Nichowilliam

 The Assignment is an Article Review. The assignment should not be written in essay form. Please see attachment for the Assignment outline and Article to use for the assignment. Please highlight where you found the information on the article to complete the outline. I have to turn in the article with completed assignment. 

Write a review of a

 

research article in the outline form listed below. The article must be a quantitative design, pertain directly to counseling, and have been published in a national peer-reviewed counseling journal within the last five years.

Many of these are published by the American Counseling Association; the most current list can be found at 

https://www.counseling.org/publications/counseling-journals

. Please attach a copy of the article to your assignment.

This assignment is similar to a Search and Find or scavenger hunt. The purpose is to locate each of the components listed in the outline within the article. (For example, where is the research question/s located within the article? Write out the research question and include the page number and paragraph where it can be found.)

Please list the page and paragraph numbers in parentheses of where each item below can be found in the article. Write the number and the question for each section of the outline in your paper and please write in complete sentences. Please do not write in essay format!!!! Just fill in each section of the format.

 The following is the format:

1. Write the article citation in APA 7 format at the top of the paper

2. In the introductory section, locate:

a. Statement of the problem( list the pg. # and paragraph where found)

b. Explanation of grounding in the research literature, e.g.( this is what research they are pointing to, what has been done before this issue, where is the author of the article stating that:

i. Smith & Wesson (2012): summary

ii. Turner & Hooch (2004): summary

c. Suggestion of possible contribution to knowledge or practice ( where are they stating possible contributions to knowledge or practice, why is the article or research important, where are they telling the reader that)

d. Research hypotheses, questions, or objectives to be addressed (any hypothesis, questions, or objectives to be addressed need to be identified)

3. In the literature review section, locate:

a. Underlying and related studies, e.g. (list the authors and their studies (list the authors that they studied with a brief summary of what they found; don’t go into a whole lot of detail):

i. Simon & Simon (1992): summary

ii. Brooks & Dunn (2006): summary

b. Critique of previous methods (talk about critique of previous methods; maybe they talk about previous study and say what they missed; list where they say what they missed (paragraph and page #)

c. Prior conclusions (list previous literature conclusion, page #)

d. Applications (what did they use to apply to the current situation)

4. In the research design and methods section, locate:

a. Type of study (Qualitative, quantitative, mixed) (find it and put the page# and paragraph in parenthesis)

b. Population and sample (who were the participants) ( list where they talk about the population and where they talk about the sample)

c. Sample selection (type of sampling used)(how was the sample selected; type of sample used)

d. Instrumentation (how data was collected; what instruments were used; did they use surveys, interviews with survey attached to the end, other type of assessment methods as instruments to gather the data)

5. Data analysis

a. Types conducted (Statistical methods e.g. T-Test, ANOVA, descriptive statistics, etc.) (what type of data analysis used; what kind of statistical method they used to understand and make sense of the data; list where you found in the article and what typed used)

b. Findings of the data analysis (what were the results of the study; list where in the article)

6. Study limitations ( where did they discuss study limitations)

7. Discussion and Conclusions: describing the results and tying them back to the literature

8. Implications for practice or directions for future research(list implications for practice or directions for future research)

 

From your examination of this article, please answer the following questions

1. How did the researchers address multicultural concerns?

2.What was done well in this article? How could it have been improved?

3. Why is this article important to counselors? How does it advance the counseling profession?

4. In general, how does research advance the counseling profession?

 

Special notes: Remember to select a 
quantitative
  research article, not a meta-analysis or qualitative study. To see an outline of what needs to be included in a quantitative research article please see the APA 7 Manual, p. 77-81.

 

Challenges and Opportunities Associated With Rural Mental
Health Practice

Sarah L. Hastings and Tracy J. Cohn
Radford University

This manuscript outlines the challenges and opportunities associated with rural mental
health practice, and provides descriptive data on the scope of care, area of competence,
and clinical training of a group of practitioners providing services in rural central
Appalachia. Thematic content analysis reveals ethical challenges encountered, job
satisfaction, and the pinnacles and pitfalls of mental health care practice in the region.
Implications for training, recruiting, and retaining practitioners to work in underserved
rural settings are described. The authors highlight a number of areas that need
additional research attention in order to address remaining questions relevant to clinical
practice in rural settings.

