Based on 2010 U.S. Census data, over 80 percent of the land mass of the United States is considered rural or frontier, with only 20 percent of the US population residing within that vast area.[1] Rural and frontier America comprises a diverse mix of communities, from those outside major urban and suburban regions with relatively easy access via major highways to the services and infrastructure of these metropolitan communities, to truly remote and frontier regions where fewer than six people per square mile reside and where the nearest city may be hours away by car.  The majority of true frontier regions are in the thirteen states served by WRCAC.[2]

Children residing in rural and frontier America share many of the same risk factors for abuse and neglect faced by children in more populated communities, but distance and isolation, higher poverty levels, fewer community services, and higher rates of substance abuse may place them at increased risk of maltreatment and associated traumatic stress. In fact, the Children’s Bureau indicates rural children have a higher incidence of reported child abuse and neglect, with one study (Sedlak, 2010) demonstrating a 1.7 times higher rate of reported maltreatment than their urban counterparts. 

CACs serve as a multidisciplinary hub for communities to determine the facts surrounding allegations of child abuse and, at the same time, help children recover and heal from the abusive events they have experienced.  For many children, their recovery will require access to skilled, well-trained mental health clinicians. However, while 20 percent of the population lives in rural communities, 65 percent of rural counties lack a single psychiatrist, 47 percent lack even one psychologist,[3] and the 20 percent of licensed social workers who live outside of urban regions are concentrated in areas just outside the urban centers, leaving very few licensed mental health providers to serve rural and frontier communities.

[1] https://nosorh.org/about-rural-health-in-america/

[2] The states included in the Western Region are Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington and Wyoming.

[3] Andrilla, C. H. A., Patterson, D. G., Garberson, L. A., Coulthard, C., & Larson, E. H. (2018). Geographic variation in the supply of selected behavioral health providers. American journal of preventive medicine, 54(6), S199-S207.

Access to services is a common barrier shared by mental health providers in communities large and small.  Families living ten miles from a service delivery site in a metropolitan area may have to change buses several times to reach their provider’s office, even in a community with decent public transportation.  Access problems are amplified in rural and frontier communities where there may be no public transportation and where the distance to the service site may be measured in hours and made impossible in the height of winter weather. In Alaska, for example, the Department of Transportation and Public Facilities reports that 82 percent of communities are inaccessible by roads, leaving airplanes as the only way to reach the service delivery site, with flights being routinely grounded by severe weather.

Issues of stigma and resistance to mental health services also take on new meaning in communities where everyone literally knows everyone else.  Confidentiality is difficult when families fear that merely being seen walking into a therapist’s building will lead to gossip about why the family needs mental health treatment.  Parental resistance to seeking mental health assistance can be further complicated by parental pride and a culture of fierce self-reliance that characterizes some rural communities and where even children are expected to stand on their own without government or professional assistance. 

Rural and frontier communities must also take unique cultural factors into consideration in any meaningful response to the trauma needs of abused children and their families.  A significant percentage of American Indian and Alaskan Native families reside in the Western and Midwestern states, and it is not uncommon for families in rural communities in the West to speak Spanish at home and require services in their native language.  The overlay of historical trauma can impede trust in professionals from outside the culture. Finally, suspicions about the long-term reliability of well-meaning but naive outsiders, who often have not stayed past their first winter, increases skepticism.

All mental health clinicians face challenges in their work, including overcoming community stigma associated with seeking mental health treatment, parental denial and resistance to seeking and following through with treatment, obstacles to workforce recruitment and retention, and language barriers.  While these barriers prevail in nearly every community, they present themselves in unique and challenging ways in rural and frontier settings.  Unlike their urban colleagues who can choose to specialize in specific areas of practice, such as trauma treatment, mental health providers in rural and frontier communities often are generalists who see patients across the lifespan and respond to everything from learning disabilities to severe mental illness.  Trauma treatment is just one of the issues they must address, making it harder, if not impossible, to master all the evidence-based treatments needed by their diverse clientele.  Issues of workforce recruitment and retention take on different meaning when only a handful of providers live in the community and new providers moving from outside the community, unaccustomed to rural life, the relative physical and social isolation, and limited resources, may soon seek employment elsewhere, creating the next vacancy.  In some rural communities, there are extreme shortages of housing, so even when a provider is successfully recruited, there may not be a place to live locally and they must commute long distances to the service delivery site, adding to burnout.

For abused and neglected children, CACs may hold the best hope for healing and recovery.  All accredited CACs must provide an array of mental health services, either directly through CAC-employed therapists or via a linkage agreement with another community mental health provider who meets the NCA standards for accreditation. Meeting accreditation standards is difficult.  The traditional path of recruiting and retaining strong professionals, training them well in the appropriate evidence-based treatments (EBTs), specializing their caseload so they use the EBT frequently enough to excel in its delivery, and providing effective clinical supervision  may not fit with the reality of service delivery in rural and frontier communities. With few mental health providers, turnover among providers, and the general and very diverse caseloads common in rural areas, it is difficult to achieve competency in the needed EBTs.

A high-quality response to child traumatic stress requires the availability of adequate numbers of experienced, highly trained, skilled mental health clinicians who are competent in standardized assessment techniques and have the capacity to deliver multiple EBTs with fidelity, such as those identified as effective on the California Evidence-Based Clearinghouse (www.cebc4cw.org).  To achieve this level of experience and training, it is vital that the mental health provider’s organization can offer strong clinical supervision, support the therapist with the infrastructure necessary to serve the complex needs of families, and address the inevitable secondary traumatic stress they will be exposed to in the course of their work.  

To address these challenges and support rural and frontier CACs in meeting the mental health needs of traumatized children and their families, the WRCAC has convened a forum of experts, including representatives of CACs in rural and frontier communities; state, regional and national partner agencies in the CAC field; experts on mental health treatment; experts in related fields such as policy, technology and licensing; and researchers actively testing innovative models that go beyond traditional in-person therapy with licensed mental health providers.

In addition to identifying a number of common challenges, the group explored innovative strategies to increase access to effective mental health services and generated a number of action items that have the potential to change the landscape of trauma mental health in rural and frontier communities for the better.  The WRCAC is developing materials and strategies from these action items.