Many rural and remote communities have very limited access to mental health services, especially psychology services. There are a multiplicity of reasons for this limited access including the obvious geographical isolation, plus costs associated with transport (whether the service comes to the client or the client goes to the service), the poor condition of many rural and remote roads and susceptibility to weather conditions, lack of suitable accommodation for psychologists, and the difficulty of recruiting to rural and remote areas. The isolation and nature of many rural communities mitigates against the delivery of the traditional model of psychological care, that is, regular (often weekly) face-to-face service delivery by a psychologist to a client in an office setting. This article documents some of the innovative ways in which services have adapted to the needs of their unique environment and clientele to deliver best practice psychological services to rural and remote Australia, and presents three examples of innovative and sustainable psychological services available in the bush.
Technological advancements have clearly assisted psychologists to get their services to the bush. This has included relying heavily on telephone counselling, but also supplementing face-to-face outreach services with ‘top-ups’ via telephone, videoconferencing, email and other internet-based delivery options. The evidence of the efficacy of some of these mechanisms for delivering psychological treatments is growing, although many working in rural Australia describe a number of barriers to technology becoming the ultimate solution to the tyranny of distance. One of the major barriers cited is the limited access to reliable internet access in many rural and especially remote communities. Other factors mentioned are the level of discomfort felt by both the psychologist (who has rarely been trained in the use of such service delivery mechanisms) and the client. Developing a strong therapeutic alliance can be challenging when you cannot see each others’ non-verbal communication and there is a brief pause between what you and the client are saying. The level of discomfort can be significantly magnified for Aboriginal and Torres Strait Islander clients. Some services have addressed these barriers by alternating traditional face-to-face services with technology-based service delivery (e.g., Saint & Roufeil, 2004) so that there is an opportunity to develop a trusting relationship in person.
Primary health models of care
The importance of quality primary health care for all Australians was recently highlighted by the release of Australia’s first National Primary Health Care Strategy (2010). Primary health care incorporates first-level care with health promotion and prevention and community development. Importantly, primary health care includes the principles of equity, access, empowerment, community self-determination and intersectoral collaboration along with an understanding of the social, economic, cultural and political determinants of health (Keleher, 2001).
Many of the organisations that deliver health services to rural and remote regions have been early adopters of the principles of primary health care. Perhaps because of the challenge posed by vast distances, staff shortages and the complex chronic health care needs of many rural populations, services in rural and remote areas have realised the value of the integrated, community and value-driven approach to care offered by comprehensive primary health care models. This integrated approach has the potential to provide lessons to metropolitan primary health care teams.
Particularly in remote regions, many psychologists work as part of genuine multidisciplinary primary health care teams that operate from a commitment to maximise community and individual self-reliance. Groups of allied health professionals travel together as functional teams according to a regular travel schedule to provide holistic care to meet local population health needs. Teams are often away for a week at a time and many not only deliver individual care, but also support local health workers. The use of the psychologist as the mental health care specialist to support the remote health care workers on the ground is a form of multidisciplinary care that has long been called for in rural and remote Australia (e.g., Dunbar, Hickie, Wakerman & Reddy, 2007).
What is noteworthy about these team-based services is the focus on holistic wellbeing as opposed to simply absence of illness, and the location of control over health in both the individual and the community. The services operate on the assumption that treating the individual is insufficient unless one also addresses the wider conditions in which these poor health outcomes were created. Thus, promoting equity and community participation and addressing the underlying causes of ill health is part of the job of the whole team, including the psychologist. Working with the community not just the individual might mean building community trust in health services and transforming attitudes to health by regularly attending play groups and youth clubs, attending or running community events and providing community barbecues. Such activities offer community members a chance to develop trust in the psychologist long before any traditional psychological treatment is delivered. Additionally, one of the unwritten rules of these teams is regular and reliable service delivery to address one of the major factors contributing to distrust: that is, the outreach service not turning up to town when they say they are coming and frequent staff turnover.
Being part of a multidisciplinary team appears to have benefits for both the clinician and the client (Dennis et al., 2008). Working in an outreaching multidisciplinary team with a base ‘hub’ in a larger regional centre, for example, assists in recruitment and retention and avoids the negatives associated with being a solo practitioner in an isolated community (Wakerman et al., 2006). However, outreach multidisciplinary team work in remote communities can provide challenges for psychologists, in part because of the frequent absence of interdisciplinary education and limited exposure to primary health care, collaborative care and community capacity building principles in psychologists’ basic training. It may be that clinical and community psychology training would be the optimal preparation for a psychologist wishing to work in rural and remote regions. In addition to these limitations in training, recruitment difficulties are such in many rural and remote communities that psychologist positions are frequently filled by new graduates (or provisionally registered psychologists) with limited experience. For many psychologists in such situations, understanding one’s scope of practice can be a challenge.