Keywords: Appalachia, ethics, job satisfaction, mental health practice, rural

Depictions of rural life in mainstream media
vacillate between poles of bucolic pastoral
scenes lush with livestock and steep mountain
slopes strewn with dilapidated trailers. Indeed,
scholars on the rural experience note that rural
life is widely diverse in economic resources and
racial diversit

y.

Depictions of rural life gener-
ally rely heavily on stereotypes (Cooke-Jackson
& Hansen, 2008). Rural Appalachia especially
has been stereotyped, as residents are depicted
as “hillbillies,” and cast as backward, fiercely
opinionated, impulsive, and clannish (Harkins,
2004).

Yet commonalities exist in rural areas within
the domain of mental health and access to care.
Compared with metropolitan settings, rural ar-
eas have fewer mental health and medical ser-
vices, higher levels of unemployment, and
limited educational opportunities (Economic
Research Service, 2004; Murray & Keller,
1991; Reed, 1992). Many practitioners working

in rural settings have been trained according to
an urban model of therapy, in which boundaries
between counselor and client are clear and re-
ferral options are plentiful (Helbok, Marinelli,
& Walls, 2006). The challenges of counselor
visibility, lack of anonymity, and the reality of
interfacing with clients in social and community
settings can be taxing (Campbell & Gordon,
2003). These and other stressors associated with
rural practice, including professional isolation
and fewer resources for after-hours emergency
care, may contribute to reduced job satisfaction
and, ultimately, to burnout.

Although the literature has highlighted a
number of challenges associated with rural
practice, as of yet, scholars have not attended to
factors practitioners find appealing regarding
working in a rural setting. We were interested in
learning what motivates individuals to work and
remain in rural areas. In the next section, we
describe the challenges of rural practice, fol-
lowed by the potential benefits. We then de-
scribe a research study in which we surveyed
mental health practitioners in the central Appa-
lachian region in an attempt to understand per-
ceived opportunities as well as challenges.

Challenges of Rural Practice

Rural practice presents many special chal-
lenges for the clinician. Some degree of profes-
sional isolation seems inevitable, given that re-
search consistently points to a shortage of

This article was published Online First May 6, 2013.
Sarah L. Hastings and Tracy J. Cohn, Department of

Psychology, Radford Universit

y.

We thank Amy Burns, Mandy Sanderson, Erica Whiting,

and Alia Zaro for their assistance in data collection and
qualitative analysis.

Correspondence concerning this article should be ad-
dressed to Sarah L. Hastings, Department of Psychology,
Radford University, P.O. Box 6946, Radford, VA 24142.
E-mail: slhasting@radford.edu

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Journal of Rural Mental Health © 2013 American Psychological Association
2013, Vol.

37

, No. 1, 37– 49 1935-942X/13/$12.00 DOI: 10.1037/rmh0000002

37

mental health professionals in rural areas (Gold-
smith, Wagenfeld, Manderscheid, & Stiles,
1997; Health Resources and Services Adminis-
tration, 2005). For example, in the United
States, half of counties with populations be-
tween 2,500 and 20,000 lack a master’s-level or
doctoral-level social worker or psychologist
(Holzer, Goldsmith, & Ciarlo, 2000). The ma-
jority of Mental Health Professional Shortage
Areas, identified by the U.S. government as
areas critically in need of mental health practi-
tioners, are, in fact, rural (U.S. Department of
Health and Human Services, 2005).

A shortage of mental health professionals
translates into having fewer peers with whom to
consult on difficult cases and fewer referral
options. Isolated clinicians may lack the profes-
sional and emotional support professional col-
leagues provide, and the costs can be signifi-
cant. For example, in a study examining
burnout among clinicians practicing in rural
Kansas, Kee, Johnson, and Hunt (2002) found
that 65% of participants reported at least mod-
erate levels of burnout. The authors concluded
that rural clinicians who lack colleagues with
whom to share interests and concerns, and who
experience a deficiency of mutually nurturing
relationships, were at higher risk for emotional
exhaustion. The authors concluded, “Lack of
sufficient guidance, reassurance of worth, social
integration, and attachment were associated
with the rural mental health counselors at high
risk for burnout” (p. 10).

