Rural communities tackle youth mental health care gaps

Youth mental health concerns are widespread, and in rural communities, where resources are often limited, risk factors can be more pronounced. A 2022 analysis by researchers at the Rural & Minority Health Research Center found that young people in rural communities were more likely than their urban peers to experience problems such as anxiety, depression, and behavioral concerns. When these concerns are left unaddressed, youth are at a heightened risk for alcohol and drug use, risky sexual behavior, self-harm, and suicide (Graves, J. M., et al., JAMA Network Open, Vol. 3, No. 10, 2020opens in new window).

“As problems increase, services simply aren’t meeting the demand,” said Douglas Knutson, PhD, an associate professor of counseling psychology at Oklahoma State University. “I expect over the next 10 years as these pressures continue, we’ll see this long-standing behavioral health care crisis even more pronounced among rural youth.”

Recognizing the need, the U.S. Department of Educationopens in new window has awarded more than $208 million in new grants through the Mental Health Service Professional Demonstration and School-Based Mental Health programs to 65 recipients, with the goal of increasing the number of credentialed school-based mental health providers serving students in high-need districts. These awards prioritize boosting capacity in rural communities, with 33 grants and more than $120 million allocated to rural states and districts.

[Related: Rural mental health toolkit]

Psychologists play an essential role in supporting youth in rural communities, applying their expertise to form partnerships with schools, train school faculty and staff to recognize mental health symptoms and make appropriate referrals, and develop resources for communities to apply psychological principles to better support children and teenagers.

Research indicates that rural communities face higher poverty rates and general economic distress compared with suburban and urban areas (Clark, S., et al., The Russell Sage Foundation Journal of the Social Sciences, Vol. 8, No. 4, 2022opens in new window). Youth living in economically marginalized communities experience elevated risk for adverse childhood experiences and toxic stress, which can have long-term impacts on development and well-being, said Jamie Pratt, PsyD, an associate professor of educational and school psychology at the University of Southern Maine who specializes in supporting school-age children with emotional and behavioral challenges.

Rural families tend to have less access to domestic violence services, with fewer transportation options and shelters spaced much farther apart than in more densely populated areas, said Mary Louise Cashel, PhD, a professor of psychology at Southern Illinois University Carbondale who lives and works in a rural community. But more importantly, going to a local provider means revealing yourself to the community, which can create safety issues.

Challenges can extend beyond the home. Bullying can occur in any school, but it may leave students feeling more isolated in smaller, rural schools where there are fewer students and everyone knows everyone else. “You can’t just choose different friends with so few peers available, and it can be hard to obtain school support if the person bullying is a person of social power within the community,” said Cashel.

Marginalized youth, including LGBTQIA students, face additional challenges in all communities but often feel an added sense of “othering” in rural areas, say psychologists who work with these youth. “In many rural communities, there can be penalties for supporting queer youth because you’re seen as liberal or accused of grooming. These are sociocultural factors that can make these problems more difficult and create more barriers to care,” said Knutson.

Relative to other geographic locations, rural communities typically have fewer available mental health providers. Psychologists may prefer to seek jobs in higher-paying areas or those with more community support and infrastructure. “I may be willing to work in a rural area, but there may not be a job for my spouse or resources for my family,” said Ashley Norwood-Strickland, PhD, a clinical psychologist and vice-chair of the APA Committee on Rural Health embedded in a primary care/rural health clinic in Alabama, where she also serves as the on-call provider for pediatric behavioral health crises in the emergency department of her local rural hospital.

Even if a community mental health center exists, it is often a 1- or 2-hour drive away. In rural North Dakota, for example, the nearest therapy clinic is 80 miles away, requiring students to get rides and miss half a day of school for an appointment. Waiting lists are often even longer for specialized services, such as LGBTQIA-affirming care. Rural teenagers may not reach out for support even when the opportunity is available. “They aren’t convinced adults will take action, and sometimes they try to protect their parents from problems,” said Cashel.

