A quote from a journal article I found written by K Rost, G R Smith, and J L Taylor did a wonderful job encompassing the issue of the stigma surrounding mental health in small towns:
“stigma may be a particularly important barrier to mental health care in rural communities where lack of anonymity increases the probability that someone who seeks care will be labeled 'crazy'."
People who live in small and rural communities are more likely to experience mental health issues, and less likely to seek out care. And most of these people suffer in silence.
Adults in rural small towns are more likely to suffer from depression, anxiety, and commit suicide than those in their urban and suburban counterparts.
Coming from a small town where we have a “bring your tractor to school day”, I’ve seen some of these issues firsthand just living here. Mental health is never really discussed until something bad happens, then everyone talks about it for a while, and that’s followed up with no actual change.
So what are some of the causes of this stigma? And can we start a conversation about mental health to someday remove this stigma?
Addressing disparities around mental health access is at the core of our mission at Telebehavioral Health.US, so I talked with our team to gain more insight into mental health treatment in these towns.
What’s Causing this Stigma?
A large portion of small towns are composed of older generations where mental illness was never talked about or really ever heard of-they didn’t really even have a language for it. Having depression or some other mental illness was often seen as a sign of weakness and people rarely ever sought out care. Most mental health providers that do practice in small towns are going to be generalists as well, and it is going to be very unlikely that someone specializes in treating older adults or the elderly.
The fear of being seen causes a lot of people in small towns not to seek mental health care. A lack of providers may mean they have to go see the one person in town who is licensed to give mental health care, and what if someone they know recognizes their car? Or sees them walk into the building? All of a sudden the fear of being gossiped about around town sets in and deters people from getting help. There is a big sense of “community” and “everybody knows everybody” in small towns, meaning it might not take long for people to find out you’re seeing a therapist. And for people in small towns where some people may think of you as crazy for having a mental illness, that could be enough for someone to not seek therapy. It doesn’t take long for mental or physical health problems to become common knowledge.
The lack of accessibility is probably the biggest barrier to mental health care, causing the stigma to be even further pronounced. Most small towns have no mental health providers, and some may only have one. For towns with just one provider, it may be weeks or even months before someone can see a therapist. People in rural areas are also more likely to be uninsured, and the out-of-pocket costs deter people from seeking treatment. With the new trend of online therapy, this issue is beginning to get tackled. Betty Sue, a clinician with us at Telebehavioral Health.US had some thoughts on this matter. "Technology has allowed rural communities to expand their networks of support. Physical distance is no longer a barrier. If there is no one in your community that you feel like you can ask for help, you can now open your browser and find highly credentialed therapists that can meet your unique needs! I'm so grateful that companies like TBH exist, because I can partner with clients across the state, even if they feel like there aren't people or resources in their own communities to help. We are all a part of one big village!"
Betty Sue also made a good point on the strong-willed nature of people who live in small town America. “I think another barrier to accessing services in rural places is that, often, small towns have tough histories, and residents really take pride in being able to overcome hardship through a "pull yourself up by the bootstraps" mentality. I think what this perspective fails to take into account is how, by nature, small communities tend to thrive not when a few individuals find success, but when residents collectively work together and build off of each other's strengths. Rural communities should take pride in overcoming their hardships! But they should also give credit to the fact that it's easier to overcome hardships when neighbors and community members can help each other out. And individuals should understand that there is strength in asking for help.” Coming from a farming community in mid-Michigan where her graduating class was only 66 people, and then moving to a town called Crested Butte, Colorado, with a year-round population of 1,600, Betty Sue has been apart of the small-town culture her whole life, and loves living in a quirky, rural city.
Starting the Conversation
With alarming rates of mental illness and suicide in small rural towns, it is time to start having the conversation around mental health. No one person can tackle this issue on their own, so it truly does take a village.
Someone seeking out help for their mental health needs shouldn’t be seen as a sign of weakness, but a sign of getting help to make the community stronger.
I believe companies like TBH are going to be an amazing stepping stone in stopping the stigma that comes along with mental health in small towns. Finally people have the ability to access care without all the worries they had before of being seen or people “knowing their business.”
Maybe it will be the small town people seeking therapy from their own couch who spread the word and let their community know of the wealth of resources available to them online.