Experiences of Black Adolescents With Depression in Rural Communities

TeShaunda Hannor-Walker, Lynn Bohecker, Lacey Ricks, Sarah Kitchens


Literature does little to explore the perceptions of Black adolescents with depression or their perspective of treatment effectiveness. Studies are usually from urban areas and there is a dearth of research with Black adolescents from rural areas. This study explored the unique personal experiences of Black adolescents located in the rural southeastern United States, with the purpose of gaining a clearer understanding when working with this population. An interpretative qualitative method was used to explore 10 participants’ interpretation of their experiences to gain insight in how they make meaning of those experiences. Five significant categories were found to capture participant themes: (a) definition of depression, (b) seeking treatment, (c) coping and problem solving strategies, (d) types of emotional support, and (e) contributing factors to depression. Specific recommendations and interventions are suggested for mental health clinicians to become more educated and aware when working with Black adolescents.

Keywords: Black adolescents, depression, treatment effectiveness, rural, contributing factors


Depression is a leading cause of disability worldwide (World Health Organization, 2020). The World Federation for Mental Health (2012) estimated that by 2030, more people will be impacted by depression than any other health problem. In the United States, approximately 13.3% of adolescents, or 3.2 million, had at least one major depressive episode and 9.5% were Black (National Institute of Mental Health [NIMH], 2013). Black people have experienced more severe forms of mental health conditions than individuals of other races because of unmet needs and other barriers (NIMH, 2013). In fact, Black people were reported to be 10% more likely to experience serious mental health problems than the general population (Shushansky, 2017), and Black children have a suicide rate that is almost two times higher than that of their White counterparts (Bridge et al., 2018).

Weaver et al. (2015) noted that although 90% of rural Black people live in the southeastern part of the United States, there are only two studies that specifically examined depression among rural Black people using national data (i.e., Probst et al., 2006; Willis et al., 2003). Most studies of depression that include Black youth are based on data from urban communities (Al-Khattab et al., 2016; Conner & Yeh, 2018; Ofonedu et al., 2013; Robinson et al., 2015). This suggests there is a dearth of research exploring Black adolescent experiences of depression in rural communities, and there is even less research focusing on Black youth who live in the rural southeastern United States (Smokowski et al., 2015: Weaver et al., 2015). The goal of this study was to explore the unique experiences of Black adolescents living in the rural southeastern United States who had been diagnosed with depression.

Contributing Factors to Depression in Black Adolescents

Adolescents who suffer from depression may experience substantial negative health and social consequences in late adolescence and adulthood (Lu, 2019). Black adolescents are particularly vulnerable to these consequences because they are more likely to live in low-resource neighborhoods and because they contend with the negative psychological impacts of racial discrimination (Robinson et al., 2015). Choi et al. (2006) found that ethnic minorities have higher scores on social stress and mental distress and lower scores on coping, self-esteem, and family cohesion. The depressive symptoms experienced by Black adolescents are often socially and culturally based (Lu et al., 2017). Therefore, it is essential for counselors, school personnel, and related professionals to remain abreast of the current research on depressive signs and symptoms, beliefs about treatment, and specific needs of Black adolescents.

Choi et al. (2006) discovered that Black, Hispanic, and Asian adolescents in the United States have consistently higher levels of social stress beginning in childhood compared to their White counterparts. Breland-Noble et al. (2010) found that relationship problems, academic problems, bereavement, and stress were primary triggers for depressive symptoms among Black adolescents. Ofonedu et al. (2013) determined in their study of Black adolescents that life events in the home, school, and community contributed to depressive symptoms. These factors included (a) a stressful home life, (b) stressful life circumstances and unique life experiences at school, and (c) the experience of high levels of violent crimes in neighborhoods. Stress is clearly a contributing factor to the depressive symptoms of Black adolescents.

Symptoms of Depression in Black Adolescents

Although understanding national trends and contributing factors can help practitioners identify adolescents suffering from depression, it is also important to understand potential racial and ethnic differences in the expression of adolescent depression (Lu, 2019). The manifestations of depressive symptoms vary in Black youth and affect all dimensions of physical, psychological, interpersonal, and social being (Ofonedu et al., 2013). In the Black community, mental health conditions have often been unacknowledged, misunderstood, and misdiagnosed (Shushansky, 2017; Vontress et al., 2007). According to Vontress et al. (2007), Black people often experience cultural dysthymia and mental health symptoms such as low-grade depression; feelings of sadness, hopelessness, and anger; aggression; and self-destructive behaviors. Vontress et al. (2007) characterized these symptoms as a “psychosocial condition” grounded in external societal experiences of discrimination and oppression that often go unrecognized (p. 131). Additional studies are needed to show how to better identify individuals suffering from depression and thereby increase the effectiveness of treatment for Black adolescents (Ofonedu et al., 2013).

As in adults, unrecognized or undiagnosed dysthymia or symptoms of low-grade depression in adolescents can contribute to poor health and problematic behaviors (Saluja et al., 2004). Researchers discovered that untreated dysthymia elevates the risk of disruptive behaviors, anxiety, substance abuse, unsafe sexual practices, involvement in fights, lower achievement on tests, lower teacher-rated grades, and poorer peer relationships (Saluja et al., 2004). Auger (2005) discovered that the many signs and symptoms of adolescent depression were overlooked not only by parents but also by school systems, administrators, counselors, and teachers who daily were in a very unique position to identify those at risk of depression. Many cases of adolescent depression, particularly among minorities, have gone undiagnosed, misdiagnosed, and untreated (Cook et al., 2017; Shushansky, 2017). A better understanding of the unique experiences of Black adolescents diagnosed with depression would help improve symptom recognition, which may in turn reduce misdiagnosis and increase treatment effectiveness.

An understanding of the cultural implications and influence that oppression, prejudice, and various forms of discrimination have on Black people’s mental health in the United States is helpful in contextualizing and normalizing symptoms of depression and reducing instances of misdiagnosis. Hope et al. (2017) posited that discrimination remains a common experience for Black adolescents that can impact not only the onset of depression but also the quality of and access to mental health services. Furthermore, according to Liang et al. (2016), racial disparities exist, as Black youth are more likely to be misdiagnosed as having psychotic and disruptive behavior problems compared to mood (i.e., depression) and substance abuse disorders.

Lu et al. (2017) echoed these sentiments, stating that depression presents differently for Black adolescents. It is essential for Black adolescents to use their own language when describing their depressive symptoms. Additionally, it is important for clinical and school counseling professionals to be aware of gender differences in Black adolescents’ expression of depression, specifically in terms of internalizing and externalizing symptoms. The findings of Breland-Noble et al. (2010) indicated that female Black adolescents seem to internalize behaviors (e.g., becoming withdrawn, exhibiting visible sadness), while male Black adolescents seem to externalize behaviors (e.g., becoming angry or acting out). Lu et al. (2017) further highlighted that “adolescents develop [symptoms] as a means of coping in response to environmental factors” (p. 614). More research is needed to understand how depressed Black adolescents describe their symptoms and assign meaning to their experiences of depression.

Coping Strategies of Black Adolescents

In addition to presenting different symptoms than individuals of other racial groups, Black adolescents have the lowest coping skills scores compared to their peers (Conner & Yeh, 2018). Recent studies suggest that adolescents who live in low-resourced neighborhoods feel like they have limited options in how to respond to stressful and anxiety-provoking situations because of limited or ineffective coping skills (Robinson et al., 2017; Robinson et al., 2015). There are indications that Black adolescents cope with depression in a variety of contexts. Some Black adolescents describe depression as a way of life, noting that everybody becomes depressed one way or another (Ofonedu et al., 2013). Researchers have shown that some Black adolescents conceal their feelings of depression because they are uncertain of how others would perceive them (Al-Khattab et al., 2016; Ofonedu et al., 2013). For instance, some Black adolescents reported trying to manage their depression independently and only going to an adult as a last resort (Breland-Noble et al., 2010). Black adolescents have been shown to manage their depression by strong will and spiritual beliefs (Ofonedu et al., 2013). Conner and Yeh (2018) highlighted how Black adolescents cope with depression in spiritual and creative ways such as listening to music, dancing, and writing.

In 2016, Al-Khattab et al. discovered that Black adolescents controlled their depression through their interactions with other people. Al-Khattab et al. identified five typology interaction models, which include hiding feelings of depression, lashing out verbally or physically toward others, seeking help from others to address emotional feelings, joining with others in social activities, and having others approach them about behavioral and mood changes. Therefore, it is critical for Black adolescents to better understand their experiences with depression and how interactions with others may influence their symptoms.

Treatment of Depression in Black Adolescents

Cook et al. (2017) noted that there are barriers to accessing mental health services and quality of care, which include stigma associated with mental illness, distrust of the health care system, lack of providers from diverse racial/ethnic backgrounds, lack of culturally competent providers, and lack of insurance or underinsurance. Often these barriers cause Black people to be unable or reluctant to seek help (Shushansky, 2017). Although Black adolescents may feel that treatment can be effective, many are reluctant to attend therapy because of the stigma and possible misdiagnosis of their symptoms, much of which has been influenced by their culture (Al-Khattab et al., 2016; Lindsey et al., 2010; Ofonedu et al., 2013). Positive results have been seen when using family-centered prevention programs to address depressive symptoms in Black adolescents (Brody et al., 2012). Jacob et al. (2013) determined that behavioral activation was effective for decreasing depressive symptoms and impairments for the Black adolescents who participated in their study.

As highlighted by a study of Black adults from a rural faith community, Black people living in rural communities suffering from depression face additional barriers to treatment such as (a) a lack of medical resources, (b) insufficient education about depression, and (c) stigma (Bryant et al., 2013). Sullivan et al. (2017) learned that terminology was crucial when discussing treatment with rural Black adults on a stigmatized topic such as mental illness. Parental concerns about marginalization because of having a child with a mental health diagnosis and some primary care providers’ characterization of mental health symptoms as a “phase” have been found to be barriers to treatment for Black children living in rural communities (Murry et al., 2011). Working with Black children who live in poverty, Graves (2017) identified cultural and macro-level barriers that influence the process of seeking treatment.

Treatment of mental health disorders extends from diagnoses. Considering the differences in symptoms and frequency of misdiagnosis, it is not surprising that treatment options for Black adolescents have shown varied outcomes across the literature. Additionally, some researchers suggested that new measures need to be developed for accurately identifying depression in diverse populations, which would then inform modifications in treatment (Ofonedu et al., 2013). Having a better understanding of the unique and complex experiences of Black adolescents may help parents, therapists, schools, and counseling professionals understand and identify those most at risk for depression. Planey et al. (2019) discovered that Black youth viewed seeking mental health treatment as a contextual and relational process rather than an event. What is clear is that more culturally diverse training for therapists, schools, and counseling professionals is needed to prevent, detect, and implement interventions for minorities experiencing depression during the disease’s earlier stages. Likewise, research exploring Black adolescents’ unique experiences of symptoms, environmental factors, and coping strategies remains necessary in order to inform effective treatment.

Purpose of the Present Study

The review of the literature captured symptoms and coping strategies unique to Black adolescents. Studies highlight that environmental factors contribute to depressive symptoms in this population. Furthermore, disparities exist in mental health care for adolescents, specifically for minorities (Alegria et al., 2010; Brenner, 2019; Lake & Turner, 2017). This clear gap in the literature indicates insufficient knowledge regarding the personal experiences of Black adolescents with depression. Most of the studies in the extant literature took place in urban areas; little is known about rural experiences and even less is known about experiences in the southeastern United States. This qualitative study was designed to help fill that gap. It posed an overarching research question to Black adolescents living in the rural southeastern United States: “What is your experience with depression?” This study was designed to offer human services professionals a clearer understanding of the unique experiences of Black adolescents in this geographical region who had been diagnosed with depression, with the hope of informing clinical practices.


The goal of this study was to explore the unique experiences of Black adolescents living in the rural southeastern United States who had been diagnosed with depression. The research design for the study was a basic interpretive qualitative method, as described by Merriam (2009). The purpose of this method is to understand the perspectives of the participants involved by uncovering and interpreting their meanings (Everall et al., 2006). This purpose was well-suited to the overall objective of this study, which was to gain a clearer understanding of the unique personal experiences of Black adolescents living with depression in the rural southeastern United States.

According to Merriam (2009), interpretive qualitative research is founded on the idea that people and their interactions with their world, or reality, socially construct meaning. Researchers using this method are interested in how individuals “interpret” their experiences, “construct their worlds,” and assign “meanings” to their experiences (Merriam, 2009, p. 38). Moreover, Merriam asserted that interpretive qualitative research has multiple meanings and is a complex phenomenon ideal for attempting to understand and treat Black adolescents with depression. Using Merriam’s (2009) model, researchers “strive to understand the meanings individuals construct regarding their world and their experiences” in a natural setting (p. 4). Another characteristic is that the researcher serves as the primary instrument for both collecting and analyzing data. The research process is inductive rather than deductive, which means that the researcher gathers data in an effort to “build concepts, hypotheses, or theories” in the forms of themes and categories (Merriam, 2009, p. 5). A final characteristic of this model is that interpretive qualitative research is richly descriptive and includes details about the context, the participants involved, and quotations and interview excerpts (Merriam, 2009).

Merriam (2009) noted that certain elements of the basic interpretive qualitative design may overlap with other designs, particularly when concepts of cultural values are discussed and explored. Merriam’s design does not require researchers to give a full sociocultural interpretation of the data, as is done in ethnography. Indeed, this study does not provide a full sociocultural interpretation. However, the data were analyzed using Patton’s (1987) content analysis model because the model provides a rigorous, systemic, and ethical procedure for analyzing data. Merriam’s model for collecting data and Patton’s model for analyzing data form a rich methodological combination that enhances the trustworthiness of the research study and improves the transferability of its findings.

