By Dr Louise Roufeil FAPS, Kristine Battye Consulting, Bathurst, NSW and Anne Lipzker MAPS, Coordinator, Child and Adolescent Mental Health, North Coast Area Health Service, NSW
Dr Louise Roufeil was Program Director at the NSW Central West Division of General Practice for four years where she managed an innovative rural and remote psychology service. She is currently a consultant psychologist providing primary health care planning and evaluation services to rural and remote Australia. Anne Lipzker has been involved in rural public sector psychology practice for the last sixteen years, specifically in the Child & Family and Mental Health Programs. As Regional Psychology Advisor for about ten years, she also participated with other rural and metrotropolitan senior psychologists across the government sector in the NSW Statewide Psychologists Forum.
Psychology has been described as an urban-centric profession. The majority of the Australian population reside in large metropolitan centres where the bulk of universities, research centres, hospitals, and large organisations can be found. Both the training and practice of psychology largely happen in capital cities and to a lesser extent in sizeable regional centres. Moreover, the vast majority of our knowledge base is derived from research with samples of individuals who reside in urban locations. This urban focus may be beginning to change. The rural crisis that has developed over the last decade and destroyed the economic foundations of many rural communities has resulted in increased attention being given to rural issues by governments and policy makers. The impact of drought on the mental health of people living in rural and remote communities has focused popular attention on the plight of farmers and resulted in the implementation of various support programs by State and Federal Governments. Psychologists also appear to be showing greater attention to rural issues, although the limited amount of psychological services delivered in rural and remote regions remains a central issue that will be explored in more detail in this article.
The developing interest of the profession in rural issues is to be welcomed given the fact that while Australians are overwhelmingly urban creatures, a surprisingly large percentage of our population (34%) reside in rural and remote regions (AIHW, 2006). The Australian Institute of Health and Welfare define rural and remote as living outside cities with populations greater than 250,000 although there are a number of definitions and methods of categorising rurality. The critical point is that while some general patterns can be seen in rural communities according to distance from services, there is considerable variation within each broad geographical area. As many rural people will be quick to tell you “If you have seen one country town, you have seen only one country town”.
In this article, we set out to explore the issues and challenges in the delivery of psychology services in rural and remote Australia. Despite our own intimate knowledge of service delivery in the mental health sector in rural regions, our goal was to look at all domains of psychological services. However, the literature remains scant outside the mental health arena, although the rural psychology workforce also provides significant and valued services in the education, occupational and rehabilitation health sectors. These services, like those in the mental health sector, generally have a focus on some aspect of the psychological distress/wellbeing of individual clients. There is very little representation of organisational psychology or of specialised sectors such as forensic or neuropsychology. Thus, we acknowledge the limited focus of the evidence we present in this article but would argue that many of the issues we raise have relevance to all domains of psychological practice given that many of the challenges of rural practice are clearly related to obvious isolation issues.
Despite the positive marketing associated with the so called ‘tree change’ and ‘sea change’, the health of rural people does not appear to be particularly positive. People living in rural and remote communities generally score lower on various health indices and display higher disability and mortality rates than their urban counterparts (AIHW, 2006). Rural people are more likely to smoke, drink to risky levels, be overweight, inactive, have lower education and lower income, have less access to work, be employed in dangerous jobs and face increased risk of car accidents due to their extensive travelling. The poor health status of rural people may also reflect the high incidence of Indigenous people residing in rural regions. There is consistent evidence that the health of Indigenous people is significantly poorer than the non-Indigenous population (AIHW, 2006). Moreover, Indigenous Australians have higher rates of serious mental disorders and mental health problems, with this rate being highest for thosewho live in rural and remote regions (Hunter, 2007).
The recent drought has drawn considerable attention to the mental health of rural Australians. However, there are mixed findings with regard to the question as to whether or not rurality is a critical factor in the incidence of psychological problems. These mixed findings may, in part, be explained by the strong evidence that rural people are less likely to seek help for psychological problems and lack accessible services if they do choose to seek help.
Rural populations face numerous stressors. Financial stressors and unemployment have been particularly evident during the recent drought. It is important to note the unpredictable nature of many rural stressors. Farmers and industries supplying the farming community can be at the mercy of unpredictable events such as the weather, government regulations, machinery breakdowns, and farming accidents. Other stressors include a lack of leisure time, long hours, difficulty for couples in balancing roles, exposure to toxic chemicals, working with dangerous machinery and coping with new legislation. Moreover, it seems farmers cope with these issues in the context of lack of understanding by non-rural people and media criticism.