Job dissatisfaction and burnout threaten to
prompt rural clinicians to leave the area, at a
time when one of the most critical issues rural
mental health care must face is recruiting and
retaining personnel to provide much-needed
services (Jameson & Blank, 2007). Professional
isolation and lack of support from members of
their own discipline are concerns for rural prac-
titioners (Battye & McTaggart, 2003). Helbok
(2003) noted, “Although psychologists may ob-
tain phone supervision, it does not replace the
day-to-day learning and growing through daily
interactions with peers” (p. 378).

Social support may be difficult to find outside
the work place as well. Rural community values
may make it difficult for a psychologist to be
accepted. Stigma regarding mental health prac-
tice (Hoyt, Conger, Valde, & Weihs, 1997) and
suspicion of outsiders are not uncommonly re-
counted facets of rural social life. Rural com-

munity values tend to be more conservative,
with religion playing a central role in residents’
lives. Yet mental health providers, as a group,
generally endorse more liberal and less religious
ideologies (Aten, Mangis, & Campbell, 2010;
Campbell & Gordon, 2003). These cultural bar-
riers and a lack of understanding regarding the
mental health profession (DeLeon, Wakefield,
& Hagglund, 2003) may impact a psycholo-
gist’s satisfaction in a rural area. A clinician’s
family may struggle to make connections in the
community as well. Worries about employment
options for a psychologist’s partner and chil-
dren’s educational opportunities may be real
concerns for providers contemplating rural
practice.

An additional reality of rural practice is the
need to serve as a generalist in order to meet the
needs of a heterogeneous clientele (Stamm,
2003). Because there are fewer referral options
for clients, mental health providers need to
work with people presenting with issues across
the life span and, as a result, may be challenged
in terms of their boundaries of competence
(Gamm, Stone, & Pittman, 2003). It is likely
that the scope of care for clinicians is very
broad. Most research indicates prevalence rates
of mental illness in rural areas are comparable
with rates in metropolitan areas (Kessler et al.,
1994; Roberts, Battaglia, & Epstein, 1999; Rob-
ins & Reiger, 1991). However, Wagenfeld and
Buffum (1983) suggested that mental health
problems in rural areas are more significant than
in urban areas, citing stress associated with pov-
erty, farm crises, numbers of high-risk popula-
tions, and the effects of natural disasters. In-
deed, suicide rates, alcohol abuse, and disability
are higher in rural settings (Roberts et al., 1999;
Wagenfeld, Goldsmith, Stiles, & Manderscheid,
1988).

Potentially exacerbating the severity of dis-
tress is the challenge in finding employment.
Unemployment rates tend to be high in rural
areas, and many rural residents lack adequate
health care coverage. Fewer transportation op-
tions and greater distances to travel for care may
mean psychologists find it more difficult to de-
liver uninterrupted coordinated services. The
lack of employment opportunities, paired with
the difficulty of accessing transportation, affects
clients’ ability to afford services.

Another stressor for the rural clinician is the
visibility often cited as characteristic of rural

38 HASTINGS AND COHN

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areas. Rural scholars frequently describe this
dynamic of rural life, some referring to rural
residency as living “in a fishbowl.” One of our
graduate students who had grown up in rural
West Virginia referred to it as the “who’s your
daddy” phenomenon. She recounted numerous
incidents in which, when meeting people from
adjacent counties, she was asked that very ques-
tion, as residents attempted to “place” her
among her kin. According to Campbell and
Gordon (2003),

People are known in family, social, and historical
context. Individuals are known not simply by the work
they do or where they live but also by their family
legacy in the community. It is common to know some-
one not only by name but also as someone’s son or
daughter, aunt, or grandson. (p. 431)

Rural residents recognize each other by
their vehicles and tend to know “everything
about everybody.” The stigma associated with
seeking mental health treatment is exacer-
bated by the difficulty in remaining discreet in
small communities.

