Center for Rural Psychology: Training Philosophy

 

The primary mission of the Center for Rural Psychology is to train Christian mental health professionals with the unique skills and knowledge needed to effectively serve in rural communities. Such unique training requires a unique model. The following points will provide the framework for training CRP students. Such a unique model requires that CRP clinical staff have direct management of the training and that students be directly exposed to practice that is guided by this model. In other words, CRP students' training must be "hands on" and not in theory only. Their training may not be provided exclusively at sites that are operated under more traditional urban and suburban models or in which they have no exposure to rural populations.

 The Center for Rural Psychology was founded in part because students who enter graduate school with the dream of serving rural communities often leave graduate school only to settle in the suburbs where they were trained. By keeping these students focused on their original goals and providing them practical examples of people who have met those goals CRP serves its primary mission.

Heartland Counseling was developed around the following principles. Admittedly this model was developed haphazardly and is continually evolving. The link between CRP and Heartland Counseling, however, has been important because students need a place to be directly mentored by clinicians who are practicing the CRP model. It is not enough to simply inspire students to work in rural communities without providing practical experience to support it.

 

I.              Christian

Rural Communities often revolve around church communities. It is difficult, if not impossible, for a mental health professional to successfully serve a rural community without first engendering the trust of the clergy of that community. It is important to maintain trust with as many of the clergy as possible rather than becoming identified as "sectarian."

It is central to the CRP mission to provide training and service that is thoroughly grounded in the Christian faith. This mission helps CRP in developing the trust of communities we seek to serve. More importantly, however, it provides students with the grounding in practice that is thoroughly integrated with their faith and will serve communities whose life revolves around faith communities.

 

II.            "Down to Earth"

Rural communities are generally skewed toward the lower end of the socio-economic scale. While the values in the suburbs often seem oriented toward keeping up the appearance of wealth and success rural folks often look down on those who seem to think they are "better" than others. While professionals are respected for their training and the service that they provide they are often not fully accepted if they evidence a significantly different lifestyle from the norm.

Rural values emphasize independence and self-sufficiency. They deemphasize the kind of values that are often associated with psychotherapy. While the roles of psychological assessment and treatment of severe mental illness will generally be welcomed, the role of therapist/counselor may not. As one rural man put it "I'd rather have my car seen in front of the motel than in front of the psychologist's office." The clinician's office or clinic should be welcoming and not austere. A rural practitioner should be willing to flex the "boundaries" of the office and seek creative ways to help people feel comfortable with the relationship.

 

III.         "Owned" by the Community

In the same way that rural communities value self-sufficiency they will be distrustful of those who are perceived to be making money from the misfortune of others. This, coupled with the fact that rural populations are chronically underinsured, suggests that a not-for-profit agency will be welcomed more easily than a private practice. NFP status also requires greater ownership by the community and gives it an opportunity to rally around those in need of psychological services.

The agency should be governed by key gatekeepers who are known and trusted within the community.

IV.          Community Oriented

A rural practitioner needs to adopt a community psychology model rather than a private practice model. Ultimately the community is the client and a psychologist's livelihood will rise and fall with the perception he or she builds in the community as a whole rather than with individual referral sources.

 

A.      School Needs

Many of a rural community's needs will be experienced at the level of the schools. Just as churches provide one anchor for rural life the school provides another. A collaborative relationship needs to be maintained with school personnel. A rural practitioner should seek to respond to crises in the schools if allowed by school administrators.

 

B.       Churches

Collaboration with clergy is essential for the rural practitioner. Support should be offered to clergy in their role as counselors to their members. Support from clergy should also be sought when working with their parishioners. Release should be sought from clients to collaborate with their pastor for more complete care.

Churches will also be a frequent "client" for a rural psychologist. Some churches will see wisdom in helping to pay for the services of parishioners. Office space may also be provided in church facilities (though caution should be used not to be to closely identified with one church). Churches will seek the services of a psychologist for workshops and consultation.

 

C.      Sliding Scale Services

It is important to provide some form of sliding-scale services in rural settings. It is better to seek creative sources for supporting such services, or even to take some loss on such services, than to be perceived as turning people away for financial reasons alone.

 

D.      Needs Assessment

It is important to enlist the help of gatekeepers in the community to perform a needs assessment. Such a survey should be as complete as possible and should be initiated from within the community as much as possible.

 

E.       Education

One of the key roles of a community psychologist is to promote mental health education within the community. Primary and secondary prevention roles are served by giving educational workshops, organizing support groups for at-risk populations, and speaking out on relevant issues in the community. Workshops for law enforcement, hospital and nursing home staff, bank loan officers, and many other creative groups help both to promote healthy understanding and to build trust with those who may seek or recommend your services.

 

V.            Confidentiality and Dual Roles

Confidentiality is the cornerstone of ethical mental health practice. Rural practice, however, introduces challenges and variations to confidentiality that a rural practitioner must anticipate. For example, merely parking in front of a psychologist's office will broadcast one's presence. For this reason and others it is best to have one's office in a place where people could have many reasons to visit. A doctor's complex or a hospital could serve this need well. It may actually be helpful to have more than one office in a town. For example a church may donate the use of an office during the week for those who would be more comfortable going there.