Participants and Procedure

The university IRB granted approval for this study. Purposive sampling was used to identify 10 Black adolescents living in the rural southeastern United States who were being treated for depression. The southeastern part of the United States was selected because it contains fewer metropolitan areas that have been studied specifically. Each of the participants met the following criteria: (a) self-identified as Black, (b) was between the ages of 13 and 17, (c) was willing to participate, (d) had secured a signed informed consent form from their parents, (e) had signed a participant assent form, and (f) was currently under the care of a counselor either in or out of school for depression. The participants ranged in age from 13 to 17 years old and were in grades seven through 12. Six participants were female and four were male.

Approval was obtained in advance from a public school system located in the rural southeastern United States. The public school system administrator agreed to send the letter of invitation along with the consent and assent forms to the parents and potential participants. In addition, the first author sent a packet of information to a counseling agency; school professionals, including professional school counselors and school psychologists; and social workers. The packet contained an invitation letter requesting that the packet be shared with potential participants and their parents; it also contained consent and assent forms. The informed consent form described the study and the efforts that would be taken to protect the confidentiality of the participants’ information. The informed consent form stated that the risk of participating was the normal discomfort of sharing one’s experiences with depression and that if a participant felt uncomfortable, they could withdraw from the study at any time.

Parents and participants signed the consent and assent forms, respectively, and returned them to either the local counseling agency or school professionals, who forwarded the forms to the first author. The first author then contacted the parents, with the participants present, to schedule a 45- to 90-minute, face-to-face interview with the participant. The informed consent form was verbally reviewed, ensuring that the parents and participants understood that a second interview to review and correct the interpretation would be optional. Interviews took place either during the day in a private room at the school or outside of school hours in the first author’s office. Because adolescent depression is considered a sensitive topic, participants were instructed to follow up with their counselor if they experienced adverse feelings as a result of participating in the study.

Data Collection and Analysis

The first author met with each of the 10 participants for a single semi-structured interview that lasted between 45 and 90 minutes. In phenomenological research, the researcher follows the essence of participants’ responses (van Manen, 1997). The first author spent time establishing rapport with the participants. Once the first author believed a participant was comfortable, she asked the participant the overarching question, “What is your experience with depression?” Follow-up questions specific to each participant were used to probe the participants’ responses regarding their experience as Black adolescents living with depression in the rural southeastern United States. Several participants expressed a reluctance to fully disclose or discuss their experiences with depression; however, no participants withdrew from the study, and all participants completed the first interview. At the end of the first interview, the participants were notified that they would be contacted for a second interview to review the transcript of the first interview and verify its accuracy and trustworthiness.

Interviews were recorded and transcribed verbatim by both the first author and a professional transcriber. The transcripts were coded and analyzed for themes related to the research question of this study. The first author utilized Patton’s (1987) content analysis model as a process of bringing order to the data by organizing the data into major themes, categories, and case examples. The first author consulted with two experts in qualitative research in the human services field and used three levels of coding: open, axial, and selective. Open coding included reading the transcribed interviews several times and coding phrases, from one word to portions of paragraphs. Based on input from the consultants, the first author enhanced the coding process by entering the data into the NVivo QSR software program, which facilitated organization and analysis. The first author then condensed the data into five categories. Axial coding enabled the first author to organize, link, and cluster codes, while selective coding allowed the first author to analyze the words, sentences, and themes from the interviews. Data analysis via coding was a back and forth process, and staying close to the transcripts was essential. The labeling and coding allowed the first author to interpret and classify the data and themes into five categories that were supported with direct quotations from the participants.


Trustworthiness is an important aspect of qualitative research (Hays & Singh, 2012). The generally candid nature of each participant in relating even the most difficult experiences, such as rape, would suggest a high degree of trustworthiness in their responses. Member checking was offered to all participants in the form of a follow-up interview. When contacted by the first author to schedule this interview, however, none of the participants felt that it was necessary. Rather, all of the participants stated they were satisfied with their responses in the first interview. In addition to offering member checking, the first author used rich data, prolonged engagement, respondent validation, a search for discrepant data, and peer review to ensure trustworthiness. A peer review of the method was conducted by doctoral-level professors in human services who specialized in qualitative research in order to enhance internal validity (Lincoln & Guba, 1985; Merriam, 2009). The first author used an audit trail by engaging in memo-writing to express thoughts, perspectives, observations, and reactions to interviews, transcriptions, and coding. An audit trail is a strategy in which a researcher explains as best as possible how they arrived at the results of the study by documenting how the data were collected, how categories were developed, and how findings were interpreted throughout the study (Lincoln & Guba, 1985). An audit trail thus improves the quality of a study. The information and details from this study may be generalizable to other groups and may contribute to the knowledge base of best practices when working with this population in counseling.


Through data analysis, the researcher identified five significant thematic categories: (a) definitions of depression, (b) seeking treatment, (c) coping and problem-solving strategies, (d) types of emotional support, and (e) contributing factors to depression. These five thematic categories were broken down into their constituent contents. Each thematic category was addressed with the invariant constituents that make up that category, including elaboration on any significant constituent patterns (such as high and low frequency of occurrence). Quotations from the participants are included in the text as examples to elucidate the invariant constituents and thematic categories. For reasons of confidentiality, some identifying information was excluded. All participants identified as Black and lived in the rural southeastern United States.

At the time of the study, the participants were living in a southeastern U.S. community in one of the lowest socioeconomic brackets of the country. In the participants’ community, the majority of the population was Black and participated in the school’s free or reduced-fee lunch program. Because of the homogeneous nature of the community, the participants did not speak of any adverse social or political circumstances, and the researcher avoided broaching the topic in an effort to do no harm. The researcher believed that overlooking the social and political climate of the community increased the trustworthiness of the participants’ responses, as the participants were not influenced by the discussion of the climate nor did they voluntarily express its relevance to their experience. As a Black adult, the researcher, who is first author, was aware of how the social and political climate played into their experience. However, because the participants were adolescents experiencing emotional pain, the first researcher attempted to instill hope in them as part of their experiences of this study. To maintain confidentiality, specific details about the contextual factors in the participants’ community have been omitted.

Definitions of Depression

Data analysis identified 18 codes that were relevant to the category regarding how participants defined depression. Of these codes, three emerged with significantly higher prevalence than the others: (a) sadness; (b) isolation, social withdrawal, or loneliness; and (c) permanent or persistent. Nine out of the 10 participants (90%) indicated that they experienced the feelings associated with these three codes. For example, in response to how he defined depression, Participant 5 noted that he became “sad, mad, and very frustrated.” Participant 1 defined depression in terms of social withdrawal, saying, “Usually I stay in my room and I don’t talk to anybody, I just stay in there, and that is about it.” Participant 4 provided an example of the theme of permanent or persistent experiences by stating, “I don’t think it could just go away, especially when it’s very serious.” Participant 3 provided an example that captured the overall essence of this category when he stated:

I have been sad a whole lot, without reason; and so, I think that is why I was depressed . . . when I am around people for too long, I get sad; but when I am alone, I am happier. I feel safe when I am by myself. When it [depression] comes on, it comes on strong. It is really bad. Because I feel really, really sad, and my thoughts aren’t, you know, normal. Sometimes they are violent . . . like I don’t have any hope at all. I don’t think like I normally would. Sometimes I don’t think at all. Sometimes when I get really sad or angry, I think about hurting people. So, I have to withdraw further. I have to push it further down into my mind so that I won’t act on it.

It is interesting to note that the next most frequently found codes were stress-related and frustration, each with a prevalence of 60%, and more common in young Black girls, which had a prevalence of 50%. Alternatively, only one participant mentioned each of the following codes with regard to defining depression: suicidal thoughts or attempts, more common in young Black boys, and feeling sick.

Seeking Treatment

The category of seeking treatment contained 10 codes. Participants expressed contradictory feelings about the effectiveness of treatment and the barriers to seeking treatment. For example, 90% of participants expressed that they felt that therapeutic treatment was effective in mitigating or curing depression, including Participant 7: “To me, to talk to my therapist was like a relief to me, because he was the only person that I can be able to tell my thoughts, get my thoughts together why I was in there.” Simultaneously, 30% of participants noted that they felt that therapy was not effective as a treatment. This overlap and apparent incompatibility in the data helped reveal the full breadth of Black adolescents’ opinions and feelings about depression and seeking treatment, as participants expressed both positive and negative experiences.

This overlapping trend was seen elsewhere in this thematic category. For example, there were codes of medication is effective (50%) and medication is not effective (30%). This apparent contradiction was highlighted not only between participants but also within a single participant. Participant 10 directly stated she believed medication to be effective; she then revealed that she had been given medication that sent her into a coma. She reported taking her medication as prescribed but “after that I passed out, and I didn’t remember nothing, all I knew I woke up in the hospital.” Three codes were identified as directly related to seeking treatment. Significant barriers to therapeutic treatment were negative connotation of mental illness (80%), uncomfortable issues brought up in treatment (80%), and lack of trust (70%). The code negative connotation of mental illness was grounded in external perceptions, as many participants indicated that they did not want other people to know that they were in treatment.

For example, Participant 2 stated, “I don’t tell them. I don’t want them to know,” when referring to his friends. Participant 3 provided an example of the code of uncomfortable issues, noting, “I don’t like to talk about it much. You know, it is kind of aggravating. It makes me feel weak when I talk to people about my problems.” Regarding the code lack of trust, Participant 6 noted, “I have very weak trust issues. Sometimes they can be strong but mostly weak.”

Three minor codes emerged relating to seeking treatment. Two were trouble expressing self in therapy (40%) and treatment was not necessary (40%). Participant 3 stated, “I have a lot of trouble expressing myself. You know, when I get into the office, I just forget what to say.” Three of the 10 participants openly discussed lack of Black people’s knowledge or education about depression as a specific barrier to treatment. They shared their perceptions of the lack of education and discussion about depression within their own community, which they felt presented a specific barrier to treatment for them. Participant 6 stated, “I can’t overly generalize it, but some people need to know more, ’cause they don’t understand, because sometimes you just need that time and people they don’t understand that you need it.” However, taking these and the other barriers in this thematic category into account, the prevalence of participants who reported that treatment was effective was three times greater than the prevalence of participants who thought that treatment was ineffective.

Coping and Problem-Solving Strategies

The third thematic category contained 29 different codes related to problem-solving strategies and behaviors or activities the participants used to cope with depressive symptoms. The participants described various strategies to cope with depression, but the most prevalent was suppressing/hiding thoughts/feelings. There were seven strategies that more than half of the participants reported using as problem-solving strategies and strategies to cope with depression. The positive problem-solving strategies were listening to music, turning to religion/going to church/praying, and talking/spending time with family. The problematic coping strategies reported were using illegal drugs, engaging in self-harm, having sex, and isolating. See Table 1 for codes and results.

It is encouraging that 18 out of the 29 codes could be characterized as neutral or positive coping strategies. The other 11 are areas of concern, even if only one participant reported engaging in the behavior. Participant responses overlapped and participants reported coping and problem-solving strategies that might be characterized as both positive and negative. In addition to contrasts in the specific codes and types of behaviors, contrasts in the percentages of participants who reported negative behaviors compared to positive behaviors were noted. For example, participants reporting the negative problem-solving strategy of engaging in self-harm as a way to cope often went into detailed narrative descriptions. This strategy was more frequently reported than any of the positive or neutral coping and problem-solving strategies.

Types of Emotional Support

This thematic category addressed the types of emotional support that the participants received during their experiences with depression. Four distinct subthemes of codes were identified: peers; family; school (teachers); and helping professionals such as hospitals, managed care facilities, and therapists. Each of the four subthemes contained codes that were sorted as either positive or negative. A lack of support or refusal of support was considered a negative, and similar to other categories, participants shared multiple overlapping experiences. Negative support from peers was the only theme to have 100% prevalence; every participant mentioned that peers had negatively affected them through a lack of emotional support during their experience with depression, including Participant 2: “They didn’t believe me at first, but later they just seem like they don’t care.” Half of the participants expressed that they had also received positive emotional support from their peers during their experience with depression. In the family group, equal percentages of participants (60%) reported receiving positive support from family and experiencing a lack of support from family. The participants were similarly split regarding their perceptions of receiving positive (50%) and negative (50%) emotional support from teachers at school. The greatest proportional difference in negative and positive emotional support was within the category of helping professionals. In this subtheme, four times as many participants (40%) reported that they had had positive emotional support from mental health care providers in a hospital, halfway house, or therapeutic community than participants reporting negative emotional support from mental health care providers (10%).


Table 1

Coping and Problem-Solving Strategies

                                                 Strategy Percent of Respondents

(N = 10)

Positive or Neutral

Coping Strategies

Listening to music 70%
Turning to religion / going to church / praying 70%
Talking / spending time with family 60%
Attending therapy 40%
Writing 40%
Creating art 30%
Playing video games 30%
Watching TV 30%
Crying 30%
Taking prescription drugs 20%
Eating food 20%
Reading 20%
Talking / spending time with friends 20%
Distracting self 20%
Laughing 20%
Joining clubs 10%
Working out 10%
Researching 10%

Coping Strategies

Suppressing / hiding thoughts / feelings 90%
Using illegal drugs 70%
Engaging in self-harm 60%
Having sex 60%
Isolating 60%
Attempting suicide 40%
Engaging in violence 40%
Running away 30%
Yelling / shouting 10%
Having violent thoughts 10%
Avoiding responsibilities / rebelling 10%


Contributing Factors to Depression

This theme of contributing factors to depression appeared to be the most salient to the central research question of how Black adolescents living in the rural southeastern United States described their experiences with depression. The previous themes captured definitions of depression, seeking treatment, coping and problem-solving strategies, and types of emotional support. This theme provided a description of the participants’ lives in terms of their context and environment, which the participants identified as contributing factors to their experiences of depression. When asked about contributing factors to their depression, the three most noted by the participants were verbal abuse (70%), differences from other people and being bullied (70%), and parental or family problems (70%). Participants also reported sexual abuse (40%) and physical abuse (30%) as contributing factors. Participant 6 made the following statement, which captures the essence of this theme:

My depression started really kicking in when I was around 13 . . . it runs in my family. My mom has it and when I was little, I was sexually abused . . . and I’ve been made fun of all my life . . . my weight . . . a scalp infection. People make fun of stuff like that. And that’s been going on since I was little.