Adopting the principles of primary health care, in particular the concepts of community self-determination and an understanding of the social, economic, cultural and political determinants of health, may also have benefits for psychologists in terms of working with Indigenous clients in a culturally competent manner. Psychologists who work in rural and remote locations are likely to encounter Indigenous clients and therefore need to intentionally develop culturally safe practice. ‘Cultural safety’ is safe service as defined by the Indigenous clients who receive the service (Edwards, Smith, Smith & Elston, 2008). Developing a culturally safe practice requires psychologists to undertake a process of personal reflection on their own cultural identity to be able to recognise the impact that their own culture has upon their practice. This involves understanding that their own beliefs, values and attitudes, when imposed on others, can have a negative impact. Indigenous psychologists are leading the way in assisting non-Indigenous psychologists and mental health workers to develop culturally safe practice through the delivery of Cultural Competence Workshops (see www.indigenouspsychology.com.au) by the Australian Indigenous Psychologists Association.
There is no ‘one size fits all' way of delivering health care services to rural and remote Australia (Wakerman & Humphreys, 2011). However, psychologists are making a difference in getting mental health services to the bush. The innovative use of technology, the delivery of effective cultural competency training to the mental health workforce, and playing an essential role in outreaching multidisciplinary teams that operate according to the principles of primary health care are just some of the contributions of the profession to the social and emotional wellbeing of people living in rural and remote Australia.
The author can be contacted at email@example.com
Primary Health Outreach 'On Country' At Port Stewart Outstation
John Hannan, Team Leader – Wellbeing Centre, Royal Flying Doctor Service, Queensland
Coen is a small town of about 300 people roughly in the centre of the remote area of Far North Queensland’s Cape York Peninsula. Being part of the Cape York Welfare Reform Trial, it has a Wellbeing Centre that is operated by the Royal Flying Doctor Service and is community controlled through a Local Advisory Group made up of select members of the township’s Indigenous locals. I work at the Wellbeing Centre which has its origins as a centre to deal with referrals from the Reform Trial’s Family Responsibility Commission for issues of drug and alcohol, domestic violence, gambling and mental health. It still performs this function but is also now an odd mix of services with the feel of a community centre combined with the capacity and actions of a mental health service.
Coen is also blessed with a number of community-supporting outstations: a mixture of private cattle stations, traditional land settlements and also now a highly effective ranger program. The Indigenous settlement of Port Stewart is one such place about an hour and a half southeast of Coen, over 95kms of roads that are rough at the best of times and often completely impassable in the wet. At the initiative of Shaun Sellwood, a counsellor with the Wellbeing Centre, an outreach was trialled to bring primary health care, including psychology services, to the inhabitants of this settlement.
And so it was that on a sunny but cool morning in early July our Wellbeing Centre team combined with a troupe of Royal Flying Doctor Service, Apunipima Cape York Health Council and Queensland Health employees to take a GP, men’s health advisor, child nurse, dietitians and counsellors out 'on country'. After an unusually smooth (but always dusty) ride out to Port Stewart we arrived at ‘Top Camp’ and were greeted by traditional owners. After the first order of the day (putting the billy on the open fire) we all chipped in to prepare the various work spaces for the day. For the dietitians this involved setting up a small marquee near the cooking area; for the men’s health advisor a table with brochures and other paraphernalia; and for the GP a cleared space amongst the remnants of unanticipated guests in the main room of the rustic timber building. For myself, setup involved analysing which patches of grass would be most private yet also offer some shade as the sun rose over the day. As it turned out there was a progression of optimal locations throughout the day, but most involved squatting cross-legged next to one of a selection of old troop carriers.
