Outlook Is Improving for Rural Mental Health

A Rural Mental Health Checkup

Ranching in rural Nebraska allows ample space for Ryan Sexson to ride his horses, something he's enjoyed since he was a baby riding with his mom. (Joel Reichenberger)

As Ryan Sexson sat on his bed -- rifle in hand, finger on the trigger, pointed at his head -- he knew he needed help.

Up to that point, he had largely downplayed the anxiety, depression and lack of self-worth he felt from "just being a teenager."

Having grown up in rural Nebraska to a family of ranchers -- the profession he and his family have carried forward -- Sexson adopted the "can do" frontier attitude of taking care of things himself rather than seeking professional help.

That's the way he was brought up, but it obviously wasn't working.

"For years, I told myself it wasn't a big deal, that it would work itself out as I got older," says Sexson, who calls home a small custom calving ranch on the north-central edge of the Nebraska Sandhills, close to Nenzel, with wife, Jamie, and daughters, Rylie and Addie.

"But, I didn't get any help. I was taught growing up that people don't self-diagnose and was told to get my shit together. What stopped me from pulling the trigger was the image of my mother having to clean the mess up."

Sexson says isolation combined with his parents' divorce and his tenuous subsequent relationship with his father played significant roles in his anxiety and depression.

As the youngest of four siblings growing up in remote Whitman, Nebraska, he lived far from everything -- 185 miles from the closest Super Walmart, 120 miles from a regular Walmart, 15 miles from the nearest grocery store and 3 miles from his closest neighbor. His high school in neighboring Hyannis was even several miles away.

When he tried to end his life again as a college student, he consulted his college counselor and then sought professional help. He was placed on medication, and his mental health outlook improved.

Several years later, when his son, James, died from injuries suffered in a car accident, Sexson found himself struggling again. Fortunately, he was able to cope, choosing to focus on his faith and family, and eventually take his story public to help others.

"We all struggle from time to time, but I've learned it's important that we don't discount our own struggles, because they are important," he says. "No one is more significant than another. They are all worth talking about, and they matter regardless of how simple you may think they are. Say it out loud and own it."


Historically, people living and working in rural settings have been largely self-sufficient because they had to be. They were forced to take care of things themselves.

This "frontier" way symbolizes a rugged and independent way of life, characterized by self-sufficiency, resilience and the ability to survive and thrive in harsh and isolated conditions.

This also applies to dealing with mental health issues and the attitude that no outside help is needed.

"Rural areas, farming and ranching communities, have a lot of this frontier attitude," says Cate Jones-Hazledine, co-director of the Panhandle office of the Behavioral Health Education Center of Nebraska (BHECN), a service of the University of Nebraska Medical Center (UNMC). "It is part of what has kept them strong and resilient, but can work against them getting the help they need."

Still, in rural places, there is stigma attached to talking about troubles, asking for help and showing weakness. In these communities, the mention of "mental health services" often makes people think they're just going to be put on pills and sent home, or they will be labeled as "crazy" and ostracized.

"Primarily, I see the stigma of seeking behavioral health services as a barrier," says Tara Wilson, associate professor of counseling at Chadron State College and co-director of BHECN Panhandle. "Individuals are hesitant to even park in front of a behavioral health clinic because of the high visibility aspect of rural communities."

Linnea Harvey, Rural Renewal Initiative coordinator in the Department of Agricultural Education, Communication and Leadership at Oklahoma State University, explains it's a complicated mix of barriers that plays into the reluctance to seek mental health services.

"People with the frontier attitude miss their daughter's wedding because the cows need to be milked," she says. "Or, they work when they have strep throat, appendicitis, broken bones or other ailments -- physical and mental -- because those cows have to get milked."

Harvey says many of the smaller farms she has worked with didn't have hired help. The more she got to know these farmers on a personal level, the more she saw the constant stress they were under.

No one talked about it, but there was a lot of loneliness, depression and anxiety.

"Given all the other obstacles, I think ignoring it is the way most people go about it -- not out of pride but kind of out of necessity," she says. "If you're looking at something really scary, maybe closing your eyes so you don't see it, even though it's there, will help."


