Transcript Working with Veterans in Rural Communities

WORKING WITH VETERANS
IN RURAL COMMUNITIES
DEVELOPED BY MEMBERS OF THE
MULTICULTURAL AND DIVERSITY
COMMITTEE OF THE VA PSYCHOLOGY
TRAINING COUNCIL (2014 -2015)
ANGELIC CHAISON PH.D.
JAMYLAH JACKSON PH.D.
PHILLIP KECK M.A.
DARYL FUJII PH.D.
MULTICULTURAL & DIVERSITY COMMITTEE
MEMBERS
Committee 2014-2015
•
•
•
•
•
•
•
•
•
•
•
•
•
Daryl Fujii Ph.D., Honolulu (Co-Chair) ([email protected])
Linda Mona, Ph.D., Long Beach (Co-Chair) ([email protected])
Angelic Chaison Ph.D., Houston
Joseph Fineman Ph.D., Miami
Jamylah Jackson Ph.D., ABPP , Dallas
Jae Yeon Jeong Ph.D., Richmond
Rex Swanda, Ph.D., Albuquerque
Melinda Trujillo Ph.D., Portland
Sam Wan Ph.D., San Francisco
Marci Flores Ph.D., Long Beach (Post-Doc)
Phillip Keck M.A., Tennessee (Intern)
Jennifer Peraza Psy.D., Albuquerque (Post-Doc)
Katherine Ramos M.A., Durham (Intern)
OVERVIEW
• Definitions and Heterogeneity among individuals in
Rural Communities
• Healthcare Disparities
• Cultural Perspectives: Values/Worldview
• Common Presenting Problems and Unique
Challenges
• Clinical Implications: Assessment and Treatment
• Case Example
• References
HETEROGENEITY AMONG
RURAL VETERANS
HETEROGENEITY
•
•
•
•
•
•
Ethnicity
Regional
Religion
Sexual Identity
Educational attainment
Income
DEFINITIONS
Urban
• All territory, population, and housing units in urban areas
• A cluster of one or more block groups or census blocks, each of which has a
population density of at least 1,000 people per square mile at the time
• Surrounding block groups and census blocks, each of which has a population
density of at least 500 people per square mile at the time
• Less densely settled blocks that form enclaves or indentations, or are used to
connect discontiguous areas with qualifying densities
Suburban
• Not classified by the US Census Bureau
• Urban areas can be inside or outside of metropolitan areas. Geographic areas
such as counties and places can contain urban areas, rural areas, or both.
For more information on urban and rural areas, please visit our urban and rural
classification page.
Rural
• All territory, population, and housing units not classified as urban
REGIONAL VARIATION
• The urban areas of the United States for the 2010 Census
contain 249,253,271 people, representing 80.7% of the
population, and rural areas contain 59,492,276 people,
or 19.3% of the population.
• In Puerto Rico, 3,493,256 people, or 93.8% of the
population, reside in urban areas, and 232,533 people,
or 6.2% of the population, reside in rural areas.
• In the Island Areas, 92.6% of the population, 347,487
people, live in urban areas, and 7.4% or the population,
27,678 people, live in rural areas.
RURAL VETERANS
• Currently, 3.2 million—35 percent—of our enrolled
Veterans are rural, and the number is growing.
• Our Office of Rural Health (ORH) works to ensure
rural Veterans receive the same level of care and
access to services as their urban counterparts.
• Rural Veterans face some unique barriers to care,
including a lack of public transportation, limited
broadband coverage, and a smaller number of
community providers.
Interim secretary for health ( 2015, Feb.)
HEALTHCARE DISPARITIES IN RURAL
COMMUNITIES
MENTAL HEALTH SERVICES
• Shortage of qualified mental health professionals in
rural areas (Goldsmith et al. 1997)
• Counties with populations under 20,000
– Three quarters do not have access to a psychiatrist
– Half do not have access to a psychologist or social worker
(Holzer et al., 1998)
• Only 13% nonmetropolitan areas have inpatient
psychiatric facilities (Wagenfeld et al., 1993)
MEDICAL SERVICES
• Approximately one third of counties with
populations of less than 2,500 do not have a
physician practicing within boundaries (Gamm et
al., 2002)
• Implication is that only one third of these rural
counties have any type of health care provider to
deal with mental health issues.