The least prevalent factors mentioned by participants were foster care (20%), stress of schoolwork (20%), and a scary book (10%). Verbal abuse was reported 30% more frequently than sexual abuse and 40% more frequently than physical abuse. However, it is interesting to note that Participant 2 considered foster care to be a cause of depression and not a solution. Most participants identified a combination of these factors as contributing to the onset of their depressive symptoms.

Discussion and Implications

This study sought to examine the unique experiences of Black adolescents diagnosed with depression living in a rural community located in the southeastern part of the United States. Five themes emerged when examining the participants’ narratives with depression. These themes included definitions of depression, seeking treatment, coping and problem-solving strategies, types of emotional support, and contributing factors to depression. In defining depression, 90% of the participants in this study cited sadness, isolation, and depression’s ongoing nature. This is not surprising, as these codes fit within the diagnostic criteria for depression. It was surprising, however, that participants defined depression as stress-related, as stress is not one of the diagnostic criteria. At the same time, the idea of depression as stress-related is supported in other studies (Breland-Noble et al., 2010; Bryant et al., 2013; Choi et al., 2006; Ofonedu et al., 2013; Robinson et al., 2015). The mental health community would do well to acknowledge the differences in how Black adolescents from rural U.S. communities may define depression. When working with Black adolescent clients, practitioners may wish to inquire about stressors and consider their relation to depression in order to inform treatment plans and interventions.

Most participants who sought treatment for depression indicated that treatment was effective; however, 30% of participants expressed that therapy was ineffective. Additionally, only 50% of participants indicated that medication was an effective form of treatment. Participants also identified barriers to seeking treatment, which included negative connotations associated with mental illness and discomfort discussing issues in treatment. Barriers identified included a lack of trust, problems with self-expression, the belief that therapy was not needed, and a lack of knowledge about depression in the Black culture. These results are consistent with prior research (Al-Khattab et al., 2016; Bryant et al., 2013; Lindsey et al., 2010; Ofonedu et al., 2013; Sullivan et al., 2017), indicating that mental health conditions are often misunderstood, misdiagnosed, or unacknowledged within the Black community (Graves, 2017; Murry et al., 2011; Shushansky, 2017).

Prior research has also highlighted the stigma of mental illness in the Black community (Cook et al., 2017). This stigma helps to explain previous research showing that Black people often seek help as a last resort (Al-Khattab et al., 2016; Breland-Noble et al., 2010; Ofonedu et al., 2013; Vontress et al., 2007). It is essential that counselors acknowledge the stigma associated with mental illness and reluctance to seek treatment within the Black community. More practitioners who are aware of and sensitive to the mental health needs of Black communities are needed. It is imperative that clinicians take it upon themselves to become competent when working with this population. To address the stigma, practitioners might offer training in evidence-based practices related to Black adolescents’ mental health at churches, schools, and various community organizations in the Black community. These types of trainings could be particularly effective in rural communities where participants are likely to communicate to others about the trainings, thereby validating the information and possibly reducing the stigma. One of the codes from this study was related to the effectiveness of medication for reducing depressive symptoms. More research is needed to explore factors that may contribute to this experience. Additionally, more research is needed to understand the unique traits of Black adolescents seeking treatment in other regions of the United States.

There were a few positive strategies for coping with depression that the participants identified, including listening to music, engaging in spiritual practices, and spending time with family. These positive coping strategies supported the constructs of spiritual beliefs and relationships with others, which were established in prior studies (Al-Khattab et al., 2016; Conner & Yeh, 2018; Ofonedu et al., 2013). The theme of coping and problem-solving strategies was dominated by the most common strategy: participants hiding their thoughts and feelings as a way of managing their depressive symptoms. This result corroborates the findings of prior studies that show Black adolescents conceal their feelings and symptoms of depression (Al-Khattab et al., 2016; Breland-Noble et al., 2010; Ofonedu et al., 2013; Vontress et al., 2007). As previous studies have suggested, hiding thoughts and feelings may be due to the stigma associated with mental illness and limited options in how to respond to stressful and anxiety-provoking situations (Robinson et al., 2017; Robinson et al., 2015). The finding that the participants hide thoughts and feelings also supports previous research that Black adolescents may be fearful of how others will react to them and isolate themselves as a result (Al-Khattab et al., 2016; Breland-Noble et al., 2010; Ofonedu et al., 2013). Participants also reported engaging in unhealthy coping behaviors such as self-harm, sexual intercourse, and isolation. These harmful strategies may be due to the limited coping skills of Black adolescents that have been identified in prior research studies (Robinson et al., 2017; Robinson et al., 2015). Again, these findings highlight the need for culturally specific training regarding mental health in Black communities.

The theme of emotional support resonated with all participants in this study, suggesting the significance of relationships (Breland-Noble et al., 2010). When examining emotional support, positive and negative experiences emerged. Positive emotional supports were found in family members (60%), teachers (50%), and mental health professionals (40%). Yet all participants indicated being negatively impacted by a lack of support among their peers. Participants reported feeling invalidated or not believed by their peers. They also reported that their peers did not seem to show concern. These experiences may have exacerbated the participants’ symptoms. Only half of the participants indicated receiving positive peer support when seeking help for depressive symptoms. These findings are concerning because of the heavy emphasis placed on relationships within Black communities (Breland-Noble et al., 2010).

Relationships were identified as significant to all participants in this study, indicating that healthy relationships may be a protective factor and may increase emotional and mental health. Counseling professionals in private practice and in schools are thus encouraged to inquire about a wide range of relationships when working with their Black adolescent clients. For example, a counseling professional might ask a client to complete a detailed relationship profile for each significant person in their life. This would help to uncover significant relationships that could support the client’s current challenges and to identify those individuals who might not be providing support. Counseling professionals might also conceptualize client symptoms as connected to these relationships. Family or systemic interventions may be incorporated into treatment planning to decrease depressive symptoms.

The theme of contributing factors encompassed a surprisingly high number of significant adverse and traumatic experiences. When examining the factors contributing to the development of depression in Black adolescents, most participants in this study cited verbal abuse, differences from others/bullying, and family-related issues as salient factors. Other contributing factors included sexual and physical abuse. Participants reported verbal abuse (70%), sexual abuse (40%), and physical abuse (30%) as contributing factors of depression. However, participants did not identify one single factor but rather described multiple and overlapping factors that contributed to their depressive symptoms. The connection between adverse and traumatic experiences and depressive symptoms specifically within the Black adolescent population appears to be underreported in the literature.

It is important to note the high prevalence of abuse indicated within the study. The lack of existing studies exploring the relationship among Black adolescents, depression, and adverse childhood experiences indicates that additional research is needed. An implication of this study is that when working with Black adolescent clients who are presenting with symptoms of depression, counseling professionals might incorporate an adverse childhood experience screening tool. Assessing clients for adverse childhood experiences as a matter of regular practice may better inform preventative measures and treatment. As this study highlights, it is essential for clinical and school professionals working with Black adolescents to understand that abuse can contribute to depressive symptoms.

Overall, many of the symptoms described by participants could be associated with a diagnosis of
dysthymia as a result of oppression, supporting the work of Vontress et al. (2007). However, the participants did not use the word “oppression” and may not have recognized the systemic aspects of their experiences (Vontress et al., 2007). It may be that the participants’ adverse experiences of abuse overshadowed any cultural or historical factors that may also have been present. The current study highlighted the overlooked and undertreated experiences of Black adolescents with depression. Counseling professionals may choose to gain a preliminary understanding of Black adolescent depression and dysthymia symptoms “within the context of their legacy of discrimination and oppression” (Vontress et al., 2007, p. 132).


Overall, these findings need to be considered in light of some specific limitations. First, the interview questions were semi-structured. This means that the researcher used open-ended questions followed by discussion. As a result, the interviewer may not have covered the exact same content with each participant. Furthermore, because of the nature of the study, some participants may have been more forthcoming about their personal experiences. Thirdly, although the participants were asked about past events, the memories of those events may have been compromised because of the passage of time or because of received or ongoing treatment. Lastly, given the limited number of participants interviewed, more research is needed to understand the mental health needs and experiences of Black adolescents who are experiencing depression.


In this qualitative study of 10 Black adolescents living in a rural community, the authors provided space for the participants to use their own terms and language to define depression. It is clear through this and other research that contextual factors are often involved in the onset of depression in Black adolescents, and there is not enough active therapeutic and medical treatment for Black adolescents living with depression. There is a stigma associated with mental illness and reluctance to seek treatment within the Black community, particularly in rural areas. As a result, counselors and mental health providers need to become more educated and aware when working with Black adolescents who live in rural communities.


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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TeShaunda Hannor-Walker, PhD, NCC, LPC, CPCS, is an assistant professor at Liberty University. Lynn Bohecker, PhD, LMFT, is an associate professor at Liberty University. Lacey Ricks, PhD, NCC, is an assistant professor at Liberty University. Sarah Kitchens, PhD, NCC, is an assistant professor at Liberty University. Correspondence may be addressed to TeShaunda Hannor-Walker, 1971 University Blvd., Lynchburg, VA 24515, thannorwalker@liberty.edu.

In My Own Words: Exploring Definitions of Mental Health in the Rural Southeastern United States

Allison Crowe, Paige Averett, Janeé R. Avent Harris, Loni Crumb, Kerry Littlewood


The following study assessed the utility of the U. S. Department of Health and Human Services’ definition of mental health among participants in the rural Southeastern United States. Using deductive coding, qualitative results revealed that participants do not conceptualize mental health in comprehensive terms. Rather, they tend to describe mental health with a focus on cognition. The sample articulated “well-being” to describe mental health; however, they most often connected it to cognition. The findings suggest that rural communities could benefit from mental health education with a holistic approach and that the use of the term well-being provides a pathway for clinical connections. Future research should consider interviewing rural participants to gather more detail on their definitions and understanding of mental health.


Keywords: mental health, education, cognition, rural, well-being



Mental illness is a pervasive health care concern in the United States. Even though approximately one fifth of adults experience mental health concerns in any year, only 70% of those in need of mental health services seek care (National Alliance on Mental Illness, 2015). Because of how common and widespread mental health conditions are in the United States, mental health professionals have become increasingly aware that educating the public about mental illness is of utmost importance. Mental health literacy (MHL; Jorm, 2012), or the knowledge and beliefs about disorders that assist in the recognition, prevention, or management of a mental health concern, is one way those who are struggling with mental health concerns can manage mental illnesses more effectively. Improving MHL can have the capacity to positively impact negative attitudes, biases, or assumptions that are associated with having a mental illness as well as assist with help-seeking so those who have a mental illness will receive necessary treatment (Crowe, Mullen, & Littlewood, 2018; Jorm, 2012; Kutcher, Wei, & Coniglio, 2016). Researchers have consistently demonstrated that a stigma still exists toward seeking help for mental health concerns and that reducing that stigma is of utmost importance (Kalkbrenner & Neukrug, 2018).


Increasing help-seeking behaviors might best be done through first exploring attitudes and perceptions, as cognitions are closely tied to emotions and behaviors. Therefore, the current study is framed through the theoretical lens of cognitive behavioral therapy (CBT; A. T. Beck, 1970). CBT is based on the notion that how one thinks, feels, and acts are all intertwined. Specifically, one’s thoughts impact how one feels and behaves. Because of this, negative or unrealistic thoughts may contribute to psychological distress. When a person feels distressed, the way that they interpret situations may become skewed or distorted, which then impacts their behavior. From the lens of CBT, one’s decision to not seek treatment for a mental health concern may be closely tied to the thoughts and feelings they hold about negative associations about mental illness. Counselors who practice from a CBT perspective work with clients to identify and eliminate cognitive distortions in order to minimize painful emotions and promote more adaptive behaviors. CBT has been applied to diverse populations and found to be effective with various presenting concerns (A. T. Beck, 1970; J. S. Beck, 2011; Crumb & Haskins, 2017).


Cognitive distortions exist as they relate to having a mental health concern, and researchers have shown that rural residents with mental health concerns fear being negatively labeled, stereotyped, and discriminated against and thus are apprehensive to seek mental health care services (Crumb, Mingo, & Crowe, 2019). Therefore, it is vital that counselors and other mental health providers consider how clients’ thoughts, beliefs, experiences, and other contextual factors contribute to their understanding of mental illness. Intentional acknowledgment of the factors that influence clients’ perceptions, attitudes, and behavior may enhance treatment efficacy for rural residents (Crumb & Haskins, 2017). Along with exploring negative thoughts related to mental health, researchers also have considered MHL, or one’s understanding of mental health, as it impacts behaviors.


Mental Health Literacy (MHL)


Health literacy researchers suggest low health literacy is related to a number of negative health outcomes, including higher instances of chronic illness, lower usage of health care programs, higher costs of health care, and premature death (Baker et al., 2007; Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). The World Health Organization (WHO; 2013) posits that health literacy is more important than demographic factors (e.g., income, employment, status, education, race, ethnicity) as they relate to health status. Perhaps because of this, the importance of health literacy is well established in the health professions.


