural identities that seem to be well illustrated in one participant’s poem:

Rural Women
Resilient; stubborn; motivated
frightened; broken; courageous
Struggling; down-trodden; strong
Relentless in self-expectation
Armed with determination.
A common thread unites us
The heart gently calls, and the
soul asks only—please—listen to me.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Appendix
Twelve Interview Questions

Tell me about what comes to mind when you think about working with rural women.
Tell me about where you grew up and how that has influenced your work with rural women.
Tell me about how you began your work with rural women.
What have you learned about rural women through your work with them?
What are the unique mental health needs of rural women that you have seen in your work?
Tell me about some of the benefits and rewards, if any, you have experienced working with rural women.
Tell me about some of the challenges, if any, you have experienced working with rural women.
How have your experiences working with rural women changed you as a mental health counselor?
Tell me about any academic/classroom experiences in your graduate program that involved the mental health issues of rural women (e.g., class discussions, special projects, conversations with colleagues, internship experiences).
Tell me about any training experience post-graduation that have involved the mental health issues of rural women (e.g., workshops, conference presentations, webinars, conversations with colleagues).
What would you like other counselors to know about working with rural women?
Please describe how the artifact that you have chosen relates to your work with rural women.

Lisbeth A. Leagjeld, PhD, NCC, LCPC, LPC-MH, is a program liaison and faculty member at South Dakota State University – Rapid City. Phillip L. Waalkes, PhD, NCC, ACS, is an assistant professor and doctoral program coordinator at the University of Missouri – St. Louis. Maribeth F. Jorgensen, PhD, NCC, LPC, LMHC, LIMHP, is an assistant professor at Central Washington University. Correspondence may be addressed to Lisbeth A. Leagjeld, 4300 Cheyenne Blvd., Rapid City, SD 57709, Lisbeth.leagjeld@sdstate.edu.

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