RURAL HEALTHY PEOPLE
1. Access to quality health care (insurance, primary
care, emergency medical services) 73%
2. Heart disease and stroke 41%
3. Diabetes 40%
4. Mental health and mental disorders 37%
5. Oral health 35%
Rural Healthy People (2010)
RURAL HEALTHY PEOPLE (CONT.)
6. Tobacco use 26%
7. Substance abuse 25%
8. Educational and community programs 25%
9. Maternal, infant and child health 24%
10.Nutrition and overweight 22%
Rural Healthy People (2010)
CULTURAL WORLDVIEWS
OF RURAL POPULTIONS
RURAL VALUES
• Self-reliance/individualism
• Conservatism
• Distrust of outsiders
• Strong religiosity
• Strong work orientation
Slama (2004)
RURAL VALUES (CONT.)
• Practical thinking
• Respect for authority
• Self-abnegation
• Emphasis on family
• Fatalism
Slama (2004)
GOLDFISH PHENOMENON
• Believe others interested in their business and talking
about them
• Less open about nonconventional aspects of
themselves and opinions
• Magnification of usual concern for stigma (gossip,
everyone will know)
• Reluctant to find therapist due to dual relationships
Slama (2004)
ISOLATION
• Most mental health issues taken to general practitioners, ministers,
family, friends, bars,
• Tendency to hold in emotions increases isolation and exacerbate
problems
• More enmeshment
• Fewer social and activity options, thus teens more likely to
engage in sex and drugs
Slama (2004)
POVERTY
• Less transportation to services
• Less likely to have government insurance
• shame not self-sufficient
• employers family or small businesses, who often cannot
afford to pay health insurance
• many cannot afford mental health services
• thus more ill if come for services
Slama (2004)
POVERTY CASCADE
• No jobs, thus children move away
• Leaves older population with less support and more
health care needs
• Providers more dependent upon Medicare, thus
lower average reimbursement
• Thus providers more likely to leave
Slama (2004)
ATTITUDES TOWARDS
MENTAL HEALTH
ATTITUDES
• Stoic attitudes toward life in general
• Rural residents tend to ‘‘avoid conflict and
discussion of feelings, have limited tolerance for
diversity, have high religious involvement, possess
fatalistic and stoic attitudes, and are less likely to
seek mental health services because of the stigma
and lack of education about such services’’
Helbok, 2003, p.368
COMMON PRESENTING PROBLEMS AND SERVICE
CHARACTERISTICS AMONG RURAL
POPULATIONS
RURAL VS. URBAN
• MHICM participants who lived in rural areas had clinical
problems broadly similar to those in urban areas
• Although more rural veterans were unemployed, disabled,
received VA disability compensation, and had a payee or
fiduciary
• MHICM clients in smaller or isolated rural areas received slightly
less frequent and less intensive contacts and less recoveryoriented services than those in large urban locations.
Mohamed, Neale, & Rosenheck, 2009
PROVIDING MENTAL HEALTH
SERVICES IN RURAL COMMUNITIES
CONFIDENTIALITY
•
•
•
•
•
•
•
Family relationships
Differing expectations regarding referrals
Support staff
Vehicle recognition
The “expert” psychologist and public commentary
Group therapy and dynamics
Potential for incidental encounters
Schank & Skovholt, 2006; Werth, Hastings, & Riding-Malon, 2010
MANY ROLES!
•
•
•
•
•
Mental health provider
Parent
Coach
Social justice advocate
Member of community groups
• In rural communities, health providers make up most highly
educated subgroup of residents
• Unhappy customers in the grocery?
• Role strain!
• Competing roles overlap more so in a rural environment
Hastings & Cohn, 2013
APPROACHES TO MENTAL HEALTH
CARE IN RURAL COMMUNITIES
• The American Psychological Association created
the Committee on Rural Health (CRH) in 1996 to
identify the unique behavioral health care needs of
rural.
• The CRH identified 3 ways that psychologists can
address rural mental health concerns.