In a 2011 literature review on health literacy outcomes, Berkman and colleagues found that lower levels of health literacy were related to more hospitalizations, increased emergency center use, misuse of medications, confusion with medication instructions, higher death rates, and poorer overall health among the elderly. Baker and colleagues (2007) had similar findings related to the impact of poor health literacy on health outcomes. In Baker et al.’s cohort study (N = 3,260), inadequate health literacy independently predicted mortality and death because of cardiovascular disease in elderly populations. They concluded that health literacy is an influential component of overall health.


Compared to general health literacy, the same cannot be said specifically for MHL in the field of mental health. In fact, knowledge of mental health concerns is greatly lacking and largely ignored (Jorm, 2012). The most current study related to MHL found that MHL had a negative relationship to self-stigma of mental health concerns and help-seeking, signifying that when a person knows more information about mental health, they have less stigma about mental health concerns and engage in more help-seeking behaviors (Crowe et al., 2018). In this same study, health outcomes (i.e., blood pressure and body mass index) were assessed to test whether MHL was related to improved physical health. Results were nonsignificant, suggesting that there was not a relationship between MHL and physical health outcomes.


Regional disparities and sociodemographic variations in treatment utilization and efficacy reflect a crucial need for increasing MHL in rural areas in particular (Smalley, Warren, & Rainer, 2012; Snell-Rood et al., 2017). Although prevalence rates of mental health concerns are similar to urban and suburban regions, the amount of and access to mental health services differ vastly in rural regions. Rural residents have fewer options for services, and in fact many rural areas have no health care services at all (Rural Health Information Hub, 2017). Residents in rural regions must travel greater distances for mental health services, are less likely to have health insurance, and have lower MHL (Rural Health Information Hub, 2017). Therefore, professional literature and research studies that assist with raising knowledge about MHL are warranted, as the current literature based on this topic is lacking, especially as it relates to types of settings and samples of the population. Thus, the current study was an attempt to address this gap in the literature. The following section focuses on what is known about mental health in rural areas and highlights the salient issues that are of importance to clinicians and researchers alike.


Mental Health in Rural Areas

The mental health of rural residents is of importance, as 16% of the U.S. population lives in rural areas (Rainer, 2012). Of those living in the rural United States, 90 million residents live in areas that have been designated as Mental Health Professional Shortage Areas and are lacking mental health professionals and resources (Health Resources & Services Administration, 2011). Researchers, practitioners, and recipients of mental health services purport the underutilization of mental health services and inadequacies in the quality of mental health care among rural populations (Smalley et al., 2012; Snell-Rood et al., 2017). Specifically, factors related to acceptability, accessibility, and availability intensify rural mental health disparities across the United States (Office of Rural Health Policy, 2005; Smalley et al., 2012).


A study completed in Australia sought to explore perceptions about mental health in a rural sample (Fuller, Edwards, Procter, & Moss, 2000). Themes revealed a reluctance to acknowledge mental health concerns and seek help from a professional. Results also demonstrated there is a mental health stigma that is particular to rural communities. Although the study provided an initial look at how mental health can be understood in rural areas, the sample consisted of mental health professionals and others who were knowledgeable about mental health issues rather than those from the general client population.


Mental health stigma is one of the most common reasons for unmet mental health needs in rural areas (Alang, 2015; Stewart, Jameson, & Curtin, 2015). For example, residents in rural communities report fear of taking psychotropic medications and that seeking treatment for mental health might adversely impact their employment (Snell-Rood et al., 2017; Stewart et al., 2015). Resultantly, rural clients who experience mental illness enter mental health care later, present with more serious symptoms, and often require more intensive treatment (Smalley et al., 2012). Insufficient MHL, such as misinformation related to common mental health disorders and treatment, can lead to lower rates of recognizing symptoms of depression, anxiety, and an array of other mental health concerns among rural residents in various ethnic and age groups (Kim, Saw, & Zane, 2015).


A quantitative study conducted by Alang (2015) investigating the sociodemographic disparities of unmet health care needs revealed men in rural areas were more likely to forgo mental health care because of gender stereotypes about mental health problems that encourage men to ignore mental health concerns and avoid help-seeking behaviors. Similarly, Snell-Rood et al. (2017) found that rural women face issues with mental health treatment quality and stigma related to specific disorders such as depression as well as a cultural expectancy of self-reliance, which impacts treatment efficacy. Study participants shared that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with their daily routines and beliefs, not offering adequate “direction” on how to approach treatment for their concerns, and having a lack of therapeutic interaction (Snell-Rood et al., 2017). Because of negative perceptions of the quality of mental health treatment, many women in the study were ambivalent in regard to seeking professional help. Rather, they relied on their personal approaches to symptom management (e.g., avoidance, reflection, and prayer).


Accessibility of mental health services is a significant concern in rural areas. Rural residents face challenges in finding transportation to facilities for professional care. Consequently, rural residents often forgo attaining adequate and timely mental health treatment (Alang, 2015; Hastings & Cohn, 2013). Rural residents often depend on alternative sources such as faith-based organizations to address mental health concerns (Bryant, Moore, Willis, & Hadden, 2015) or ignore the prevalence of mental health symptomology altogether (Snell-Rood et al., 2017). Unfortunately, researchers indicated that rural residents seek treatment for mental health disorders after they have become progressively worse, resulting in more extensive treatment, which is often unavailable or costly for rural clients (Gore, Sheppard, Waters, Jackson, & Brubaker, 2016; Hastings & Cohn, 2013; Snell-Rood et al., 2017). Deen and Bridges (2011) suggested these delays in seeking mental health treatment are associated with low MHL.


Treatment availability for mental health care in rural areas is fragmented because of critical shortages in mental health care providers in these communities (El-Amin, Anderson, Leider, Satorius, & Knudson, 2018; Snell-Rood et al., 2017). Practitioner shortage is attributed to difficulty in recruiting and retaining professionals for rural practice as well as practitioners’ limited understanding of cultural norms and effective interventions to address mental health needs in rural communities (Fifield & Oliver, 2016; Hastings & Cohn, 2013). Among practitioners who provide clinical services in rural areas, many report feeling incompetent to work with the population because of receiving fewer training opportunities to learn how to work with rural populations, less access to consultation resources, and professional isolation (Hastings & Cohn, 2013; Jameson & Blank, 2007). Fifield and Oliver (2016) found the most common need of rural-area mental health professionals was training opportunities specific to rural mental health counseling. Pointedly, rural mental health service providers are encouraged to tailor interventions and informational material to meet the needs of the specific communities in which they practice (Crumb, Haskins, & Brown, 2019; El-Amin et al., 2018). For example, a qualitative study examining the experience of rural mental health counselors found it was necessary for rural counselors to modify their interventions to include community-based interventions and expand their roles to include consulting, advocacy, and case management to effectively meet the needs of rural clientele (Crumb, Mingo, & Crowe, 2019). In 2012, rural-specific supplemental materials and curricula were integrated into the standard Mental Health First Aid program, a training course disseminated by the National Council for Behavioral Health to address gaps in MHL by teaching skills to help individuals identify, understand, and respond to mental illness (El-Amin et al., 2018; National Council for Behavioral Health, 2019). Based upon extant research evidence, cultural distinctions in rural living impact MHL and, subsequently, the quality of mental health care in rural regions of the United States.


Despite the above-mentioned disparities, there are opportunities for improving the mental health care of those in underserved rural areas. By becoming familiar with how rural residents in the United States define mental health and investigating the sociodemographic idiosyncrasies in the meaning of mental health for rural residents in specific regions of the United States, mental health practitioners can understand how to better address needs, counter structural barriers to treatment, and improve overall mental health care in rural areas. As far as we are aware, there are no studies that have examined how those in rural communities define and conceptualize mental health. Thus, the current study was designed to fill this gap in the literature.


This study sought to understand how individuals in the rural Southeast define and conceptualize mental health in order to explore MHL and serve as a guidepost to providing culturally relevant services to residents in these regions. Areas in the Southern United States have a high concentration of rural residents who potentially have less access to mental health services, which may influence their overall MHL (El-Amin et al., 2018). Furthermore, we know little about how rural populations define mental health and the knowledge and beliefs that undergird their understanding of mental health. Rather, we have definitions of mental health that are taken from large national and international entities (e.g., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention [CDC], WHO) that offer broad ways of understanding the term. These definitions, although useful, may not capture distinctions associated with region, socioeconomic status, or cultural group differences. Understanding how groups of people view mental health has many benefits to enhancing MHL. A more specific understanding of mental health concepts can serve as a foundation to increase the utilization of mental health services, improve the quality of care, and enhance clients’ ability to communicate concerns. If there are to be greater gains in prevention, intervention, and management of mental health in rural, southern regions of the United States, we need a comprehensive understanding of aspects that are included in perceptions of mental health—using their own words.





Prior to data collection, the Institutional Review Board at a Southeastern U.S. university granted approval to complete the study to explore MHL. Data were collected via a paper-and-pencil survey. Research team members approached patients waiting for a regularly scheduled medical appointment with their primary care physician to complete the survey. Paper copies were stored in a locked filing cabinet within a locked office. The family medical center was located in a rural area of a state in the Southeastern United States. The family medical center where the research took place also housed a mental health provider who received referrals from the medical doctors at the same site. The research team asked permission to collect data on-site, and the lead physician at the center agreed. The mental health provider provides services to many of the same patients who receive medical care at the office. This study was part of a larger, quantitative research investigation on mental health, mental health stigma, and MHL (Crowe et al., 2018). Because of the expansive nature of the dataset, however, this article only focuses on the qualitative components of the survey.



Using published guidelines for in-person recruitment, the research team approached patients as they waited in the waiting room and asked if they would be interested in joining the research study (Felsen, Shaw, Ferrante, Lacroix, & Crabtree, 2010). When participants elected to participate in the study, they completed an informed consent and survey in the waiting area or in an exam room while waiting for the medical professional. All data were collected over the course of approximately six months. Incentives were not offered to participants and all participants could choose to opt out of participation at any time.


Participants included 102 individuals, including 65 females (63.7%) and 37 males (36.3%). A total of 70 participants identified as White (68.6%), 25 identified as Black/African American (24.5%), four identified as multiracial (3.9%), two did not know or endorsed the “other” category (2%), and one identified as Asian (1%). Regarding age, 30 (29%) participants were age 60 and above, 21 (21%) were between the ages of 50–59, another 21 (21%) were between the ages of 40–49, 14 (14%) were between the ages of 30–39, 14 (14%) were between the ages of 19–29, and two (2%) were 18 or younger. Fifty-six participants (55%) were married, while 27 (26%) were single. A total of 15 (15%) were separated/divorced, and four (4%) were widowed. One hundred and twelve participants were asked to complete the survey, and102 individuals completed the materials, yielding a 91% useable response rate. Demographic information is summarized in Table 1.


Table 1

Demographic Information

Characteristic n %
     Male 37 36.3
     Female 65 63.7
     African American/Black 25 24.5
     Caucasian/White 70 68.6
     Multicultural   4   3.9
     Other   2   1.9
     Asian   1   0.9
     18 or younger   2   1.9
     19–29 14 13.7
     30–39 14 13.7
     40–49 21 20.6
     50–59 21 20.6
     60+ 30 29.4
Marital status
     Married 56 54.9
     Single 27 26.5
     Separated/Divorced 15 14.7
     Widowed   4   3.9
Seeking treatment for
     Physical health concerns 88 86.3
     Mental health concerns   3   2.9
     Both   2       2
Treatment status
     Never sought treatment 54 52.9
     Sought treatment in the past 48 47.1
Length of treatment
     1 year or less 18 17.6
     1–4 years 11 10.8
     5–10 years   9   8.8
     11–25 years   5   4.9
Description of treatment
     Not at all helpful   1       1
     Somewhat helpful   9   8.8
     Generally helpful 10   9.8
     Very/Extremely helpful 28 23.3
Family mental health
     No immediate family member with
a mental illness
       66      64.7
     Immediate family member with a
mental illness
26 25.4
     Not sure 10  9.8
Would you seek treatment for mental health concerns in the future?
     Yes         78    76.5
     No   3   2.9
     Not sure 21 20.5





For purposes of the current analysis, an open-ended question prompted participants: “In your own words, please describe what you believe the term mental health refers to.” Analysis was completed by comparing and contrasting the participant responses to this prompt with the U.S. Department of Health and Human Services (HHS; 2019) definition of mental health. This definition states that:


Mental health includes emotional, psychological, and social well-being. It affects how we think,
feel, and act. Mental health helps determine how we handle stress, relate to others, and make
choices. It is important at every stage of life, from childhood and adolescence through adulthood.
. . . Many factors contribute to mental health problems, including: biological factors, such as
genes or brain chemistry; life experiences, such as trauma or abuse; [and] family history of mental
health problems. (para. 1–2)


We elected to use this definition as opposed to similar definitions of mental health offered by WHO or the CDC because each member of the research team chose it as the most comprehensive of the three. Although there were many overlaps in the three definitions (i.e., all three descriptions mention well-being and handling or adjusting to stressors, and included some dimension of biological, psychological, and social aspects), the HHS definition also included the notion of life stages, past life experiences, and how these factors impact mental health.


Data Analysis

The deductive qualitative analysis method (Gilgun, 2011) was used to analyze participant responses to the open-ended prompt. In deductive coding, the researchers begin with existing codes, as deductive coding is utilized to test existing theories or frameworks. Because the current research was attempting to test the HHS definition, deductive analysis was considered the most fitting analysis method by the research team.