On a number of levels, it would appear that psychologists have a variety of skills that could be of particular benefit to people living in rural and remote Australia. Rural populations, in general, experience both significant physical and mental health issues, a situation that is made increasingly complex by high levels of risky health behaviours and multiple psychosocial vulnerabilities. The Indigenous population experiences these challenges to an even greater extent than the non-Indigenous population. Other groups in rural Australia that are particularly vulnerable are the elderly for whom transport and specialist services are scarce, and adolescents who struggle to find their place in a rural environment that appears to offer them little for their future. Despite this high level of need most rural and remote communities have very limited access to psychology services.
In terms of psychologists working in the health field, 20.5 per cent of psychologists were reported in the National Allied Health Workforce Report (2003; cited in NRHA, 2004, p.8) as working in rural and remote regions. This equates to between 0.83 psychologists per 10,000 head of population in very remote areas to 3.44 in inner regional centres, compared to 5.92 psychologists per 10,000 head of population in major capital cities. The rural sector tended to attract the youngest and hence least experienced health professionals. Although data is scarce, there would appear to be few Indigenous people working as psychologists, regardless of whether or not they are located in rural and remote regions.
The health-oriented psychology services that exist in rural and remote regions of Australia operate using mainstream treatment approaches and are largely supplied through State health departments often outreaching from central hubs in larger regional centres. These are supplemented by some services delivered by non-government and community organisations, often on a shoe string budget and not attracting recurrent funding. Non-government mental health services tend to focus on non-clinical support services. The traditional hub and spoke/ outreach models of care mean that what services do exist are more likely to be found in larger regional centres with services beyond these localities being unreliable or non-existent.
Over the last decade, Federal initiatives such as the More Allied Health Services program and Better Outcomes in Mental Health Care appear to have had a positive impact in at least some rural communities. It is difficult to assess the impact of the Better Access program as Medicare-rebateable services by private practising psychologists only commenced in November 2006. From a recent survey, the Australian Psychological Society notes that around 26 per cent of psychologists currently providing Medicare funded services are outside the metropolitan area and that the majority of psychologists (55%) are bulk billing clients in financial need. This data is encouraging but it nevertheless represents a significant mismatch with the non-metropolitan population (34% of the total population), with the workforce diminishing with increased remoteness. Urgent attention is needed to assess the nature of the rural and remote psychology workforce and the factors that might contribute to future growth.
Internet-based therapeutic programs have been suggested as one solution to the absence of mental health services in rural Australia. A systematic review of two Australian web-based self help and information programs for depression indicated they can be effective in reducing symptomatology and may be particularly useful in rural regions due to the so called ‘self-reliant’ rural culture (Griffiths & Christensen, 2007). Psychologists need to be involved in refining such programs for use in rural regions and in identifying how best to integrate them with face to face care.
The lack of psychology services means that rural communities often do not have a good understanding of what psychologists can offer, thus further contributing to the low rate of helpseeking in rural communities. If people do not know what services a psychologist can provide or when they can be of help, demand for such services will suffer. This issue is especially relevant for the non-mental health domains of psychological practice. Given the media attention to rural mental health, rural populations may increasingly perceive the role of psychologists as limited to the mental health arena with the concomitant stigma that accompanies mental health issues. Research efforts are needed to better understand rural people’s beliefs about the psychology profession followed by a coherent marketing effort.
Dealing with rural people: A unique population?
It has been proposed that people who live in rural communities are somehow unique. A recent study of rural Australian adolescents found some evidence of the stoicism of rural people (Boyd et al., 2007). These young people emphasised the importance of dealing with problems on one’s own: “You can’t be weak in the country you know ... you know you can’t be weak, you can’t have mental illness”. The self-sufficiency thought to be characteristic of rural communities and the strict boundaries on self-disclosure that rural people display (i.e., what is considered ‘family’ is considered private business) can pose problems when issues related to it prevents people seeking help when it is needed. The concept of a ‘rural culture’ raises concerns about stereotyping but an awareness of common belief systems in rural cultures can be critical to successfully working with this population.
The lack of understanding of rural cultures by outsiders presents itself in many ways. Many government-funded programs are developed in urban cultures but translate poorly to rural settings. The growing emphasis in youth mental health programs on co-location of services is a classic example of an urban model that is unlikely to translate well to the ‘bush’; creative, mobile, localised rural solutions will be needed. The Better Outcomes in Mental Health Care initiative, while dramatically improving access to quality psychological interventions for many people, does not yet allow the delivery of interventions by telephone or other electronic means. This is despite the use of electronic technology by psychiatrists to deliver interventions and the increasingly strong evidence base for such interventions.
The generalist rural psychologist
There is considerable pressure on rural psychologists to be generalists as a result of a combination of high demand and lack of a range of skilled service providers. The demands on psychologists may be increased as a result of the lack of specialist and support services commonly seen in metropolitan regions. The lack of broad ranging services in rural communities places pressure on psychologists to provide adequate treatment and tests their ethical imperative to refrain from undertaking work beyond their professional competence. For remote psychologists, many of whom may be in the early stages of their career, it can become an issue of “it’s me or no one!” Training programs need to raise these ethical dilemmas with all students and work with them towards identifying professionally appropriate but realistic ways of managing them. It is sometimes not possible in the bush to avoid such dilemmas, only to manage them through competent supervision and consultation.