While telehealth can be a viable option, especially with the Psychology Interjurisdictional Compact (PSYPACT) allowing many clinicians to practice across state lines, many rural families do not have reliable broadband internet. According to data from the U.S. Department of Agricultureopens in new window, 22% of Americans in rural areas and 28% of individuals in Tribal lands lack broadband coverage (compared with only 1.5% of people in urban areas). “Stigma about seeking mental health care compounds the issue,” said Nicole Barnes, PhD, APA’s executive lead psychologist for education.

Rural individuals may distrust health care providers, especially those they perceive as not understanding rural or local culture. In small, rural communities, concerns about confidentiality are also common. “Parents may tell kids not to talk about their problems because everyone will hear about it,” said Norwood-Strickland. “When you’re fighting that, you get a lot of kids who are suffering.”

Many districts share school psychologists, if they have one at all. In some districts, these issues affect school counselors, too. In Oklahoma, amid a teacher shortage, anyone with a bachelor’s degree can pursue alternative teacher certification in a subject area aligned with their degree (so, according to Knutson, they may not be specially trained in pedagogy or classroom management). In Texas, with too few school counselors, school boards can turn to chaplains to offer students support—yet people serving in ministry are not always formally educated in mental health.

With reduced school resources, some rural families are opting out of the public school system. In some states—including West Virginia—students can use public school funding to attend other schools. While it is positive for students to have options for schooling, this approach also defunds public education, leaving public schools with fewer resources. “Many students end up going to virtual school, with little access to mentors or other trusted adults,” said Casey Jo Cottrill, PsyD, a clinical psychologist with Barbour Community Health Association in West Virginia.

The result of delayed care is often more severe outcomes. By the time a child sees a therapist, the case may be complicated. “I’ve seen nonspeaking autistic children who were on a waitlist for 3-plus years,” said Norwood-Strickland. The necessary focus on higher-acuity care also means less attention to prevention, which Pratt said can perpetuate the cycle, creating more kids in need as time goes on.

Researchers and educators consider the community-school model the gold standard for both prevention of crises and addressing rural youth mental health. One effective model is integrating behavioral health services into schools, as in many primary care settings and on college campuses. “Students are more likely to use services if we can overcome common rural health challenges like distance, provider shortages, and confidentiality,” said Tess Kilwein, PhD, a clinical and sport psychologist and past chair of APA’s Committee on Rural Health.

Barbour Community Health Association, based in Belington, West Virginia, where Cottrill serves as a psychologist, is a federally qualified health center with locations inside several West Virginia schools. The center offers primary care medical services and psychological services during and after the school day, reducing the most significant barriers to care for students and staff. In Cashel’s rural Illinois community, a similar school-based model also offers primary care services to parents and teachers.

Until school-based programs become the norm, innovative approaches are needed to expand access, build the workforce, and provide services in convenient locations. In southwestern North Dakota, where families routinely need to travel more than an hour to therapy appointments, clinical social worker Melissa Buchholz expanded her office-based private practice to meet with students for psychotherapy at their schools, during the school day.

Families typically self-refer their kids to her, but as she has built relationships with three school districts, she also receives referrals from staff and teachers. “While kids may have to miss several hours of school to come see me at my office, I can drive 45 minutes to meet an essential need,” she said. “Therapists are used to working in an office, but being flexible can be such a value to children and families in these communities.”

To address the ongoing provider shortage, some universities are creating programs to train psychologists to specialize in rural youth, including practicum opportunities in rural schools. “I’ve sent students to conduct therapy groups in local schools on topics like life skills, problem-solving, and anger management,” said Cashel.

Oklahoma State University is in the process of rolling out undergraduate coursework to support the expansion of community-based behavioral health practice on Tribal land. The coursework helps build toward behavioral health aide certification, which prepares students to deliver culturally responsive, Tribe-specific community-based behavioral health services under appropriate supervision. By creating a local training pathway, the program aims to strengthen the Tribal behavioral health workforce while expanding access to care in underserved communities.