Deductive analysis attempts to understand how a particular theory or framework is useful or not (Gilgun, 2011). In deductive coding, data is sorted as it fits with existing concepts, or codes, within a framework. Deductive coding includes levels of analysis, including open coding, axial coding, and selective coding (Strauss & Corbin, 1990). According to Gilgun (2011), during open coding, the data is read line by line, sentence by sentence, and is placed as it is understood within the existing concept(s) with which it best aligns. Axial coding then occurs to refine the existing theory or framework via further analysis of data that is already placed within concepts. This data is then reconsidered to attend to groupings or subthemes within the concept to see if further details of a theory/framework are possible. Selective coding within deductive analysis is when the data is further examined to see if there is possible reduction to a single category or core concept. Selective coding is also an attempt to refine and further consider the existing framework to determine its utility and add to its use. As well, lines or sentences that do not fit existing concepts are noted. This is referred to as negative case analysis.


In the current research, the open coding analysis process was conducted repeatedly to consider and reconsider the data and its fit to the concepts within the HHS (2019) definition of “think, feel, and act.” These three concepts in the HHS definition were evident as the most salient. To aid in coding, these three HHS concepts were further understood by utilizing several online dictionaries (e.g., Google dictionary, Merriam-Webster, dictionary.com, and Cambridge English Dictionary) to define each concept. For example, the think code included all participant responses that are associated with this term via dictionaries, including intellectual, cerebral, brain, cognitive, and rational. The research team continually used several dictionaries to understand participant responses that were not exact or clear upon first reading. For example, state of mind was coded as think because of it being defined as a cognitive process and the condition of a person’s thoughts. Axial coding then occurred through the research team reconsidering the fit of the responses to the existing codes and if further codes could be developed via negative case analysis. As demonstrated below, axial coding produced a negative case analysis, that of overall well-being. Selective coding occurred through the team considering all codes and the utility of the original framework or, in this case, the HHS definition. This utility or lack thereof is further considered in the discussion below.


The entire analysis process was completed by two members of the research team independently. Independent coding enhances credibility in the analysis process, a technique promoted among qualitative researchers (Lincoln & Guba, 1985). The two researchers met on two occasions to discuss their findings and found consistency in their coding in both meetings. This consistency is often found when pre-existing codes with set definitions are utilized, as was the case in this analysis.




The following section presents the results of the deductive coding of the data in comparison to the HHS definition of mental health, specifically the concepts of how we “think, feel, and act.” The existing concepts used as codes for analysis included the psychological, emotional, and social well-being—how we think, feel, and act. Sample quotes from participants (Ps) are provided. The research team also presents further points of possible refinement of the definition and sense of a core concept.


Concepts Used to Describe Mental Health

     Think, feel, and act. Only 15 participant responses provided support for a definition of mental health that encompassed all three aspects found in the HHS (2019) definition of “think, feel, and act.” One participant stated, “mental health to me personally is the state of one’s condition of emotional, mental, social and physical well-being” (P2), and another shared that mental health is the “ability to succeed, fully participate in social, emotional and occupational and recreational leisure” (P3). Thus, there was only a small subset of participants who viewed mental health as comprehensively as federally defined.


     Well-being. It should be noted that although most participants did not provide comprehensive definitions that specifically mentioned all three concepts of think, feel, and act, as used by HHS, there were 23 participants in the sample who used the term well-being. As indicated in the following, well-being was not seen as specific to one area but rather an overall experience. One participant stated, “More than a sense of psychiatric disease—overall well-being” (P4), and another shared, “Overall health of a person—their well-being” (P5). Thus, for many of our participants, a comprehensive definition of mental health they demonstrated was the general term well-being.


     Think. The most salient concept found among our participants was related to cognition, thinking, the mind or brain, or the term mental. Thirty-four responses focused solely on mental health as being how we think, including statements such as “state of mind” (P6), “mental health refers to your thoughts” (P7), and “brain imbalance” (P8). These responses suggest that the cognitive aspect of mental health is a primary way these rural participants conceptualize mental health. We also saw this demonstrated in other definitions provided by the participants that had think in combination with either feel or act.


     Think and feel. The next most salient conceptualization provided by participants included elements of both cognition and emotion—how we think and feel. Eighteen participants provided responses in this code, including “mental health is my ability to cope, how I think, rational thinking, and my emotional stability” (P9) and “state of mind and feeling of well-being” (P10). It is noteworthy that again when discussing cognition and emotion, there was frequent use of the phrase well-being, even when limited to just think and feel, thus further supporting the term well-being.


     Think and act. Cognition or thinking was further salient and used in connection with behavior, or how we think and act. Conceptualizations from these 10 participants included statements such as “condition of one’s mind and if any affect [sic] on behavior” (P11) and “well-being in thought and action” (P12). Again, also noted is the use of the term well-being, even when specifying think and act.


     Non-salient concepts within the HHS definition. There were other conceptualizations of the term mental health that supported aspects of the HHS definition. There were seven participants who focused solely on feelings—how you feel. Although there were five participants who only focused on mental health as behavior or how one acts, neither of the singular concepts were considered salient in participant responses because of infrequent responses.


     Other non-salient concepts. Also provided by participants were concepts focused specifically on a mental health diagnosis such as “depression” (P16, P17) and “depression, bipolar” (P18). Also, it is interesting to note that although not salient, a few participants saw mental health as a function of physical health. This was demonstrated in definitions such as “condition of health” (P19) and “special help for the sick or assist those that have some type of disease” (P20). It is important to note that a few responses were unclear or too vague and could not be categorized, such as “Don’t know” (P21, P22).



     Overall, participants’ responses suggest a strong tendency toward cognitive aspects of mental health rather than a comprehensive definition that can be found when looking in formal sources, such as the HHS definition (2019). However, a negative case that emerged was that these rural participants did provide the term well-being as an overall comprehensive definition for mental health. Frequency counts for each concept can be found in Table 2. In the following section, we discuss these findings.


Table 2

Frequencies According to HHS Definition Code

HHS Definition Codes              Participant Response Count

Think                                                   34

Think and Feel                                      18

Think, Feel, and Act                             15

Think and Act                                      10

Well-Being                                           23






     In the current study, we explored MHL, specifically focusing on the efficacy of the HHS mental health definition in a rural, Southeastern U.S. sample. We sought to understand how this population conceptualized the term mental health. The current research literature provides very little information about this topic, so the following study offered initial findings to offer professional counselors and researchers implications and areas for further investigation.


It is important to reflect on the ways results from this sample of rural residents compare to the existing knowledge about the larger public’s MHL levels and ideas about mental health. Jorm (2000, 2012) noted that lack of MHL among individuals inhibits their ability to recognize mental health concerns when they arise. Although MHL may be an area for more intensive focus across all populations and settings (Jorm, 2000, 2012), results from this study suggest that there are a number of unique considerations in rural areas. Moreover, it is important to situate the current findings in the context of the challenges faced by rural residents. Knowing how those in rural communities define mental health, in their own words, will lend mental health practitioners information about how to communicate and connect effectively to increase the utilization of mental health services, improve the quality of care, and enhance clients’ ability to communicate concerns. If there are to be greater gains in prevention, intervention, and management of mental health in rural regions of the United States, a nuanced understanding of perceptions about mental health may offer a starting point.



In terms of the HHS definition, the current sample supported the concept of well-being. Although well-being was not necessarily connected concretely to the specific terms of think, feel, and act, it was often associated with one or two other concepts as well as used singularly as a holistic definition. Research on well-being has been of increasing interest in the past two decades (Dodge, Daly, Huyton, & Sanders, 2012), and many of the current national and international definitions of mental health refer to well-being (LaPlaca, McNaught, & Knight, 2013). Recent attempts have been made in the literature to more clearly articulate the definition of well-being (Dodge et al., 2012; LaPlaca et al., 2013), as this concept is being used to determine policy and practice on many national stages.


Current definitions of well-being combine elements of the psychological, social, and physical. However, these descriptions also focus on the ratio of resources to challenges that individuals and communities experience, and some have described well-being as the equilibrium between the two (Dodge et al., 2012). Thus, well-being should be considered within the context of social issues, economics, and service provision. This definition of well-being can be particularly useful for rural communities and populations, as resources and service provision are often lacking in rural communities (Health Resources & Services Administration, 2011). Our finding that participants connected with and utilized the concept of well-being suggests that both counseling practitioners and researchers should utilize the term and seek to better understand it, especially those working with rural communities and clients. However, participants in the current study did not provide an expansive level of detail in their conceptualization of well-being; rather, they focused on the cognitive or physical aspect of well-being.


Cognitive and Biological Focus

When comparing the current sample’s definitions to the HHS definition of mental health, the think/cognitive aspect of mental health was most supported and relevant to these rural participants. Most participants believed that mental health describes how individuals think, followed by those who described it as a combination of thoughts and feelings. As noted in the literature review, HHS (2019) considers mental health as impacting the way individuals think, feel, and act. In the current sample, however, only a small fraction of participants defined mental health as a combination of thoughts, feelings, and behaviors. Instead, participants considered mental health from a cognitive and biological perspective, focusing on the brain and chemical imbalances. Thus, results of this study suggest that individuals in rural communities might lack a holistic understanding of mental health.


Our findings add to the literature by providing context for rural individuals’ perceptions and possible explanations for treatment and help-seeking patterns. Rural residents may be especially vulnerable to misinformation about mental health disorders because of mental illness stigma, a cultural expectancy of self-reliance to resolve mental health concerns, and ascertaining mental health–related information from nonprofessionals (e.g., family members, religious leaders; Smalley et al., 2012; Snell-Rood et al., 2017), thus further underscoring the importance of improving MHL in rural communities. In the current study, for example, many participants listed only one component of mental health (e.g., brain imbalance, thoughts), suggesting that their understanding of the concept of mental health is lacking. The focus on the biological composition of the brain in mental health is consistent with definitions of mental illness promoted by organizations such as the National Institute of Mental Health. Thus, although participants’ definitions of mental health are not incorrect, in many ways the focus is narrow and not comprehensive. Study participants excluded emotions and when speaking about biology focused on the brain, which potentially discounts somatic manifestations of mental illness (e.g., stomach pains).


A more comprehensive understanding of mental health, with a specific focus on the connection between emotions, behaviors, and somatic symptoms, could potentially assist rural residents with becoming more conscious of signs and symptoms related to common mental health concerns such as anxiety and depression (Kim et al., 2015). It seems important for mental health educators, organizations, and counseling practitioners in rural communities to provide education that broadens the beliefs about the nature of mental health. Educational campaigns and direct work that are more inclusive and broadly focused could be of benefit.


Implications for Professional Counselors

     Professional counselors and related mental health practitioners in rural areas noted they need training opportunities focused on clinical issues that are important in rural settings (Fifield & Oliver, 2016). Thus, the results from this study may offer mental health professionals guidance for reaching residents in rural communities and providing efficacious mental health services. Foremost, counselor training programs could consider developing courses with a specific focus on rural populations, which can assist counseling students in increasing their understanding of the culture of rural settings, how rural residents comprehend mental illness, and effective counseling practices in rural communities (Crumb, Mingo, & Crowe, 2019; Rollins, 2010). For example, counselors in training would be privy to facts such as how many people living in rural areas across the United States face additional life stressors, including poverty and housing and food insecurities, that impact their mental health and well-being.


The results of this study also illustrate the importance of building partnerships and collaborative relationships in rural communities, as rural residents may present varied concerns (e.g., concerns about physical health, family members, finances, spirituality) to counselors when seeking help. Thus, building both informal and formal professional support networks in rural communities is vital. Counselors in rural communities may consider building resources with physicians, faith-based organizations, and other mental health providers for consultation purposes (Avent, Cashwell, & Brown-Jeffy, 2015; Crumb, Mingo, & Crowe, 2019).


El-Amin et al. (2018) suggested programs such as rural-focused Mental Health First Aid to help increase MHL in rural communities. Because access to mental health services is often limited and/or non-existent in rural communities, counselors and related mental health professionals should be more intentional in implementing these forms of programming because of the large number of residents who reside in rural communities who have not yet been helped (El-Amin et al., 2018). Trainings such as this may assist with MHL, as well as mental health stigma, which has been associated with MHL in rural areas (Crowe et al., 2018).


Last, the focus on cognition in participants’ definitions of mental health may indicate a positive response to more cognitive-based theories such as CBT (A. T. Beck, 1970) and rational emotive behavioral therapy (Ellis, 1962). As this study was framed through the lens of CBT and the notion that cognition impacts emotions and behaviors, this theory and related interventions may fit well when working with clients in the rural United States. This type of “matching” related to how clients in the rural parts of the United States understand mental health (with a more cognitive focus) might lead to increased participation in counseling and therapy in rural areas. This might be a way for practitioners to join with the client initially, at the beginning of the therapeutic relationship, in order to “speak the same language.” However, given the findings of the current study, although individuals may have a natural inclination toward more cognitively focused theories, it is incumbent upon mental health professionals to challenge individuals to consider the ways emotions and behaviors are connected to their mental health as well. CBT fits this model well; however, scholars have also found ways to integrate other theories to provide an even more comprehensive and culturally responsive theoretical framework for clients. For example, one of the suggested interventions in Crumb and Haskins’ (2017) integration of CBT and relational cultural theory is to “apply cognitive restructuring through relational resilience” (p. 268). This technique could be especially beneficial to rural communities, as it honors the focus of cognitions while also considering how these thoughts and messages may be related to a broader systemic and environmental influence (Crumb & Haskins, 2017).


In sum, counselors should be aware that many of their clients may present with low MHL. Thus, education and awareness about mental health, diagnoses, and symptomatology may be an integral part of the treatment process. Counselors should consider this intentionality in education as a part of their role as advocates for their clients (Crumb, Haskins, & Brown, 2019).