The lack of anonymity in country towns is frequently noted. The small size of rural communities impacts on client privacy and can create boundary issues for the psychologist. Concerns about maintaining confidentiality in rural towns are not exclusive to psychologists but there remains considerable stigma attached to a visit to a psychologist. People are simply more likely to know each other in small communities and the psychologist is more likely to meet up with their clients in non-professional situations. The Guidelines for Psychological Practice in Rural and Remote Settings produced by the APS provide direction on how to avoid and/or manage dual relationships. The ‘small town’ issue is not only of concern for clients but also for psychologists as it means there may well be no one available that they can see for their own issues.
Training, professional development and supervision
In recent years there has been significant Federal and State Government response to the rural health workforce shortage. This has focused on educational incentives although these have been largely directed at doctors, nurses and allied health professionals other than psychologists. Similar incentives need to be implemented for both undergraduate and postgraduate psychology training.
The fact that at least some postgraduate courses are offered by distance education is generally seen as positive for rural-based psychologists but the hardships associated with such study are often overlooked. For example, attending residential schools often uses up all holiday leave; there are significant costs associated with organising child care and time off work for residential schools; placements close to home are very rare and further cost is involved in temporarily moving to other locations to complete placements. Many psychologists working in rural regions are doing outreach work and thus have long professional days combined with extensive travel commitments – a situation not conducive to distance education and often a situation poorly understood by the inflexible academic system.
Beyond the requirements of formal training, rural psychologists find it difficult to access professional development, supervision, and professional networking. Despite the advent of electronic technologies that should support easier access to education, the opportunity to participate in locally-based, quality specialist professional development is not yet a reality for most rural psychologists. Opportunities to find a suitable supervisor are limited and reliance on telephone contact can be critical.
Rural psychology departments also need to give consideration to their role in developing a rural psychology knowledge base. Many of the issues confronting rural psychologists have attracted limited research interest. Our rural universities need to see this type of research as strategic core business. They also need to provide support for the research efforts of local psychologists, many of whom are working in isolation and in non-research based cultures. Research-minded psychologists may avoid working in rural areas where they are unable to obtain the support and infrastructure necessary to be research productive.
The real challenge facing rural and remote psychology is developing a sufficiently large, sustainable and diversified workforce that can assist rural communities to recognise their uniqueness and build local solutions to local problems. Building the workforce, however, is only part of the solution. There is a need to raise the awareness of people in rural and
remote communities about the variety of services provided by psychologists so that they actually seek them out. Where people have had little experience of a service, there is not likely to be an understanding of the benefits of the services and hence little demand.
We have emphasised the need to build a rural knowledge base but flagged the dangers inherent in continuing to study the effects of rurality per se. We repeat our point that no two rural communities are alike. Yet much of the literature continues to look for group differences in various constructs between rural and urban communities. As Judd (2006) argues, it may be more fruitful to explore the effect of place as opposed to the more broad construct of rurality. Such an approach could better inform the development of innovative approaches to service delivery that are urgently required. A greater integration of the public and private health system and fund-blending are some examples of ways of providing sustainable rural service delivery (Battye et al., 2006). Ultimately, the solution to the rural health problem may necessitate psychologists considering the ways in which they work and their suitability to the context in which they are working. While our traditional focus on the individual will no doubt always be needed, successfully addressing the health issues of rural Australia is likely to require cross disciplinary practice and a greater emphasis on building resilient communities as well as resilient individuals.
A fully referenced version of this paper is available from the authors.
Australian Institute of Health & Welfare (AIHW) (2006). Australia’s Health 2006. AIHW Cat.no AUS73. Canberra: AIHW.
Battye, K., Hines, J., Ingham, C., & Roufeil, L. (2006). The NSW Central West Allied Health Service Network: A model to increase access to public and private allied health services. Report written for the Australian Government Department of Health and Ageing, Canberra.
Boyd, C., Francis, K., Aisbett, D., Newnham, K., Sewell, J., Dawes, G., & Nurse, S. (2007). Australian rural adolescents’ experiences of accessing psychological help for a mental health problem. Australian Journal of Rural Health, 15, 196-200.
Griffiths, K.M. & Christensen, H. (2007). Internet-based mental health programs: A powerful tool in the rural medical kit. Australian Journal of Rural Health, 15, 81-87.
Hunter, E. (2007). Disadvantage and discontent: A review of issues relevant to the mental health of rural and remote Indigenous Australians. Australian Journal of Rural Health, 15, 88-93.
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