• Technology/Telehealth
• Integrated Care
• Prescription privileges
TELEHEALTH AS AN OPTION
• Telehealth: “the use of telecommunications and
information technology to provide access to health
assessment, diagnosis, intervention, consultation,
supervision, education and information across
distance” (Nickelson, 1998)
ADVANTAGES OF TELEHEALTH
• Provides rural populations opportunities to receive
health care services across distance regardless of
the location of the client or the provider (Nickelson,
1998)
• Both rural and urban patients were receptive to
receiving medical and mental health services using
telehealth (Grubaugh, Cain, Elhai, Patrick, & Frueh,
2008)
ADVANTAGES OF TELEHEALTH
• Telehealth-delivered services are comparable in
effectiveness to traditional psychiatric services as it
relates to reliability of psychiatric interviews (Frueh,
Deitsch, Santos, et al., 2000; Hilty, Marks, Umess,
Yellowless, & Nesbitt, 2004)
• May reduce stigma as the client does not have to
see the mental health provider in their small
community where everyone knows one another
(Wendel, et al., 2011)
DISADVANTAGES OF CHALLENGES
WITH TELEHEALTH
• Technology can be challenging:
• Have networks installed and connected at both sites
• Ensure the bandwidth can accommodate encryption to
ensure Health Insurance Portability and Accountability Act
• Technology may fail:
• Slow or no connection due to bad weather and other
factors
• Poor video quality
Wendel, Brossart, Elliott, McCord, & Diaz (2011)
ESTABLISH CLINICS IN RURAL AREAS
• CBOCs
• Provide transportation to clinics (Wendel, Brossart,
Elliott, McCord, & Diaz, 2011)
• Availability of clinicians to travel to the Center is
critical; however can be effective for some (e.g.,
the Brazos Valley in TX)
ESTABLISH CLINICS IN RURAL AREAS
• Establish a Local Resource Center that:
• The community can provides a Resource Center
for mental health practitioners to utilize in the
community to provide mental health services
• Incentives:
• Offer low overhead
• Offer support services
Wendel, Brossart, Elliott, McCord, & Diaz (2011)
MENTAL HEALTH IN MEDICAL SETTINGS
• Rural residents are more likely to look for support from informal
support networks (e.g., family/friends/religious community) or
their primary care providers than mental health practitioners
(Gale & Lambert, 2006; Harowski, Turner, LeVine, Schank, &
Leichter, 2006; Riding-Malon & Werth, 2014).
• Research shows that primary care physicians without a
psychiatric background are not as effective at identifying or
treating mental health conditions (e.g., depression) (Harowski,
et al., 2006)
• To facilitate access to mental health care, mental health
providers can work collaboratively with medical professionals
to provide mental health treatment in medical settings.
MENTAL HEALTH IN MEDICAL SETTINGS
• One approach to increasing access to mental health is to colocate mental health clinicians in medical settings.
• Integrated Care involves a mental health provider working
collaboratively and alongside the medical provider as part of
the treatment team.
• Mental health provider in this setting is referred to as a
“behavioral health consultant” whose role is to meet with
patients during or immediately after their visit with the medical
provider at the request of the medical provider.
• Research has demonstrated that integrated care produces
better physical and mental health outcomes for patients and is
cost-effective (Park, et al., 2013)
BEHAVIORAL HEALTH CONSULTANTS
IN MEDICAL SETTINGS
• Behavioral health consultants should be familiar with:
• Health psychology
• Medical and physical problems
• Evidence-based practice for physical health problems and
psychological health issues that co-occur with, mask, or are
masked by physical conditions
• Behavioral health consultants should be able to:
• Provide psychotherapy
• Brief therapy
• Behavioral interventions with individuals, couples, families and
groups
PRESCRIPTION PRIVILEGES FOR
PSYCHOLOGISTS
• The American Psychological Association (APA) has been
discussing the idea of psychologists prescribing psychotropic
medications since 1995 (Riding-Malon & Werth, 2014).
• Proponents of prescription privileges for psychologists argue
that:
• Paucity of prescribers in rural underserved areas(Harowski et al.,
2006; Fox, DeLeon, Newman, Sammons, Dunivin, & Baker, 2009)
• Prescription privileges would simply extend the existing
psychologist role as a behavioral health specialist (Gutierrez &
Silk, 1998)
• Opponents argue that psychologists would focus primarily on
prescribing and not psychotherapy (Riding-Malon & Werth,
2014)
PRESCRIPTION PRIVILEGES FOR
PSYCHOLOGISTS (CONT.)
• APA developed the following in the interest of psychologists
prescribing psychotropic medications:
• Recommended postdoctoral education and training program
in psychopharmacology for prescriptive authority (APA, 2009b)
• Model legislation for prescriptive authority (APA, 2009a)
• Practice guidelines regarding psychologists' involvement in
pharmacological issues (APA, 2011)
• Three states in the U.S. have approved licensed clinical
psychologists with advanced, specialized training to prescribe
medication for the treatment of mental health disorders.