As the morning wore on a good number of local residents convened at the site and began to flow through the various health service providers. As the men wandered around, Shaun and I opportunistically shanghaied them into consultations, whilst Marilyn Kepple (a Coen local, traditional owner for the area and Wellbeing Centre team member) and clinical counsellor, Amy Franchi, did the same with the women. Using the IRIS (Indigenous Risk Impact Screen) as a starting point, each interaction evolved into its own unique entity. As always, reflective listening, validation and a respectful client-directed therapy approach allowed the client to guide conversation to where they were comfortable. I am hesitant to preach on broad principles for engaging Indigenous clients, however, I have always found that engaging too early in a heavy psycho-education focussed style is the quickest way to repel clients. White-man burnout is a reality for many Indigenous people and the perception of you as just one more seagull is a possibility that must be respected. I find that a softly-softly approach allowing clients to ‘suss you out’ in their own time builds a platform for better work in the long term. For some clients at the outreach this was their first engagement with the service while others were regular clients. For new clients this was a great opportunity for them to engage with the service without feeling ‘targeted’ in any way. This allowed for a breakdown of barriers that has resulted in further engagement from clients that may otherwise never have utilised the service.
Other members of the outreach team had similar experiences, saying that people opened up much more about health issues on country, compared to when they visited the clinic in town, because they were much more comfortable engaging and talking in familiar surroundings. The success of the day was summed up by one of the clients, who told Shaun about her elder, who had passed away. She said: “He would be smiling down on the group because he was so thankful that people have come on to his country to provide services for us”.
Primary Health Care Delivery In Rural Northern Queensland
Pania Brown and Dominic Sandiland, North and West Queensland Primary Health Care (NWQPHC)
NWQHPC delivers primary health care services to a population of approximately 120,000 people across 776,000 square kilometres, extending from Cardwell and Mornington Island in the north, to Birdsville in the south, east to Palm Island and westwards to the Northern Territory border. Whilst visiting services may come and go, funding providers may change priority areas, and governments may have different agendas, we know with great confidence based on many years working in these areas that the issues, needs and stresses faced by rural Australians on a daily basis remain the same. Continued demand for services is supported by our ever stable and increasing referral rates. In the past 6-12 months we have seen Mother Nature at her best with catastrophic natural disasters included repeated flooding, Category 5 cyclonic activity and the usual monsoonal wet season. For some, the trauma has come from these events, but for others it has simply made the other issues impossible to ignore. Regardless of the cause, we continue to support clients and communities through periods of immense personal hardship and are supporting a variety of post-disaster recovery efforts.
With a significant number of Indigenous clients and clients from culturally and linguistically diverse backgrounds, staff also have to develop expertise, awareness and cultural sensitivity to best support a very unique client group. Some communities only receive visits from a psychologist every 2-12 weeks, so clinicians rely on a suite of creative remote support options including tele-counselling and web-based services. We also provide advice and support to isolated GPs and other health professionals as well as organising and offering a variety of community education activities in response to identified areas of need, for example Triple P Parenting, Cancer Support Groups and Partners in Depression, to name a few.
We work from a platform of sustainability, of supporting communities to identify opportunities within locally based services, and building the capacity of individuals and service providers to allow communities to empower their members and provide much longer lasting results. Whether services are delivered or accessed by road, air or (sometimes) water, the unique and inherent challenges faced by NWQPHC professionals keep us all smiling as we fondly recall and tell the tales of our latest adventure.
A typical day in the life of an NWQPHC psychologist 6:30am Climb aboard a small aircraft which appears to be roughly the size of the average family SUV with wings. You’re a little nervous, but you are told this will save you a 7 hour drive on rough roads and 3 flat tyres changed on the side of the road with road-trains breaching the shoulder of the road as they go past.
8:45am After a somewhat turbulent and bumpy flight, you spend 30 minutes circling the airstrip before your pilot skilfully lands the aircraft.
9:00am This is the point where you hope that the local hospital groundsman will remember that he was to collect you and transport you to the local bush hospital. The penny drops, perhaps this is why you also needed to bring the satellite phone given the limited network coverage on your trendy city mobile.
9:30am Once at the hospital you settle into a vacant office space with a lone chair. You desperately scour the hallways for a second. Judging by the unique light fittings this could once have been an operating theatre. No time to swap rooms now! Your first client has arrived. The referral from the GP doesn’t tell you much. It simply states that he’s is a 54 year old male suffering from long-term depression and anxiety which has been exacerbated by the drought, subsequent flooding and ever increasing financial pressures from his farm. You open the door: “Welcome, come in and take a seat”.
5:00pm All in all a successful day – three successful appointments and only two 'no shows'. You hear on the grapevine that there is a cattle muster in a nearby town and the rodeo is coming to town on Friday – maybe next trip.