This persistent visibility can prove stressful
for a mental health provider whose professional
competence may be inferred by the way her
children behave in the supermarket or the de-
gree to which her neighbors perceive her as
friendly and accessible. Helbok (2003, p. 380)
noted,

The client may also know of the psychologist’s beliefs
and values by knowing what church he or she attends,
the stand he or she takes on community concerns, the
books he or she buys, and from his or her interaction
with others in day-to-day community life.

Further, the “lack of control over what is
known about the therapist may also increase
therapist anxiety” (p. 381).

Another characteristic of rural-living thera-
pists is the increased likelihood of being en-
gaged in multiple relationships with one’s
clients. This often-cited dynamic is easily imag-
ined when one considers reduced population
density and the resulting likelihood of encoun-
tering one’s clients outside the office. For ex-
ample, it is conceivable that a client works in
the salon in which the psychologist has her hair
cut or that she sees the sherriff’s son in therapy.
These boundary issues are not necessarily prob-
lematic, provided the provider is aware of their
likelihood and is prepared to address them
(Werth, Hastings, & Riding-Malon, 2010), but

they can create stress for the clinician and re-
quire a sense of hypervigilance, which con-
sumes emotional energy.

A number of scholars have asserted that grad-
uate training provides inadequate preparation
for rural psychological practice. Academic pro-
grams have been described as adhering to an
“urban model” of training (Dyck, Cornock,
Gibson, & Carlson, 2008; Stamm, 2003), in
which boundaries between therapist and client
are clear and referral options are plentiful. Har-
grove (1991), in speculating about why clini-
cians may not choose to work in rural areas,
asserted that psychologists leave their doctoral
programs ill prepared to address the range of
problems present in rural areas. Professionals
are visible in small communities. Maintaining
boundaries between one’s personal and profes-
sional life, combined with the challenge of in-
terfacing with clients in social settings, can be
taxing. These and other stressors associated
with rural practice, including professional iso-
lation and fewer resources for after-hours emer-
gency care, may contribute to reduced job sat-
isfaction and burnout.

Opportunities of Rural Practice

Although research is clear that practitioners
in rural areas will face unique obstacles and
challenges— both in scope and ethics—in pro-
viding care, scholars have been less interested
in identifying the opportunities that exist for
rural care. Within the literature, four areas have
been identified: ability to be a generalist, inte-
grated care, financial incentives, and congru-
ence with beliefs and values.

In contrast to urban areas, in which one may
need to specialize in order to obtain a referral or
admission to insurance panels, rural areas pro-
vide the opportunity to serve as a generalist,
practicing across the life span (Hargrove, 1982).
Additionally, literature suggests that it is not an
uncommon practice for individuals to work
with members of the same family at the same
time (Curtin & Hargrove, 2010). Working
within multigenerational families provides a
unique opportunity to understand the symptom
or problem from multiple informants and may
provide a more balanced perspective from
which to conceptualize the client and situation.

A number of scholars note that rural practice
necessitates integrative and collaborative care

39RURAL MENTAL HEALTH PRACTICE

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(e.g., Haxton & Boelk, 2010). Because re-
sources are scarce in rural areas, collaboration
becomes a necessary luxury. Given the lack of
psychiatrists in rural communities (Holzer et al.,
2000), primary care physicians may rely on the
skills of psychologists to help guide them in
making decisions about medications. As Haxton
and Boelk remarked, teamwork and working as
a collaborative unit are essential in rural areas
where resources such as financial means are at a
premium. Collaborative care not only enhances
communication (Orchard, Curran, & Kabene,
2005; Suter et al., 2009), as others have noted,
but also promotes creativity in the delivery of
services (Haxton & Boelk, 2010). Federal atten-
tion has been placed on integrated care in rural
settings. Both the U.S Substance Abuse and
Mental Health Services Administration and
Health Resources and Services Administration
have called on providers in rural settings to
organize, develop, and implement behavioral
initiatives that focus on collaborative care
across disciplines (Mauch, Kautz, & Smith,
2008).