Limitations and Future Directions

As with all research, the current study is not without limitations. First, the qualitative responses received from participants were often brief. The study team was able to analyze responses, but future qualitative research on the topic of MHL in rural samples might include a focus group design or individual interviews rather than paper-and-pencil surveys to get an in-depth look at how those in rural areas define mental health. Also, future research could seek to further understand the concept of well-being as used by rural participants, looking more in depth at all components (cognition, emotion, and behavior). Future research studies could also investigate the reasons for a focus on cognitive aspects of mental health. As it is impossible to separate cognition from emotion and behavior, this study found that many participants seemed to focus on cognition rather than a more comprehensive understanding of cognition as it related to choices in behaviors and affect. The current study took place in a medical center, and participants who were approached to participate may have felt pressure to complete the survey or answer in a way that was socially desirable. The sample was a convenience sample and may not be representative of others in the rural Southeast.


Large scale quantitative studies might offer scholars interested in MHL the opportunity to use validated instruments to measure literacy and perceptions about mental health in rural samples. Assessments such as the Mental Health Knowledge Schedule (Evans-Lacko et al., 2010) have been used in recent research (Crowe et al., 2018) to measure mental health knowledge. The Revised Fit, Stigma, & Value Scale (Kalkbrenner & Neukrug, 2018) is another scale measuring barriers to counseling such as stigma, values, and personal fit. These types of assessments can measure levels of recognition, familiarity, and attitudes toward mental health conditions in order to measure MHL and perceptions of mental health stigma.




This qualitative study investigated the HHS definition of mental health to determine if it was representative of rural Southeastern participants’ definitions. This assisted with answering the call for more research on the mental health of rural residents (Simmons, Yang, Wu, Bush, & Crofford, 2015) in order to provide better services to this population. Most participants demonstrated a conceptualization that included cognition, as well as well-being, and were more concrete in their conceptualization of mental health when compared to the more comprehensive HHS definition. A promising result from this study was that many participants seemed willing to seek mental health treatment in the future. Rural communities could benefit from mental health education with a holistic approach. Future research should consider interviewing rural populations to gather more detail on their definitions and understanding of mental health. The results provided interventions for professional counselors and related mental health clinicians, particularly those in rural settings, to integrate into their present work, pointed to the need for educational campaigns on mental health in rural areas, and highlighted areas for future research exploration.



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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Allison Crowe is an associate professor at East Carolina University. Paige Averett is a professor at East Carolina University. Janeé R. Avent Harris, NCC, is an assistant professor at East Carolina University. Loni Crumb, NCC, is an assistant professor at East Carolina University. Kerry Littlewood is an instructor at the University of South Florida. Correspondence can be addressed to Allison Crowe, 225 Ragsdale Hall, Mailstop 121, College of Education, 5th St., Greenville, NC 27858, crowea@ecu.edu.

Integrating Social Justice Advocacy Into Mental Health Counseling in Rural, Impoverished American Communities

Loni Crumb, Natoya Haskins, Shanita Brown


This phenomenological study explored the experiences of 15 professional counselors who work with clients living in impoverished communities in rural America. Researchers used individual semi-structured interviews to gather data and identified four themes that represented the counselors’ experiences using the Multicultural and Social Justice Counseling Competencies as the conceptual framework to identify the incorporation of social justice and advocacy-oriented counseling practices. The themes representing the counselors’ experiences were: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The counselors’ experiences convey the need to alter traditional counseling session delivery formats, practices, and roles to account for clients’ life experiences and contextual factors that influence mental health care in rural, impoverished communities. Approaches that counselors use to engage in social justice advocacy with and on behalf of rural, impoverished clients are discussed.

Keywords: rural, impoverished communities, advocacy, social justice, multicultural


Approximately 41.3 million Americans live in poverty (Semega, Fontenot, & Kollar, 2017) and consistently face multiple chronic stressors (e.g., food and housing insecurities, social isolation, inability to access adequate physical and mental health care) that impact their quality of life (Fifield & Oliver, 2016; Hill, Cantrell, Edwards, & Dalton, 2016). Nevertheless, the scope of mental health concerns of individuals and families residing in persistently poor, rural communities remains under-researched and overlooked by the public, scholars, and policymakers (Tickamyer, Sherman, & Warlick, 2017). Furthermore, advocacy efforts that foster social and economic justice and support the mental health of persons living in rural poverty warrant further advancement.

Scarce availability of mental health care services, ineffective modes of treatment and interventions, and mistrust of mental health care professionals contribute to the low utilization of mental health care services among persons living in rural poverty (Fifield & Oliver, 2016; Imig, 2014). Consequently, there are few evidence-supported culturally relevant mental health interventions tailored to address the specific needs of people living in rural poverty, particularly with a focus on social justice advocacy (Bradley, Werth, Hastings, & Pierce, 2012; Imig, 2014). Counselors practicing in rural, impoverished areas must be prepared to address systems of oppression, discrimination, marginalized statuses, and the impact these factors have on counseling services and clients’ well-being (Grimes, Haskins, & Paisley, 2013; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). Moreover, according to the 2016 Code of Ethics from the National Board for Certified Counselors (NBCC) and the 2014 ACA Code of Ethics from the American Counseling Association, counselors are expected to take actions to prevent harm and help eradicate the social structures and processes that reproduce mental health disparities in vulnerable communities (ACA, 2014; NBCC, 2016). In recognition of this expectation, the Multicultural and Social Justice Counseling Competencies (MSJCCs) were developed to guide mental health counselors toward practicing culturally responsive counseling and incorporating social justice advocacy initiatives into the process (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). Thus, the MSJCCs’ framework undergirds our examination of counselors’ experiences and clinical practices that support the mental health and well-being of clients living in poverty in rural America.


Understanding Rural Poverty and Mental Health Care

When discussing literature pertaining to rural poverty, it is important to first define relevant terms. The U.S. Department of Agriculture’s Economic Research Service (USDA; 2017) defines poverty as having an income below the federally determined poverty threshold. For example, the 2017 poverty threshold for an individual under 65 years of age was $12,752, and the poverty threshold was $16,895 for a household with two adults under age 65, with one child under 18 years of age (USDA, 2017). Persistently poor areas are defined as communities in which 20% or more of the population has lived below the poverty threshold over the last 30 years with low populations (fewer than 2,500 people; USDA, 2017). The majority of persistently poor communities are located in rural Southern regions of the United States (USDA, 2017). Rural communities that experience persistent poverty have had little diversification of employment, are underserved by mental health care providers, and lack affordable housing and economic development (Tickamyer et al., 2017). For the purposes of this study, the definitions described above were used to define and understand rurality and poverty.


Mental Health Care in Rural, Impoverished America

An abundance of literature exists that identifies concerns related to mental health care for people who live in rural poverty (Reed & Smith, 2014; Tickamyer et al., 2017). For example, Snell-Rood and colleagues (2017) conducted a qualitative study that explored the sociocultural factors that influence treatment-seeking behavior among rural, low-income women. Participants reported that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with daily routines and beliefs (Snell-Rood et al., 2017). Alang (2015) conducted a quantitative study that investigated the sociodemographic disparities of unmet health care needs and found that men in rural areas were more likely to forgo mental health treatment because of gender stereotypes. Specifically, Alang found that men were encouraged to ignore mental health concerns and avoid help-seeking behaviors. Furthermore, children living in rural poverty have fewer protective resources and less access to services that can address their needs and are subsequently exposed to increased violence, hunger, and poor health (Curtin, Schweitzer, Tuxbury, & D’Aoust, 2016).

Adults and children living in rural poverty often have lower mental health literacy (i.e., the ability to recognize a mental health concern when it arises and how to cope with one when it occurs; Rural Health Information Hub, 2017). For example, researchers (Pillay, Gibson, Lu, & Fulton, 2018) examined the experiences of the rural Appalachian clients who utilized mental health services and found that clients were ambivalent about diagnoses and suspicious when providers suggested psychotropic medications to support treatment. Likewise, Haynes et al. (2017) conducted focus group interviews that included persons living with a mental illness, health care providers, and clergy living in rural, impoverished communities in the Southern United States, and reported a general lack of awareness about mental illness. The researchers suggested that individuals have less knowledge of what mental illness looks like, how to recognize it, and how to identify warning signs of crises in Southern rural, impoverished communities (Haynes et al., 2017). As a result of less mental health literacy, people in rural low-income communities may delay seeking counseling treatment until symptoms have intensified and face a greater likelihood of hospitalization related to mental health challenges (Neese, Abraham, & Buckwalter, 1999; Stewart, Jameson, & Curtin, 2015).


Counselor Competence and Poverty Beliefs

Researchers have indicated that mental health professionals practicing in rural, economically deprived areas are not properly trained to address the multiple needs of this population (Bradley et al., 2012; Fifield & Oliver, 2016; Grimes, Haskins, Bergin, & Tribble, 2015). Fifield and Oliver (2016) surveyed 107 rural clinicians, exploring their perceived training-related needs and the pros and cons of rural counseling practice. The researchers found that many counselors did not receive adequate training to work with the population they served, and the counselors did not feel properly prepared to address the host of issues that may arise in their rural practice.

Moreover, mental health professionals continue to hold negative poverty beliefs and social class biases (Bray & Schommer-Aikins, 2015; Grimes et al., 2015; Smith, Li, Dykema, Hamlet, & Shellman, 2013) that negatively impact the quality of services provided. Researchers have shown that some counselors are less willing to work with clients of lower socioeconomic statuses because of communication barriers, having less knowledge of and exposure to the poverty culture, and possessing negative stereotypes about poor, rural populations (e.g., uneducated, dirty, violent, lazy; Bray & Schommer-Aikins, 2015; Smith et al., 2013). Consequently, clients from lower socioeconomic statuses receive more serious mental health diagnoses or are often misdiagnosed, which may be attributed to the professional’s negative biases, as well as lack of adequate multicultural training (Clark, Moe, & Hays, 2017).


Multicultural Counseling Competence

Increased training in multicultural counseling competence has a significant impact on counselors’ poverty beliefs (Clark et al., 2017; Toporek & Pope-Davis, 2005). In a quantitative study examining the relationship between multicultural counseling competence and poverty beliefs using a sample of 251 counselors, Clark et al. (2017) identified that higher levels of multicultural competence and training decreased poverty biases and helped counselors to understand the structural causes of poverty. Similarly, Bray and Schommer-Aikins’ (2015) survey of 513 school counselors found that counselors with training through multicultural courses recognized the external factors that contribute to poverty; however, the study did not focus on effective interventions that counselors utilized with this population.

Although these studies identified that multicultural knowledge and awareness increased counselors’ understanding of the culture of poverty, more research is necessary to explore how this information is applied to provide counseling professionals with evidence-based illustrations of social justice advocacy in practice (Ratts & Greenleaf, 2018). Accordingly, the purpose of this study was to (1) develop an understanding of the experiences of mental health counselors who work in rural, persistently poor communities and (2) identify ways that counselors incorporate social justice advocacy into counseling using the lens of the MSJCCs. The research question guiding this study was: What are the lived experiences of mental health counselors working in rural, persistently poor communities?


Conceptual Framework

The MSJCCs, a revision of the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992), offer a framework to incorporate culturally responsive counseling and social justice advocacy initiatives into counseling practices, research, and curricula (Ratts et al., 2015). Established in a socioecological framework, the MSJCCs help counselors examine personal biases, skills, and the dynamics of marginalized and privileged identities in relation to multiculturalism and social justice counseling competence and advocacy. Additionally, the MSJCCs assist counselors in acknowledging clients’ intersecting identities, which bestow various aspects of power, privilege, and oppression that may impact their growth and development.

The developmental domains of the MSJCCs—(a) counselor self-awareness, (b) client worldview,
(c) counseling relationship, and (d) counseling and advocacy interventions—help counselors understand social inequalities that are perpetuated by institutional oppression in order to better serve historically marginalized clients (Ratts et al., 2015). Likewise, aspirational competencies espoused in the MSJCCs—namely (a) attitudes and beliefs, (b) knowledge, (c) skills, and (d) action—serve as objectives for multicultural, social justice competence and advocacy interventions (Ratts et al., 2015, 2016). Although the MSJCCs have been identified as goals for all counselors, limited research exists that illuminates the MSJCCs as a framework for understanding social justice applications within rural, high-poverty areas. Therefore, in considering the four distinct developmental domains and aspirational competencies, the authors utilized the MSJCCs as a basis to understand counselors’ experiences in rural, high-poverty communities. For the purposes of this study, social justice advocacy is understood as interventions and skills that counselors utilize to address inequitable social, political, or economic conditions that impede the personal and social development of individuals, families, and communities (Lewis, Ratts, Paladino,
& Toporek, 2011).



University institutional review board approval was granted for this study. We used a descriptive phenomenological qualitative research design, which is suitable for scholars to examine the lived experiences of individuals within their sociocultural context (Creswell & Creswell, 2018; Giorgi, 2009). In descriptive phenomenological studies, researchers use participants’ responses to describe common experiences that capture the “intentionality” (perception, thought, memory, imagination, and emotion) related to the phenomenon under study (Giorgi, 2009). Furthermore, using qualitative research methods allows researchers to provide an in-depth exploration of lived experiences and helps multiculturally competent counselor–researchers highlight gaps in counseling literature and inequities in counseling practices in order to advocate for systemic changes in the counseling profession (Hays & Singh, 2012; Ratts et al., 2015).