• New Mexico (2002)
• Louisiana (2004)
• Illinois (2014)
RURAL CULTURAL
COMPETENCE
ASSESSING ACCULTURATION
• Determine degree of acculturation to
mainstream/urban American culture
• Degrees of rurality on a continuum
• mainstream culture pervades rural areas via media, internet
• Moderating factors
• size of town, closeness to urban areas, geography,
specifics of town
Slama (2004)
ASSESSING ACCULTURATIONDEMOGRAPHICS
Older
Less educated
Live on a farm or smaller town
Never lived in urban area for significant amount of
time
• Parents or grandparents live in rural area
• Have not travelled often or far
Slama (2004)
•
•
•
•
ASSESSING ACCULTURATION
SPECIFIC CHARACTERISTICS
• Assess for specific
characteristics of area
• Evaluate for presentation and
body language
• Terminology
Slama (2004)
TAILORING DIRECT SERVICES
• Engage in “small talk” when transitioning into and
out of therapy
• Use self-disclosure to make clients more
comfortable in talking about themselves
• Facilitate independent decision-making
• High deference to authority
• Be aware of own values and beliefs and avoid expressing to
clients without expressing as own, as deferent to authority
Slama (2004)
TAILORING DIRECT SERVICES
• Address concerns about confidentiality
• reassure
• decide what to do if see in public or socially
• if know client in other setting do not refuse due to dearth of
services, but plan how to interact in this setting
Slama (2004)
TAILORING DIRECT SERVICES
• Difficulties experiencing or expressing emotions
• develop emotional lexicon
• use behavioral techniques if cannot tolerate
• be aware of tendency towards somatization
• acceptable way to manifest distress
• may need to work closely with physician
• therapy should address primary physical complaints
GENERAL PRACTITIONER MODEL
•
•
•
•
•
Need general/broad competencies
Flexibility where treatment occurs
Geropsychology skills
Familiarity with specific minority cultures
Be aware of resources
• Continuing education, consultation networks, translation
services
Slama (2004)
CASE EXAMPLE
THE CASE OF BILLY
• Billy is a 34-year-old, heterosexual, married,
Caucasian male veteran with three children
residing only 49 miles from your CBOC; however, the
drive is over 1.5 hours due to the mountainous
terrain and single lane roads, and transportation is
unreliable. He is referred to you through primary
care, where he arrived expressing depressive mood
and thoughts of suicide. He smelled of campfire
and alcohol in your office and his appearance is
disheveled.
DISCUSSION QUESTIONS
1. What are your initial impressions of Billy’s case and
how could you approach the referral intake and
subsequent treatment?
2. What are some potential salient issues to explore in
conceptualizing is Billy’s presenting problems and
diagnosis?
3. What would be some cultural considerations/
adaptations to consider?
RECOMMENDATIONS
Assess the need for personalized service
Assess degree of present orientation
Assess use of alternate medical systems
Assess observance of the ethic of neutrality
Assess reliance on family
Assess communication barriers
Assess your reaction to a member of a different
subcultural group
• Hire native staff (rural background)
• View patients' standards of living in the context of
their daily challenges
•
•
•
•
•
•
•
Robbins, 2014
REFERENCES
REFERENCES
• American Psychological Association (2014). APA
Applauds Landmark Illinois Law Allowing
Psychologists to Prescribe Medications. Press release
on June 25, 2014. Retrieved on 5/4/15 from
http://www.apa.org/news/press/releases/2014/06/
prescribe-medications.aspx
• American Psychological Association (2011).
Practice guidelines regarding psychologists’
involvement in pharmacological issues. American
Psychologist, 66, 835-849.
REFERENCES
• American Psychological Association (2009a). Model
legislation for prescriptive authority. Washington,
DC: Author. Retrieved from
http://www.apapracticecentral.org/advocacy/aut
hority/model-legislation.pdf
• American Psychological Association (2009b).
Recommended postdoctoral education and
training program in psychopharmacology for
prescriptive authority. Washington, DC: Author.
Retrieved from
http://www.apapracticecentral.org/advocacy/aut
hority/training-authority.pdf
REFERENCES
• Fox, R.E., DeLeon, P.H., Newman, R., Sammons, M.T.,
Dunivin, D.L., & Baker, D.C. (2009). Prescriptive
authority and psychology: A status report. American
Psychologist, 64, 257-268.