The university is also partnering with the Indian Health Service to create satellite locations that train American Indian psychologists throughout Oklahoma. Training psychologists in rural areas increases the likelihood they will stay in those areas to work, along with building trust in the community. “Local community members are more trusted than people who come from the outside,” said Knutson.

Workforce development also entails training future psychologists in cultural competence for rural communities. At the University of Southern Maine, Pratt teaches psychology students about the importance of learning about the unique cultural context of the rural communities in which they work and how to connect individuals with resources that already exist, whether religious organizations or cultural groups.

The University of Southern Maine adopts a similar approach to workforce development. Pratt and her colleagues developed a low-residency graduate program to prepare current educators in rural Maine schools for credentialing as specialist-level school psychologists. This model increases the accessibility of graduate training for professionals who are already embedded in and deeply committed to serving rural schools. Pratt also teaches her school psychology students how to leverage local resources to provide school-based mental health services within a prevention-focused, multitiered system of supports.

Until more clinicians are available, psychologists are helping train other impactful adults—such as social workers, school counselors, teachers, and other staff—to support student mental health. Norwood-Strickland created a program to bridge therapy, schools, and families by equipping teachers with practical, evidence-based skills that extend the impact of treatment beyond the therapy office.

She is currently partnering with a local middle school to provide a series of workshops for teachers and administrators focused on behavioral strategies, emotion regulation, early identification of mental health concerns, effective classroom interventions, and guidance on when students should be referred for mental health services. “In rural communities, where access to child mental health specialists is often limited, building the capacity of educators to recognize, respond to, and support students’ behavioral and emotional needs creates a sustainable, community-wide model of care that improves outcomes for children and families,” Norwood-Strickland said.

Nonprofit organizations have also developed unique approaches to support schools. The Montana-based Rural Behavioral Health Institute (RBHI) has partnered with four U.S. states to implement universal school-based mental health screening with same-day follow-up for at-risk students in more than 200 schools. Twice yearly, the RBHI’s fully virtual Screening Linked to Care (SLTC) program delivers universal mental health screening, same-day care for at-risk students, care navigation, and psychiatric services to rural students. Built for SLTC, the screening platform triages students’ results instantly and clearly, so any school adult can support a student. SLTC’s virtual design enables a small RBHI team to monitor and coordinate all steps with school staff in real time, ensuring no student leaves school without receiving support.

Involving youth in programming is also important. The Youth Mental Health Summit, an APA presidential initiative led by psychologists Celeste Malone, PhD, and Erlanger Turner, PhD, was formed on the basis that youth should contribute to the development of policies and resources that support their well-being. Along with hosting in-person listening sessions to hear directly from youth about their struggles and needs, the initiative is developing toolkits that can help communities around the country lead their own listening sessions.

“This type of resource is especially important in rural communities, which are underrepresented in research,” said Malone, a professor of school psychology at Howard University in Washington, D.C. From there, staff can better create resources based on students’ real needs—not assumptions about what they are struggling with or how they want to be supported.

Also relevant, Kilwein said, is addressing social drivers of health: for example, embedding food banks in schools to address food insecurity or providing broadband internet for local families so kids can access mental health resources at home. The YMCA of East Tennessee, as one example, uses its youth recreation and sports network to distribute meals to children and families in rural communities through schools, churches, and other trusted community sites. In rural Jasper, Texas, a former school campus was converted into a rural community resource hub housing a food pantry, public health services, the Women, Infants, and Children (WIC) nutrition program, and teacher resources, with plans to incorporate mental health, financial, and workforce services.

A holistic strategy that nurtures resilience while addressing current needs is bound to be the most effective way to support youth mental health—but it requires long-term investment from entire communities. Every adult, from a school psychologist to a bus driver or sports coach, plays an important role in supporting rural youth. “We need a comprehensive approach that addresses symptoms while strengthening protective factors that tip the scale toward resiliency and positive life outcomes,” said Pratt. “It’s not just about the absence of mental illness but the presence of wellness.”