With median debt for those psychologists
entering the helping professions hovering
around $70,000 (American Psychological Asso-
ciation, 2007), working in a rural setting has
distinct financial advantages. In 1995, the Na-
tional Health Service Corps Loan Repayment
and Scholarship Program began providing ad-
ditional funding for psychologists and training
opportunities for interns in federally under-
served areas through the use of Federally Qual-
ified Health Centers (U.S. Department of Health
and Human Services, 2005; National Health
Service Corps, 2010). More recently, the NHSC
program has begun offering loan repayment up
to $25,000 a year if the service provider agrees
to work in an underserved area (National Health
Service Corps, 2010). Resources for paying off
student loan debt, paired with lower cost of
living (Nord, 2000) in rural areas, has also been
identified as a potential advantage of rural prac-
tice.

Lonne and Cheers (2004), in their analysis on
retention of social workers in rural Australia,
found that although a number of practitioners
left because of lower salary, large and heavy
caseloads, fewer opportunities for supervision
and consultation, and limited resources for cli-
ents, a number of individuals chose to stay in
rural areas despite these challenges. Factors

such as a slower pace of life, greater physical
safety compared with metropolitan areas, and
variability in client problems have been re-
ported as factors that sustain practitioners in
rural settings. Indeed, some individuals find the
values of rural life appealing. For example,
Danbom (1997), in an essay on what Americans
value about rural life, argued that, historically,
the emphasis on family bonds, self-reliance, and
traditional values have been appealing for many
Americans. Thus, if individuals share the tradi-
tional values typically found in rural areas, they
may adapt more easily to the demands of the
environment and enjoy the respite from some of
the conditions of urban areas. Rural areas typi-
cally feature tight communities with little crime,
pollution, and traffic, yet they provide abundant
recreational activities. The autonomy offered by
rural clinical practice and the opportunity to
work with a variety of presenting issues may be
appealing to some clinicians (Jameson, Blank,
& Chambless, 2009).

Although research points to four areas of
benefits of rural practice, researchers have yet to
measure what mental health practitioners value
about their job, and find both rewarding and
challenging about rural mental health. To date,
researchers have generally focused on the bar-
riers to treatment and the many challenges the
providers face in rural care. In an attempt to
explore the positive as well as negative factors
that helping professionals find in rural care, and
to assess the degree to which rural practitioners
felt prepared for the realities of rural practice,
we proposed the following research questions:

1. What are the benefits and challenges of
employment in rural mental health?

2. What are the benefits and challenges of
residing in rural areas?

3. To what degree do practitioners view their
training as adequate preparation for the
demands of rural practice?

Method

Participants

One hundred twenty-three health mental pro-
fessionals serving in the Appalachian region
responded to an online survey. There were 97
women (78.9%) and 26 men (21.1%). Ninety-
six percent of the sample identified as European

40 HASTINGS AND COHN

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American, 0.8% as African American, 0.8% as
Hispanic American, and 1.6% of the sample did
not disclose their ethnicity. With regard to high-
est mental health degree, 86.2% of the sample
had obtained a master’s degree, 6.5% had a
doctoral degree, 4.9% had another type of de-
gree, and 2.4% had an educational specialist
degree. Nearly 6% (5.6%) of the sample was
over the age of 61, 32% was 51 to 60, 24.8%
was 41 to 50, 20.8% was 31 to 40, and 15.2%
was 23 to 30.

Instruments

Participants were asked to complete a 40-
item questionnaire that measured the domains
of job satisfaction, areas of care and practice,
competence in areas of care from schooling, and
strengths and challenges in providing services
in a rural area.

Scope of care, competence, and educa-
tional training. Participants were asked to re-
port areas of regular practice within their clini-
cal work, including substance abuse, ethnically
diverse clients, clients in poverty, older adults,
and other practice areas in responding to the
prompt of “In my clinical work, I regularly deal
with the following types of clients . . . .” The
full list of areas of practice is provided in Table
1. Practitioners were also asked to report on
their level of perceived competence as well as
whether they believed their educational experi-
ence provided training in each of the areas of
practice by responding to the following
prompts: “I feel competent in dealing with the
following clinical issues . . .” and “The program

I attended did a good job preparing students to
work with . . .” The same 5-point scale (1 �
strongly disagree, 2 � disagree, 3 � neutral,
4 � agree, 5 � strongly agree) was used to
assess areas of practice, competence, and edu-
cational training.