Regardless of the best efforts people will run into neighbors in the waiting room. It is important to disclose to people up front, as part of the initial informed consent, that their identity can't be completely protected and that they should respect the privacy of others and that you request others to respect theirs. Ultimately, if the risk seems to great to someone and they refuse to come to your office one might need to make house calls in an emergency, or at least to establish a relationship and work out something more manageable, (e.g. "could we borrow your pastor's office once a week?").

Similarly, the life of a mental health professional is very complicated in a small town. It is virtually impossible to avoid dual relationships in such a setting. If one refused to work with those with which one had a dual relationship their would be few clients left. This topic deserves a great deal of thought and preparation, more than can be summarized in a paragraph. (There are good publications on this matter.) One should be prepared, however, for the limitations one must accept on an already limited personal sphere and for the complications raised by either accepting to enter into dual relationships or by refusing to do so.

 

VI.          Collaboration with Physicians

It is difficult to imagine surviving in a rural practice without close collaboration with the medical staff that serve the same community. In many rural areas this includes physicians assistants and nurses since many communities are not served by a full time physician. Rural physicians see a significant number of referrals for primarily psychological issues and are in a place of trust and authority to make a recommendation that a patient seek psychological services. Likewise, a rural psychologist will need a place to refer patients who need psychotropic medications. There are virtually no psychiatrists in rural settings so general practitioners must see such referrals, at least initially. It is wise for a rural psychologist to seek training in psychotropic medication and remain current on such issues in order to be able to collaborate more effectively with physicians in decisions about medication.

 

VII.       Multiple Funding Sources

The typical urban or suburban private practice survives on close relationships with referral sources and the ability to take third-party reimbursement (i.e. insurance, managed care, etc.). Rural practices are quite different. Though many clients will have health insurance that covers psychological services a large percentage will not. It is important that one not depend on this source alone. Even if a community is large enough that a therapist could serve only those clients with health insurance coverage such a practice would defeat the community psychology model that is being proposed. Other sources of funding need to be sought to provide for sliding-scale services. The practitioner will need to enlist the help of people in the community, preferably on the board of the agency, who can seek local, state, and federal funds to assist in programs.

 

A.      Community Responsibility

The community should also be enlisted to assist in support of mental health services. In the first community with which CRP consulted the local hospital provided free office space and secretarial support for a counselor since the need was so great. Pastors in the community had made similar offers of their facilities.

 

B.       Loan Repayment Programs

One effort that can help to attract new mental health professionals to rural areas is found in government assistance programs that pay portions of graduate school debt for service in underserved areas. Local hospitals or medical professionals have often done the initial application and documentation for such programs so, again, a collaborative relationship with other professionals will be very helpful. This is one area that CRP can provide assistance to students who have done their training with us.

 

VIII.     Empowering the Community

A community mental health model does not focus only on the needs of individuals, or families. A rural practitioner cannot seek to be the primary resource for help within the community. The community can be empowered to meet many needs more effectively and utilize resources that are already present but not fully recognized. In CRP's pilot project of community consultation the simple act of bringing gatekeepers together in the community brought many resources to light that were simply not being effectively utilized.

 

A.      Natural Helper Training

Research has consistently shown that for the majority of life stressors that bring people to counseling, a lay counselor can be just as effective as a professional. Identifying and equipping natural helpers within the community is one of the most effective uses of a professional's time and training. Churches are especially motivated to provide lay-counselor training as ministry to the community. Rural psychologists can play an effective role in training and supervising such programs and can bridge the gap between churches or individuals that might not usually be found cooperating on such a project.

One of the goals of CRP is to develop a model for such a training program that can then be utilized wherever CRP interns go to practice.

 

B.       Gatekeeper Consultation

It is impossible to overemphasize the importance of building and maintaining relationships with gatekeepers in the rural community. The community psychology concept of gatekeepers is very helpful. These are the individuals who hold the keys to the community. They are often not highly visible individuals but they can make or break the effectiveness of a professional. The trust of a key gatekeeper will put a professional years ahead in being accepted within the community. Likewise, being rejected by a gatekeeper can completely sabotage one's practice. There is little anonymity in a rural community and one must guard one's reputation. Character counts far more in such settings than credentials.

 

IX.          Students as Partners

In the CRP model, students are collaborative partners. Since we hope that some of our students will go out to practice in rural communities it is important that they be allowed to participate fully in the day-to-day operations of a rural practice. Bigger private practices have employees who do paperwork, billing, insurance verification, janitorial work, etc. The typical rural practice will involve the psychologist either performing all of these roles or training someone else to do them.

 

A.      Training in business issues

Students need to be involved in the business side of practice. They need to see how marketing is done, how billing is done, how to establish a budget and make decisions about providing free or discounted services. To be prepared for the entrepreneurial aspects of rural practice students must have first hand experience with all aspects of such practice.

CRP should seek funding to provide start-up grants and assistance to CRP graduates who wish to establish a practice in a rural area.

 

B.       Grounded in Immigrant and Migrant Communities

Students trained by CRP should have experience in both immigrant and migrant communities. Since Heartland Counseling can only provide experience in the former it is important to raise funding to involve students in active service to migrant communities. The pilot project in Montana provides one such experience and priority should go to reestablishing such outreach efforts.