There's little question that the importance placed on overall mental health care varies from person to person.

For example, a farmer might need a knee replacement but keeps putting it off because he can't take time away from the farm. The same is true for mental health. Often, mental health is not as visibly seen, so people place an emphasis on the more obvious needs.

However, Wilson explains, it is circular. If someone isn't physically or mentally well, the overall operation will also suffer.

"I have heard some say that they notice when they place an emphasis on their marriage, the farm just naturally reaps the benefits, as well," she says. "While some see the circular aspect of, 'If I take care of myself, I am going to be a more successful farmer/rancher,' I think the majority of the individuals are going to place needs of the farm/ranch over their own needs."

What are some of the signs one should look for in themselves as well as those they love that might indicate some level of mental health crisis?

Jones-Hazledine believes changes in someone's behavior is a big one, as is feeling or acting angry or irritable, and changes in sleep patterns and appetite, among others.

"Everyone gets 'down' sometimes, but if this is more severe than normal or lasts longer, that is a sign that it might be something more," she says. "And (always), any thoughts of suicide or self-harm should be taken seriously, and help should be sought immediately.

"This is the reason that we do a lot of integrated care" she continues. "Many people, especially rural people dealing with higher stigma, seek services first from their primary care physician (PCP). This means that the PCP might see a lot of patients for things that aren't really medical in nature (or not fully)."

Jones-Hazledine adds that in the clinics where BHECN services are embedded, the doctors can refer those cases to them to provide the needed care.

"Having a doctor referral also helps people feel more comfortable seeing us, because they trust their doctors," she says. "PCPs out where we are do provide a lot of the psychiatric care (prescribing ADHD medications and antidepressants, etc.), because there is a shortage of psychiatric providers."


One of the biggest barriers to getting mental health care involves access to services and providers.

According to the National Alliance on Mental Illness, it's estimated that as many as 65% of rural counties do not have psychiatrists, and more than 25 million Americans living in rural areas are in a designated Mental Health Professional Shortage Area

Because there are many counties in the more rural parts of the country that just don't have many or any providers, individuals are forced to seek care outside of their communities.

If they want in-person services, it can be even more challenging, says Isaac Hooley, senior behavioral health clinician in the Department of Psychological and Quantitative Foundations, College of Education Affiliations at the University of Iowa.

"When we're talking about psychotherapy, I think many rural people have a particular narrative about what therapy will look like that relies on cultural stigma about seeking help, processing emotions and opening up with people outside of their trusted circle of family and friends to share what has been difficult," he says. "If you hold this view, it can be hard to imagine how therapy might be useful."

Cost is another obstacle for many in accessing mental health services.

Wilson says rural Americans are often underinsured, or they frequently have high deductibles or insurance that doesn't cover mental health services. These areas often have high poverty, making it challenging for people to even pay sliding scale fees.


One of the few silver linings of the COVID-19 pandemic is that more mental health services have been made available.

UNMC's Jones-Hazledine says in addition to more in-person services that have been established in larger rural areas over the past five-plus years, telehealth provides services that don't require transportation or the potential stigma of public visits to a mental health practitioner.

Still, in rural communities, which tend to be disproportionately older, people are often uncomfortable or unsure how to use the technology.

And, then there's the question of whether a doctor who works and lives in the city can relate to or understand the stressors of rural living -- and will they be accepted?

"Currently, we use telehealth mostly to supplement in-person care -- to provide services if there isn't a provider in the person's town (or not enough providers), or to meet more frequently if the person is a long distance away or weather interferes," Jones-Hazledine says.

"It is important that providers receive some specialized education in working with rural populations," she continues. "There are some differences between rural and urban people, and rural and urban therapy, which aren't necessarily taught in our graduate programs."

University of Iowa's Hooley says the Iowa State Psychological Association constantly looks at how to create new training opportunities and draw psychologists to the state.

Iowa recently changed its state law to allow psychology interns (who are not yet licensed but near the end of their training) to bill for services, which can potentially increase the number of providers in the state.