Job satisfaction. The Andrews and Withey
(1976) Job Satisfaction Questionnaire was used
to measure job satisfaction with a five-item,
7-point Likert-type scale (1 � delighted, 2 �
pleased, 3 � mostly satisfied, 4 � mixed, 5 �
mostly dissatisfied, 6 � unhappy, 7 � terrible).
Items on the scale include measuring how the
respondent feels about physical surroundings,
resources, people/staff, and the actual tasks that
respondent completes. Internal consistency for
the Job Satisfaction Questionnaire has been re-
ported at .80 (Rentsch & Steel, 1992). The
instrument has been found to correlate with
other measures of job satisfaction, including the
Minnesota Satisfaction Questionnaire (Rentsch
& Steel, 1992; van Saane, Sluiter, Verbeek, &
Frings-Dresen, 2003). The measure also has
been found to predict job performance and like-
lihood of employee job termination (Rentsch &
Steel, 1992).

Challenges and opportunities. Participants
were asked to respond to a series of open-ended
questions about their work in a rural setting: (a)
what do you like about your job, (b) what are
the drawbacks or limitations of your job, (c)
what are the drawbacks or limitations of the
location where you live, and (d) what are the
benefits of the location where you live?

Table 1
Descriptive Statistics for Scope of Practice (N � 123)

Regularly work with:

Degree of agreement percent of sample (frequency)

Strongly disagree Disagree Neutral Agree Strongly agree

Client of diverse ethnic/racial backgrounds 5.60 (7) 23.4 (29) 20.2 (25) 33.9 (42) 16.1 (20)
Gay, lesbian, or bisexual clients 16.1 (20) 16.1 (20) 21.0 (26) 42.7 (53) 9.7 (12)
Geriatric/older clients 22.6 (28) 21.0 (26) 14.5 (18) 31.5 (39) 9.7 (12)
Children/adolescents 8.9 (11) 10.5 (13) 5.6 (7) 28.2 (35) 45.2 (56)
Clients with disabilities 0.0 (0) 9.7 (12) 11.3 (14) 48.4 (60) 29.0 (36)
Clients with substance abuse problems 2.4 (3) 8.1 (10) 4.8 (6) 33.9 (42) 49.2 (61)
Clients dealing with bereavement .8 (1) 4.0 (5) 16.9 (21) 57.3 (71) 20.2 (25)
Clients in poverty 1.6 (2) 1.6 (2) 3.2 (4) 36.3 (45) 56.5 (70)
Clients dealing with domestic violence .8 (1) 1.6 (2) 8.1 (10) 57.3 (71) 31.5 (39)
Clients with relationship/marital problems 1.6 (2) 4.8 (6) 8.9 (11) 41.9 (52) 41.9 (52)

Note. Percentages do not add up to 100 because some respondents chose not to respond.

41RURAL MENTAL HEALTH PRACTICE

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

Procedure

Participants were recruited through a regional
counseling conference electronic mailing list,
professional organizations, and contacts at men-
tal health centers. Individuals were directed to a
Web page that provided information regarding
informed consent. Participants indicated their
consent by clicking on a hyperlink that took
them to the survey Web page. Data were col-
lected from each participant without collecting
identifying information such as name or ad-
dress. Completion time for the survey was un-
der 30 min. Approval was granted by the insti-
tutional review board prior to starting the study.

Data Analysis

Once data were collected on the four open-
ended questions on work setting and rural life,
responses to each question were distributed to
five team members, four of whom were gradu-
ate students familiar with the literature on rural
practice and their faculty research advisor. The
team used open coding to capture impressions
of participant responses. Each research team
member generated a list of predominant themes
that were then presented to the group. Catego-
ries were allowed to emerge from the data,
using codes developed by group consensus to
identify key themes. One team member main-
tained memos of the group’s process to ensure
that the coding strategies eventually adopted
would reflect the original data set. Given the
interaction between subject and researcher,
keeping notes or memos on the process of cod-
ing helps limit the impact of the researchers on
the material (Fassinger, 2005). In addition to the

use of memoing, the faculty member served to
audit the coding process, evaluating each of the
themes and assuring the individual responses
from respondents aligned with the theme. Team
members ranked emergent categories to priori-
tize those that appeared more important to par-
ticipants.