Role of the Researchers

We recognize the possibility of bias in empirical research and acknowledge our social locations, identities, and professional experiences in relation to the current research study. All three authors identify as African American women from low socioeconomic backgrounds. We identify as counselor–advocate–scholars (Ratts & Greenleaf, 2018) and incorporate advocacy for underserved populations into our counseling practices, research, supervision, and teaching (Ratts et al., 2015). We bracketed personal thoughts and feelings and discussed biases that may possibly influence the data throughout the study. For example, the frequent criminalization of poverty was a difficult finding to discuss with the participants and we met to express our thoughts regarding this finding. A graduate research assistant (middle class, European American female) was selected to assist in data collection and analysis to increase objectivity in the research process, as she was less familiar with underserved populations, but trained extensively in qualitative research techniques. We acknowledge that we used the developmental domains and aspirational competencies espoused in the MSJCCs to conceptualize this research study, analyze the data, and present the findings and implications to foster positive changes in mental health care for people living in rural, poor communities. Furthermore, it is our view that the data did not emerge independently, but that as researchers we used a rigorous process such as the use of thick descriptions to analyze and identify nuances and commonalities in the data while also accounting for our assumptions and biases (Hays & Singh, 2012; Lincoln & Guba, 1986). Our position as counselor–advocate–scholars helps to bring expertise to our scholarship and practices (Hays & Singh, 2012; Ratts & Greenleaf, 2018).



Fifteen participants (N = 15; 13 women, two men) were selected for the study using purposeful criterion sampling (Patton, 2014). Participants’ ages ranged from 28 to 67 years (M = 40). Twelve participants identified as European American and three as African American. Twelve participants were licensed professional counselors and three were licensed professional counselor associates. Two participants had doctoral degrees in counseling. Participants practiced counseling in various settings such as private practices, colleges, secondary schools, and community counseling centers. Participants also had additional credentials: three were licensed professional counselor supervisors, seven were licensed clinical addiction specialists, one was a certified clinical trauma professional, and one was a registered play therapist. Years of work experience as a professional counselor ranged from 2 to 20 (M = 6.7).


Data Collection and Analysis

Recruitment solicitation flyers were distributed to various mental health agencies located in rural counties designated as persistently poor (USDA, 2017) in one state in the Southeastern United States. The mental health agencies were identified by searching public information websites for counseling and psychological support resources within these counties. Potential participants completed a telephone eligibility screening and a demographic questionnaire. The demographic questionnaire included questions asking potential participants to identify a pseudonym, their age, ethnicity, employment status and location, and professional credentials. Participants who met inclusion criteria (i.e., licensed mental health clinicians currently employed in persistently poor rural locales) were selected to participate in the study. There is no required sample size for phenomenological studies; rather, authors (Creswell & Creswell, 2018; Hays & Singh, 2012) recommended researchers consider the purpose of the research and depth of the data. We continued to recruit participants until saturation was achieved by seeing a recurrence in the data (Creswell & Creswell, 2018; Hays & Singh, 2012). After completing Interview 15, we did not identify novel data and agreed that a sufficient amount of data was collected to provide a comprehensive understanding of the phenomenon under investigation.

The researcher is the key instrument for data collection in qualitative research (Creswell & Creswell, 2018). A graduate assistant and the first author collected all study data by the use of qualitative interviews using an open-ended, semi-structured interview protocol (Hays & Singh, 2012). Each participant completed individual, one-phase, open-ended, semi-structured, face-to-face or live video interviews, lasting approximately 60–90 minutes. We audio-recorded all interviews, and they were transcribed by a professional transcription service.

The 12 interview questions that guided the study were framed by the MSJCCs’ constructs in extant literature related to the experiences of mental health counselors and clients in rural, poor communities (Bradley et al., 2012; Clark et al., 2017; Grimes et al., 2015; Grimes et al., 2013; Kim & Cardemil, 2012) and specific multicultural and social justice counseling constructs espoused in the MSJCCs (Ratts et al., 2015; Ratts et al., 2016). Six questions focused on understanding the participants’ knowledge of rural, poor communities and their experiences. Examples of these questions were: “Can you tell me the influence that persistent poverty has on the services you provide in a rural setting? What personal and client factors or experiences are influential to your work?” and “What is needed for you to competently provide counseling services to this population, if anything?” An additional six questions, also informed by the MSJCCs, sought to further explore the participant’s beliefs, skills, and actions related to multicultural competence, social justice advocacy, and counseling, such as “Can you share with me your definition and understanding of social justice advocacy in counseling? Can you share ways (if any) you incorporate social justice advocacy into your work as a counselor in a rural, economically deprived area?” and “Please share any perceived barriers to engaging in social justice advocacy and counseling in rural, economically deprived areas.”

Analysis of the data was informed by Giorgi’s (2009) and Giorgi, Giorgi, and Morley’s (2017) process for descriptive phenomenological data analysis. Specifically, we adhered to five steps in the data analysis process. First, we assumed a phenomenological attitude, in which we bracketed suppositions that could potentially influence the data and research process, such as our frustrations with perpetual deficit ideology in research related to marginalized populations. Second, after each interview was completed, we individually read each transcript to get a sense of the whole experience (i.e., native descriptions) and wrote brief notes in the margins to pinpoint any significant descriptive statements and expressions (Hays & Singh, 2012). For instance, we notated participants describing specific counseling practices that they believed were related to social justice advocacy as significant descriptive statements. We sent participants a copy of their transcript for member checking. Third, we re-read transcripts to demarcate data into multiple meaning units by clustering the invariant descriptions of participants’ experiences.

Initially, we also used a priori codes based on the MSJCCs to begin to identify units of meaning. For example, codes such as systems, advocacy, self-awareness, community, and collaboration helped us to infuse the MSJCCs’ framework and focus the findings toward understanding social justice experiences. As an example, the recognition and appreciation of a client’s ability to ascertain needed resources despite having less access and the participants’ willingness to assist in resource allocation were two invariant descriptions of experiences. The analysis process yielded 46 initial units of meaning. Participants’ quotes and definitions related to meaning units were contained in a research notebook to manage data and establish consensus coding (Hays & Singh, 2012). We held multiple meetings to discuss if and how these meaning units related to the developmental domains of the MSJCCs. For example, we discussed how one meaning unit, idiosyncrasies in the support system, closely related to the MSJCCs’ client worldview domain and reached a consensus in understanding that the participants’ ability to recognize that their clients had often strained their natural support systems exemplified that the counselor possessed knowledge of how their clients’ economic status and limited support systems shaped their attitudes and engagement in mental health treatment. In our fourth step, we reviewed the data to transform the meaning units into sensitive descriptive expressions that highlighted the psychological meaning of participants’ descriptions. We used free imaginative variation to determine the essence of the phenomenal structures of the participants’ experiences (Giorgi, 2009; Giorgi et al., 2017). We discussed any differences in understanding participants’ invariant experiences. For example, we discussed if the participants’ recognition of their need for a professional consultation to address underdeveloped counseling skills and biases related to the MSJCCs’ counselor self-awareness domain. Finally, we negotiated the interconnections and essential meanings of the meaning units, coalesced the data, and identified four essential structures that represented the descriptions of participants’ experiences and assigned them a descriptive thematic label.


Strategies for Trustworthiness

It is vital that researchers establish criteria for trustworthiness in qualitative research studies (Morrow, 2005). We demonstrated credibility through the use of bracketing, triangulation of the data sources, member checking, and peer debriefing (Morrow, 2005). Participants were provided with a copy of their transcriptions and case displays to review for member checking. We employed triangulation of data by crosschecking data (Hays & Singh, 2012) with the existing empirical studies related to rural poverty and mental health counseling. Data collection and analysis occurred concurrently in order to triangulate findings (Hays & Singh, 2012).



Using an MSJCCs lens, we identified four themes that represented the experiences of counselors who work with clients in rural poverty: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The findings are explicated using participants’ quotes to illustrate the meaning of each theme.


Appreciating Clients’ Worldviews and Life Experiences

Participants in the study described how they developed an appreciation for their clients’ worldviews and life experiences, even if they were different from their own. For example, Jade shared how she gained insight into and showed an appreciation for her clients’ worldviews by “showing empathy, being curious, and asking questions about what it was like for them in certain situations.” Jade expressed that seeking to understand clients’ worldviews was vital when working with African Americans living in rural poverty because she did not have the same experiences. Shelly also conveyed an appreciation for her clients’ worldviews and experiences and the impact on her clinical skills, sharing that she acquired a “different perspective” in her approach by gaining knowledge of her clients’ family structures and listening to their history.

Nine participants described that working in rural, impoverished communities entailed understanding the impact that limited resources have on providing adequate mental health services and recognizing the idiosyncrasies in clients’ support systems. Three participants described how their clients had often “burned” or “exhausted” their natural support system (i.e., personal relationships with other people that enhance the quality of one’s life), which made it difficult for participants to identify persons who would be supportive of their clients in the mental health treatment process. Addie described her counseling experiences in rural, poor communities, stating, “People have so little to fall back on, if they’re chronically mentally ill or they have a family member who is, they’re just out of resources, and they’ve maybe even burned their natural supports.” Addie further elaborated on her experiences, explaining that family members would often not return her phone calls after a client was admitted for inpatient mental health treatment.

Five participants expressed the importance of considering how low mental health literacy and mental illness stigma influenced clients’ knowledge, attitudes, and beliefs toward mental health treatment. Lola explained that she observed low mental health literacy in rural, poor communities: “There is a very low level of understanding with regard to symptoms associated with mental illness.” Lola discussed the prevalence of stigma toward clients with diagnosed mental health disorders as well as toward clients that had not been formally diagnosed because of the limited understanding of mental illness. Likewise Julian, a school-based counselor, expressed the impact of low mental health literacy in rural, high-poverty communities. Julian shared that the majority of her youth clientele were being raised by their grandparents, who had less knowledge of mental health symptoms and treatment; therefore, grandparents were often hesitant to seek mental health treatment services for their grandchildren.

Many (n = 11) of the participants indicated that in understanding the clients’ experiences and worldviews they were able to see how clients managed to be resourceful and resilient when faced with hardships. In illustration, Lola stated, “They are some of the most resourceful and resilient people that I’ve ever met; they have a knack for finding ways to achieve what needs to happen despite not having the typical resources . . . that’s very admirable.” Sue and Brenda expressed similar sentiments, also describing their clients as “resourceful.” In essence, participants explicated their attitudes and dispositions (e.g., recognizing and appreciating clients’ resourcefulness, possessing curiosity, learning about family structure and support systems) in working with clients in rural, impoverished communities. In accordance with the MSJCCs, participants expressed the importance of recognizing how the worldviews and life experiences of their marginalized clients are influenced by the context of rural poverty, such as how low mental health literacy and stigma impact the utilization of mental health treatment for this population.


Counseling Relationships Influencing Service Delivery

Participants (n = 10) described the importance of having a strong counseling relationship when working with marginalized individuals and families living in rural poverty. This solid relationship motivated participants to alter the mode of service delivery or intentionally focus more on client-centered services. Reflecting on her experiences providing home-based counseling services, Sue expressed the importance of building trust and empowerment in counseling relationships, especially when clients were involved with professionals from other agencies (e.g., probation officers) who also visited their homes. Sue described how she reinforced trust and empowerment by telling her clients, “This is about you and I’m walking alongside this path with you, I’m not going to make decisions for you.” Sue expressed that reinforcing empowerment was an essential part of counseling in rural, poor communities because clients often felt as if their power has been taken away.

Other participants shared that many of their clients came to counseling sessions without their basic needs met (e.g., food, housing, and safety) and that a solid counseling relationship allowed for more trust and openness. In return, participants expressed that clients were more willing to express their need for basic necessities without feeling ashamed, and that they often altered their services to assist clients in ascertaining immediate resources. For example, Heather noted that the poverty level was so low in her community that many of her youth clients’ basic needs were not being met and they would ask her to stop and purchase them meals. Heather disclosed that she often responded by stating, “Okay, we’re going to have to change where we’re providing therapy today, or maybe how therapy’s going to look today” to accommodate their needs. Similarly, Sadie shared, “It’s hard to see your clients going without things that you would consider basic.” Sadie described circumstances in which she arranged for food to be dropped off to the school and picked up by her clients.

Che and eight other participants acknowledged that having strong counseling relationships with clients living in rural poverty increased their willingness to extend their services beyond traditional counseling roles and settings. The participants described various cases in which they assisted clients in securing food or housing, or navigating Medicaid and other entities. For example, Che shared that she attended a mental health disability hearing with her client in which she was allowed to speak on the behalf of a client who experienced severe social anxiety. Additional participants described ways they broadened their roles to include consulting and case management and provided examples of ways they altered counseling sessions (e.g., including children because clients had no childcare) or offered incentives for attendance (e.g., bus passes and toiletries) to support clients’ continuity in treatment as well as using these as a means to help meet clients’ imminent needs. Overall, participants conveyed that their counseling relationships allowed for trust and flexibility that enabled them to use ancillary skills and knowledge when working in rural, persistently poor communities, such as skills in crisis management or intentionally building resource networks with medical professionals, churches, social service providers, law enforcement, and community organizations to help meet clients’ basic needs.


Engaging in Individual and Systems Advocacy

All participants reported engaging in various individual and systems advocacy interventions when working in rural, impoverished communities. Participants shared that engaging in advocacy was necessary, ranging from their initial sessions with their clients until termination and follow-up. George shared that he started advocacy initiatives in the initial assessment by “not jumping to assumptions” and spending more time observing clients and exploring their history. He stated that he acknowledged if clients were already taking steps toward positive change to encourage self-advocacy. George explained, “I think the most direct thing that I can do is to empower people to recognize their strengths and their rights.” Similarly, Jade shared, “I use motivational interviewing with clients to help them become better advocates for themselves.” Other participants expressed that promoting self-advocacy was vital for this specific population because of the high probability that a client would not return to counseling because of barriers related to transportation, finances, and stigma. Seven participants shared that it is important to have personal knowledge of systems that affect the client in order to inform advocacy interventions. Renee mentioned, “With all the Medicaid changes . . . I’ve got to take every client into a financial conversation. . . . So keeping myself educated . . . I can be a voice of support to them and have an understanding if they come to me.”

