Although urban and rural areas face many of the same challenges in addressing the mental health needs of welfare recipients, some aspects of service provision are easier in rural areas, while others are more difficult. In general, we observed four primary considerations when providing mental health services in rural areas.
Clients in rural areas compared with those in urban areas have less difficulty accessing mental health treatment in a timely manner, but they have more difficulty accessing certain types of treatment. In two of the study states, Oregon and Utah, clients in rural sites find it easier to access mental health treatment in a timely way than do clients in the urban sites. Clients seeking Medicaid-funded mental health treatment in urban areas have had to wait up to a month to see mental health therapists, which is substantially longer than the wait experienced by clients in the rural sites. However, in most of the rural sites, clients had more difficulty accessing certain types of treatment, such as psychiatric evaluations, residential treatment, and treatment for co-occurring mental health and substance abuse conditions.
In Tennessee, the proportion of referrals to mental health services is substantially higher in rural than in urban areas. According to researchers at UT, two-thirds of the referrals to the FSC program come from rural areas even though the number of inndividuals referred account for one-third of the state's welfare population. It is unclear why there is a difference in referrals between rural and urban areas. However, employment case managers in the rural areas suggested that they get to know the clients well and tend to have strong collaborative relationships in their own offices and with other agencies. The other study sites had less data than Tennessee on this issue.
Some mental health staff and clients are required to travel long distances to provide or to access services. Mental health staff in rural areas typically provide services in multiple welfare offices and over a large geographical area compared to staff in urban sites. For example, one social worker in Utah provides services to welfare recipients in five counties, which limits the accessibility of the social worker in each of the offices and reduces the time the social worker can meet with clients. Mental health staff in other rural communities have similar arrangements and face similar challenges. Furthermore, some clients living in remote areas have difficulty accessing mental health services and participating in mental health treatment because of the distances they are required to travel.
According to mental health staff, the stigma associated with mental illness and mental health treatment is particularly strong in rural areas. The stigma of participating in mental health services is frequently discussed among mental health counselors and clients in rural areas, where there is concern that neighbors and friends might "find out" that clients are receiving mental health services. Mental health counselors in rural areas also suggested that, in general, employment case managers and clients themselves are more biased about mental illness and more uncomfortable about participating in mental health treatment.
16. Valley Mental Health is the county's sole Medicaid-funded mental health treatment provider and is paid under a capitated managed care funding arrangement.