• Frueh, B.C., Deitsch, S.E., Santos, A.B., et al. (2000).
Procedural and methodological issues in
telepsychiatry research and program development.
Psychiatric Services, 51, 1522-1527.
• Gamm, L., Hutchison, L., Bellamy, G., & Dabney, B. J.
(2002). Rural healthy people 2010: Identifying rural
health priorities and models for practice. The
Journal of Rural Health, 18(1), 9-14.
REFERENCES
• Gutierrez, P., & Silk K. (1998). Prescription privileges
for psychologists: A review of the psychological
literature. Professional Psychology: Research and
Practice, 29, 213-222.
• Harowski, K., Turner, A.L., LeVine, E., Schank, J.A., &
Leichter, J. (2006). From our community to yours:
Rural best perspectives on psychology practice,
training, and advocacy. Professional Psychology:
Research and Practice, 29, 213-222.
• Hastings, Sarah L.; Cohn, Tracy J. (2013). Challenges
and opportunities associated with rural mental
health practice. Journal of Rural Mental Health, Vol
37(1), 37-49.http://dx.doi.org/10.1037/rmh0000002
REFERENCES
• Gale, J.A. & Lambert, D. (2006). Mental healthcare in
rural communities: The once and future role of primary
care. North Carolina Medical Journal, 67, 66-70.
• Goldsmith, H. F., Wagenfeld, M. O., Manderscheid, R. W.,
& Stiles, D. (1997). Specialty mental health services in
metropolitan and nonmetropolitan areas: 1983 and
1990. Administration and Policy in Mental Health and
Mental Health Services Research, 24(6), 475-488.
• Grubaugh, A.L., Cain, GD., Elhai, J.D., Patrick, S.L., &
Frueh, C.F. (2008). Attitudes toward medial and mental
health care delivered via telehealth applications among
rural and urban primary care patients. Journal of
Nervous and Mental Disorders, 196(2), 166-170.
REFERENCES
• Hilty, D.M., Marks, S.L., Umess, D., Yellowless, P.M., & Nesbitt, T.S.
(2004). Clinical and education telepsychiatry applications: A
review. Canadian Journal of Psychology, 49, 12-23.
• Holzer, C. E., Goldsmith, H. F., & Ciarlo, J. A. (1998). Effects of
rural-urban county type on the availability of health and
mental health care providers. Mental Health, United States,
204-213.
• Hunter, C.L., Goodie, J.L., Oordt, M.S. and Dobmeyer, A.C.
(2009). Integrated behavioral health in primary care: Step-bystep guidance for assessment and intervention. Washington,
DC: American Psychological Association.
• Nickelson, D.W. (1998). Telehealth and the evolving health
care system: Strategic opportunities for professional
psychology. Professional Psychology: Research & Practice,
29(6), 527-535.
REFERENCES
• Park, A., McDaid, D., Weiser, P., Von Gottberg, C., Becker, T.,
Killian, R., & for the HELPS Network. (2013). Examining the cost
effectiveness of interventions to promote the physical health of
people with mental health problems: A systemic review. BMC
Public Health 2013, 13:787 doi:10.1186/1471-2458-13-787
• Riding-Malon & Werth, (2014). Psychological Practice in Rural
Settings: At the cutting edge. Professional Psychology: Research
and Practice, 45(2), 85-91.
• Robbins, S. (2014). APPALACHIAN CULTURE AND MEDICINE: A
voice from the hills. Presentation given at intern seminar through
Mountain Home VAMC, September 2014.
• Rural healthy people 2010: A companion document to healthy
people 2010. Texas A&M University System Health Science
Center, School of Rural Public Health, Southwest Rural Health
Research Center, 2003.
REFERENCES
• Slama, K. (2004). Rural culture is a diversity issue.
Minnesota Psychologist, 53(1), 9-12.
• Slama, K. M. (2004). Toward rural cultural competence.
Minnesota Psychologist, 1, 9-13.
• Wagenfeld, M. O., Murray, J. B., Mohatt, D. F., & DeBruyn,
J. C. (1994). Mental Health and Rural America, 19801993: An Overview and Annotated Bibliography. NIH
publication# 94-3500.
• Wendel, M.L., Brossart, D.R., Elliott, T.R., McCord, C. &
Diaz, M.A. (2011). Use of technology to increase access
to mental health services in a rural Texas community.
Family Community Health, 34(2), 134-140.