Additionally, participants reported various situations in which they engaged in advocacy interventions outside of the office setting. Two participants shared that they engaged in advocacy with and on behalf of clients to help them navigate the criminal justice system. For example, Jade advocated on behalf of a teenage client to law enforcement officials to request the removal of her client’s ankle monitor, which she believed was not necessary. Heather shared that she wrote letters to the courts on behalf of her clients.

Participants also discussed their involvement with helping clients sustain housing. Che shared, “I’ve spoken up for my clients against landlords who were trying to railroad several of my clients with their rent, and one in particular was trying to charge my client double the rent.” Similarly, Jade shared, “I was able to advocate to my supervisors to get funds to help pay the past bills so [clients] could move into a new location and not lose housing.”

Four participants conducted trainings in schools and within the community to inform others of culturally responsive practices with people living in rural poverty. Sadie shared that she provided educational workshops to school counselors, administrators, and teachers to help them understand the life experiences of individuals and families living in rural poverty. Sadie explained that she educated her colleagues on the effects of generational poverty and helped them to explore ways they could use various educational strategies for clients in these circumstances. Overall, counselors recognized clients’ needs and engaged in an array of advocacy interventions individually with clients, as well as in the community to support clients’ continuation in treatment, link clients to services, or help clients allocate resources in rural, poor communities.


Utilizing Professional Support

Some participants (n = 6) were the only mental health providers in the communities in which they worked. Thus, they spoke of instances of feeling frustrated because of the lack of resources for clients, role overload, and inability to connect with other counselors. Participants expressed that support from other professionals in the behavioral health field was helpful to alleviate frustrations. With this awareness, participants shared that conversations, consultations, and formalized supervision sessions were useful to explore their biases and feelings of hopelessness, to address compassion fatigue, and to learn new clinical interventions. For example, Blaze shared that formalized supervision was beneficial to increase his knowledge and improve his attitude about working in rural, impoverished communities. He stated, “The people who have supervised me understand that I’m coming from a different area and this is all kind of a learning curve. They’ve been good about helping me acclimate to the area.” Similarly, eight participants shared that ongoing supervision was helpful to abate adopting negative stereotypes and to address de-sensitization to clients’ needs, particularly when seeing clients who perpetually faced hardships. Lola discussed the benefits of having a professional support system among her colleagues to manage the demands of counseling in rural poverty. She stated, “We support each other personally when professional issues begin to impact our personal lives.” Furthermore, Lola described that ongoing supervision was “very helpful and necessary” as it provided her the opportunity to “check in” with herself and assess how she was managing the demands of her work.

Seven participants shared that receiving professional support reinforced ongoing self-awareness. For example, Sadie stated, “I think [it’s important] being willing to recognize that I’m not perfect . . . being willing to say here’s a place where I need to improve.” Sadie also expressed that it was important for her to seek supervision or personal mental health services to not allow her personal frustrations to “bleed over” into her client sessions. Likewise, Jade explained that supervision and taking continuing education credits regarding cultural differences were optimal to her success. In alignment with the constructs in the MSJCCs, the participants acknowledged the importance of engaging in critical self-reflection to take an inventory of their skills, beliefs, and attitudes (Ratts et al., 2016) that impact the services they provided to marginalized clients living in rural poverty. Overall, seeking ongoing supervision and engaging in professional development activities were necessary to prevent adopting stereotypes and to continue advocacy efforts.

Using participants’ voices and the lens of the MSJCCs, we illuminated the essence of providing mental health counseling in rural, persistently poor communities. The participants described the importance of showing an appreciation for clients’ worldviews and life experiences and how their counseling services encompassed varied approaches to service delivery and non-traditional counseling methods to engage rural, impoverished clients in the treatment process. Participants frequently engaged in individual and systems advocacy with and on behalf of their clients and described how having professional support was necessary to provide culturally responsive mental health counseling in rural, persistently poor communities. The findings serve as the basis for the following discussion.



This study explored the experiences of mental health counselors working in rural, impoverished communities and identified ways counselors incorporated social justice advocacy using the lens of the MSJCCs to identify advocacy skills and interventions. We found that counselors who work with clients in rural poverty appreciate their clients’ worldviews and life experiences, value their counseling relationships, alter service delivery formats, engage in advocacy, and seek ongoing professional support and development opportunities. Specifically, the first theme captured how counselors in the study expressed an appreciation for their clients’ worldviews and life experiences, as described in the MSJCCs’ client worldview domain. Counselors recognized that various contextual factors, such as family structure, nuances in the natural support systems, less access to resources, as well as how race and social class status shaped their clients’ worldviews, influenced their utilization of mental health treatment. This finding lends support to previous literature associated with examining how economic disadvantages and rurality influence mental health care services and literacy (Deen & Bridges, 2011; Kim & Cardemil, 2012). Consistent with the MSJCCs’ (Ratts et al., 2015) client worldview domain, the counselors explored and appreciated clients’ history and life experiences, and acknowledged the clients’ “resourcefulness” as a strength.

Furthermore, counselors in the study expressed a willingness to engage in their clients’ personal communities, which aligns with the suggestion in the client worldview domain that counselors should immerse themselves in the communities in which they work to learn from and about their clients (Ratts et al., 2015). The findings from the study correspond to previous research that examines how counselors with increased exposure to individuals living in poverty have enhanced multicultural competence and are able to critically examine systemic or structural factors that contribute to the underutilization of mental health services in high-poverty communities (Clark et al., 2017).

The second theme, counseling relationships influencing service delivery, reflected the MSJCCs’ counseling relationship domain. Participants recognized that their clients’ ability to engage in the traditional therapeutic process was often thwarted because many of their clients’ basic needs were not met. As implied in the counseling relationship domain, counselors are advised to utilize culturally competent assessment and analytical and cross-cultural communication skills that allow them to effectively determine clients’ needs and employ collaborative, action-oriented strategies to strengthen the counseling relationship (Ratts et al., 2015).

Reflective of this domain, counselors in the study often altered service delivery formats and assumed alternative roles to meet clients’ needs. The current findings offer support for research that advances increasing flexibility in counseling roles and culturally competent assessments when working in marginalized communities (Fifield & Oliver, 2016).

Another distinctive finding of this study was encompassed in the third theme, which captured the MSJCCs’ counseling and advocacy interventions domain, and illuminated the participants’ use of strategies to promote continuation of services (e.g., home-based counseling, group formats with the inclusion of childcare, and distributing incentives) as well as advocacy interventions to address clients’ imminent needs. Expanding previous research that illuminated the role of self-advocacy (Singh, Meng, & Hansen, 2013), the participants expressed the importance of engaging in intrapersonal, interpersonal, and institutional advocacy interventions with and on behalf of clients, such as assisting clients in securing or maintaining housing, acquiring supportive educational resources in school settings, rebuilding familial relationships, and preventing the criminalization of poverty. Although these findings are similar to previous researchers’ perspectives that suggest that counseling in rural poverty requires counselors to engage in various advocacy roles (Kim & Cardemil, 2012; Reed & Smith, 2014), this study answers the call to provide practical examples of incorporating social justice advocacy into counseling with historically marginalized populations (Ratts & Greenleaf, 2018).

The final theme identified in our study involved the participants’ use of professional support networks and seeking professional development opportunities to address areas of professional incompetence. Accordingly, this theme aligns with aspects in the MSJCCs’ self-awareness domain. As articulated in this domain, multiculturally competent counselors are expected to have an awareness of their social group statuses, power, privilege, and oppression, as well as acknowledge how their biases, attitudes, strengths, and limitations may influence clients’ well-being (Ratts et al., 2015). The counselors in our study engaged in both informal and formal action-oriented strategies, such as consultations and ongoing supervision with other mental health professionals, that helped them examine prejudicial beliefs, prevent the development of additional biases, and explore other areas of vulnerability and skills deficiencies as designated in the MSJCCs’ counselor self-awareness domain. This finding supports past research (Bowen & Caron, 2016; Reed & Smith, 2014) that indicated that because of the limited resources and remoteness in rural, impoverished areas, professional support is vital to assuage frustrations because of consistently seeing poor, rural clients navigate difficult life circumstances. However, this finding expands current understanding by focusing on the counselors’ ability to identify their own limitations and readily seek out additional supports.


Implications for Counseling Practice, Advocacy, and Training

Foremost, in order to offer culturally competent mental health counseling, it is important for counselors to appreciate their clients’ worldviews and life experiences and understand the unique oppressions that clients from rural, impoverished communities experience. For example, participants acknowledged that various contextual factors, such as family structure, mental illness stigma, and nuances in the natural support systems, shaped their clients’ worldviews and influenced their utilization of mental health treatment. Viewing clients’ concerns from a socioecological lens may strengthen the counselor–client relationship (Ratts et al., 2016) and decrease stigma related to mental health treatment (Stewart et al., 2015).

Counselors also must be flexible and recognize that altering the format of session delivery is often necessary to engage with clients in rural poverty. Individuals living in rural poverty face immense financial barriers that impede the utilization of mental health treatment (e.g., transportation issues), and there is a general lack of awareness about mental illness in rural, poor communities (Haynes et al., 2017). Thus, counseling in rural poverty should extend beyond office-bound interventions to include community-based interventions (Ratts & Greenleaf, 2018) and account for barriers that influence treatment utilization. For instance, the findings indicated that participants had a greater appreciation for clients’ worldviews and expanded their roles to include consulting, advocacy, and case management when they became more engaged in their clients’ personal environment and community.

Furthermore, counselors in this study collaborated with and on behalf of clients in advocacy efforts in various areas such as housing, criminal justice, social services, and school systems. Engaging in individual- and systems-level advocacy interventions (Ratts et al., 2016) when working in rural, impoverished communities is vital to promote equity and positive systemic changes (Reed & Smith, 2014). Given these findings, counselors should become comfortable with professionals in these areas as well as going into the respective environments. Thus, it warrants counselors to network with community partners, schools, faith communities, and law enforcement entities to establish relationships to enhance support networks. In addition, writing letters to federal and state legislators regarding national issues such as Medicaid funding is critical to address policies that benefit rural, impoverished communities.

Finally, multicultural and social justice competence is a developmental process, and professional counselors as well as counselors-in-training need opportunities for ongoing self-reflection to examine their personal assumptions and biases and enhance their skills when working with rural, impoverished communities. Clinical supervision grounded in a social justice framework can help counselors and supervisors process their biases and assumptions, develop a social justice lens of understanding clients from rural poverty, and cultivate advocacy skills (Smith et al., 2013). The MSJCCs should be facilitated throughout counseling program curricula versus one foundation course in multicultural counseling and development. Some possibilities for incorporating the MSJCCs into student learning across all courses include experiential activities, group work, and role-plays that cover topics such as worldviews, intersecting identities, power, privilege, and social class. For example, audiovisual materials found on the Rural Health Information Hub website (www.ruralhealthinfo.org) can help students visualize the experiences of rural and impoverished communities. Additionally, encouraging or requiring counselors-in-training to engage in rural, economically disadvantaged communities for their practicum and internship experiences can be incorporated into the clinical sequence in counselor preparation programs


Recommendations for Future Research

There are several pathways to advance research pertaining to mental health counseling and social justice advocacy in rural poverty. Rural, impoverished areas continue to experience low mental health literacy, which perpetuates stigma. Thus, investigations about stigma in rural poverty can provide insights into the underutilization of mental health treatment in rural communities. Research of various designs regarding the lived experiences of poor women, men, and children in rural communities can inform culturally responsive counseling practices. For example, empirical studies about the experiences of grandparents raising grandchildren in rural poverty can offer unique perspectives for ways to enhance mental health literacy and increase utilization of mental health services. Additional studies are also needed to explore social justice advocacy interventions that are necessary to test the efficacy of the MSJCCs.

Finally, a primary limitation of this study was that the participants had varied professional license levels, areas of specialization, years of professional experience, and provided counseling services to diverse clientele in various settings. The data in the current study did not allow us to assess if variances in the noted areas had a differential impact on the participants’ counseling experiences in rural poverty. Consequently, additional qualitative studies that allow researchers to examine these differences more pointedly are needed to fully understand the experiences of counselors from varied backgrounds and experience levels. Furthermore, readers should exercise caution when generalizing the experiences of the 15 participants in this sample to other counselors working in rural, impoverished communities. The experiences of participants in this sample may not capture the experiences of all counselors working in these communities; however, readers can make decisions regarding the degree to which the findings of the study are applicable to the settings in which they live and work (Hays & Singh, 2012).



Poverty significantly impacts the mental health of children and adults living in rural communities, resulting in having limited access to resources and services that can promote healthy development and well-being. Therefore, mental health counselors working in rural, poor communities must often incorporate social justice advocacy within the context of clients’ experiences of oppression in their counseling practices to provide culturally responsive services. The MSJCCs provided a lens to explore the knowledge, skills, beliefs, and overall practices of 15 professional counselors working in rural, impoverished communities. By examining the experiences of these counselors, we identified how counseling professionals working in rural, impoverished communities acknowledged and appreciated their clients’ worldviews and life experiences, created strong therapeutic alliances, altered counseling service delivery, engaged in advocacy, and sought professional support to sustain their ability to provide culturally responsive counseling services. Multiculturally competent counselors should continually explore ways to amend their current practices to address the various sociocultural barriers that impede the mental health and well-being of rural, poor children and adults. It is our hope that counselors will utilize the findings from this study to further the discourse on rural poverty and create positive change in these communities.


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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Loni Crumb is an assistant professor at East Carolina University. Natoya Haskins is an associate professor at the College of William and Mary. Shanita Brown is an instructor at East Carolina University. Correspondence can be addressed to Loni Crumb, 213B Ragsdale Hall, Mail Stop: 121, Greenville, NC 27858, crumbL15@ecu.edu.