6:00pm A quick walk from the motel to the local pub for dinner. You find yourself spoken to and greeted by name as you pass people in the street – such is life in a small community and the challenge of confidentiality when everybody knows someone. You quickly realise, there is no anonymity here and politely smile before shuffling on to order the now infamous 'Reef and Beef'.
Nationwide Telephone Counselling Support For Rural Health Providers
Colleen Niedermayer, National Program Manager, and Annmaree Wilson, Senior Clinical Psychologist, Bush Support Services
Bush Support Services is the support program of CRANAplus, the professional body for all remote health professionals in Australia. It was established in 1997 through funding from the Department of Health and Ageing to provide a 24-hour telephone psychological support and debriefing service for multidisciplinary remote and rural health practitioners and their families throughout Australia. The service is available to all disciplines of health as well as paramedics, health educators, youth and aged care workers, sexual assault, and drug/alcohol workers delivering health care to the remote and isolated regions of Australia.
Bush Support Services is staffed by eight highly trained and experienced psychologists all of whom have remote experience. The Support Line can be accessed free from anywhere in Australia, 24 hours per day, 7 days per week. The Bush Support Line also offers anonymity and confidentiality, which are rare and precious resources in remote and rural health. Callers may remain anonymous if they wish, and repeat callers may speak to the same psychologist on request.
A key understanding of Bush Support Services is that rural and remote area health workers comprise a particular group of people who have specific mental health needs of their own. Stressors associated with geographic and professional isolation see people working in these sectors facing chronically high levels of occupational stress. These same workers also face increased chances of experiencing traumatic events.
The types of issues raised by callers to Bush Support Services is extremely varied. Psychologists often deal with callers who have had inadequate education and preparation for working in rural and remote areas. Callers frequently have questions about standards of practice and professional responsibility often due to the greater responsibility that is part and parcel of working in isolated areas. As with their urban and larger regional counterparts, workplace bullying and harassment are issues raised by callers.
As well, loneliness and isolation in rural and remote health workers at times amplifies the challenges presented in the day-to-day work situation. When these challenges become overwhelming, health workers can start to feel inadequate. The Bush Support Services psychologists are able to work with these callers to enhance coping skills. Support is also provided to callers who have returned from the bush and are wishing to explore their experiences. Some callers are regulars who just want to debrief or are looking for professional consultation, while others want to discuss personal issues associated with being isolated from family and friends, including depression, anxiety, and drug and alcohol issues.
The service tries to be as culturally aware and culturally safe as possible for Indigenous practitioners, which is a challenge given the diversity of Aboriginal and Torres Strait Islander cultures. An Indigenous co-counsellor assists with managing cultural issues and provides valuable input to other members of the counselling team.
Bush Support Services also provides educational packages focussing on self care and managing stress. Printed resources include self-help booklets which are available free of charge (contact: firstname.lastname@example.org ). In addition to telephone counselling, internet counselling services, case management and professional consultation are offered (contact: email@example.com ).
Bush Support Services also outreaches to remote area health workers by running fun activities such as a stress buster competition and a de-stressing knitting project.
- Dennis, S., Zwar, N., Griffiths, R., Roland, M., et al. (2008). Chronic disease management in primary care: From evidence to policy. Medical Journal of Australia, 188, S53-S56.
- Dunbar, J.A., Hickie, I.B., Wakerman, J., & Reddy, P. (2007). New money for mental health: Will it make things better for rural and remote Australia? Medical Journal of Australia, 186, 587-589.
- Edwards, T., Smith, J.D., Smith, R.J., & Elston, J. (2008). Cultural Perspectives. In J.D. Smith, J.D. (Ed.), Australia’s Rural and Remote Health: A social justice perspective (pp.48-72). Melbourne: Tertiary Press.
- Keleher, H. (2001). Why primary health care offers a more comprehensive approach to tackling health inequalities than primary care. Australian Journal of Primary Health, 7, 57-61.
- Saint, L. & Roufeil, L. (August, 2004). Bringing psychological services to the bush: An evaluation of the delivery of psychological services in a rural general practice setting using videoconferencing facilities. National SARRAH Conference, Alice Springs, Northern Territory.
- Wakerman, J., & Humphreys, J.S. (2011). Sustainable primary health care services in rural and remote areas: Innovation and evidence. Australian Journal of Rural Health, 19, 118-124.
- Wakerman, J., Humphreys, J., Wells, R., Kuipers, P., Entwistle, P. & Jones, J. (2006). A systematic review of primary health care delivery models in rural and remote Australia 1993-2006. Canberra: Australian Primary Health Care Research Institute.