Dr. Marley Doyle, who is also an associate professor at the University of Nebraska Medical Center and director of BHECN, says she sees an overall push in Nebraska for institutions like BHECN that are located in more urban areas to extend their reach into the rural areas.

"BHECN is focused on the recruitment and retention of behavioral health providers, and that has a huge impact on overall rural behavioral health," she says. "BHECN is able to both recruit more individuals but also focus on the retention of clinicians based in rural Nebraska.

"By recruiting, BHECN is growing the behavioral health workforce in Nebraska, which means there are more clinicians available to provide services," Doyle continues. "Through BHECN's retention efforts, we are able to enhance knowledge through training opportunities and support those of us providing services in rural Nebraska."

Still, until there is a crisis, mental health care is often not a priority for most farmers and ranchers, although changes in attitude are happening.

"I do think we have made gains in the 20 years that I have been out here, but we definitely still see people waiting until things are particularly bad to seek services," Jones-Hazledine says.

"Kids are growing up with services available at school, and this helps to reduce stigma and normalize help -- seeking when needed," she adds. "We also do things like teach a stigma-reduction course in middle school health class. Things are definitely improving, and more resources are becoming available."


Multiple mental health programs are available on a national scope. Most recently, the Farm Family Wellness Alliance was unveiled at the national American Farm Bureau Federation (AFBF) convention in January. It provides free, anonymous online mental health and well-being services, and on-demand support to farmers, ranchers and farm families.

The alliance grew from a pilot project started by Farm Foundation in Iowa four years ago after many areas were hit by a derecho and later was expanded to Illinois. In addition to Farm Foundation and AFBF, the alliance includes CoBank, Farm Credit, Iowa Farm Bureau, CHS, Land O'Lakes, National Farmers Union, 4-H, FFA, Agriculture Future of America, Togetherall and Personal Assistance Services.

Under the program, overseen by licensed professionals, access is available 24 hours a day for farmers and their family members 16 years and older. Farmers connect with other farmers. If needed, they can be referred to a mental health professional.

Shari Rogge-Fidler, president and CEO of Farm Foundation, has been one of the driving forces behind the new program. As a fifth-generation farmer herself, she knows firsthand the stressors that are part of farms and rural life.

"One of the taglines that was used during the pilot phase was 'When you feel better, you farm better.' So, let's get started helping more farm families feel better so that we can all farm better," she explains.

-- https://www.farmfoundation.org/…

Similarly, the Rural Mental Health Resilience Program, a partnership between Rural Minds and the National Grange, offers insight and resources into overcoming the stigma associated with mental illness, common myths about rural mental health and suicide, as well as conversation starters to discuss mental health with a friend or loved one.

-- https://www.ruralminds.org/…

Commodity organizations like the American Soybean Association, National Corn Growers Association and United Soybean Board also are devoting efforts to the well-being of farmers. It includes guidance, resources, research and stories to help farmers find qualified help.

-- https://www.soygrowers.com/…

-- #SoyHelp

-- https://www.ncga.com/…

States like Minnesota, Oregon and Texas, among others, are also stepping up to provide more rural mental health resources, and a recent House of Representatives bipartisan bill -- the Farmers First Act -- would reauthorize the Farm and Ranch Stress Assistance Network (FRSAN) to increase funding to $15 million annually over the next five years.

It would also allow FRSAN regional centers to establish referral connections with certified community behavioral health clinics, critical access hospitals and health centers.


-- Chris Clayton, DTN Senior Ag Policy Editor, contributed to this story

For More Information about Mental Health Awareness:

-- 988 Suicide and Crisis Lifeline. Call. Text. Chat. 24/7, free and confidential support for people in distress, prevention and crisis resources. Call or text 988. Chat at https://988lifeline.org/…

-- Substance Abuse and Mental Health Services Administration National Helpline. 1-800-662-HELP (4357) 24/7, free and confidential treatment referral and information service for individuals and families facing mental and/or substance-use disorders.

-- For even more information and resources, please visit the DTN mental health awareness site at https://spotlights.dtnpf.com/…


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