Results

Scope of Care, Competence, and Training

Table 1 provides data on the areas of practice
for the participants. In general, participants
practice within a variety of clinical domains. In
particular, rural practitioners reported that they
regularly see clients with substance abuse con-
cerns (83.1% agreeing or strongly agreeing).
Nearly 90% of participants agreed or strongly
agreed that they routinely saw clients with do-
mestic violence concerns, and almost 80% re-
ported regularly working with clients with dis-
abilities. Given the frequency of working with
clients with disabilities, and thus the greater
likelihood that these individuals may need gov-
ernment assistance, 92.8% of the sample agreed
or strongly agreed that they worked with indi-
viduals in poverty. Within areas of less frequent
practice, 52.4% of participants agreed or
strongly agreed that they routinely work with
lesbian, gay, or bisexual (LGB) clients. Forty-
one percent (41.2%) of participants strongly
agreed or agreed that they routinely worked
with older clients.

Table 2 reports the level of agreement for
feeling competent to work with eight areas of
practice. In general, most participants felt com-

Table 2
Descriptive Statistics for Areas of Competence (N � 123)

Feel competent working with:

Degree of agreement percent of sample (frequency)
Strongly disagree Disagree Neutral Agree Strongly agree

Depressive disorders 0.0 (0) .8 (1) 1.6 (2) 33.1 (41) 63.7 (79)
Anxiety disorders 0.0 (0) .8 (1) .8 (1) 42.7 (53) 54.8 (68)
Substance abuse disorders 3.2 (4) 12.9 (16) 16.1 (20) 29.8 (37) 36.3 (45)
Marital/relationship concerns 0.0 (0) 8.1 (10) 6.5 (8) 46.0 (57) 38.7 (48)
Sexual offender treatment 32.3 (40) 35.5 (44) 14.5 (18) 11.3 (14) 5.6 (7)
Anger management treatment .8 (1) 10.5 (13) 7.3 (9) 41.9 (52) 38.7 (48)
Parent training 1.6 (2) 5.6 (7) 15.3 (19) 39.5 (49) 37.1 (46)
Child behavior disorders 4.8 (6) 9.7 (12) 13.7 (17) 34.7 (43) 36.3 (45)

Note. Percentages do not add up to 100 because some respondents chose not to respond.

42 HASTINGS AND COHN

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

petent to work with many groups. Sexual of-
fender treatment had the lowest level of com-
petency, with 67.8% of the sample reporting
that they disagreed or strongly disagreed that
they were competent to treat these concerns.
Most practitioners agreed or strongly agreed
that they felt competent to treat depressive dis-
orders and anxiety disorders, 96.8% and 97.5%,
respectively. Although 83.1% of the sample re-
ported that they agreed or strongly agreed that
they routinely saw clients with substance abuse
concerns, only 66.1% reported that they agreed
or strongly agreed that they felt competent to
treat individuals with these concerns.

Participants were asked to report to what
degree their educational training program did a
good job preparing students to work in different
domains. Educational training experiences are
reported in Table 3. Understandably, graduate
programs cannot anticipate all the needs their
students may face. However, 25% of the sample
disagreed or strongly disagreed that their train-
ing program had prepared them to work with
LGB clients. A quarter of the sample (25.8%)
reported a neutral training experience with LGB
clients in their educational programs. Nearly
30% (29.9%) of the sample reported disagree-
ing or strongly disagreeing that their educa-
tional program did a good job preparing them to
work with older clients, but only 12.9% of the
sample disagreed or strongly disagreed that
their program did a good job training to work

with children. The lack of formalized training in
working with older adults could be a significant
concern for rural practitioners who may have
fewer options to refer clients for who they have
little training or experience.

Job Satisfaction

Internal consistency for the Andrews and
Withey Job Satisfaction Scale was � � .74. Of
those responding to the survey, nearly 24%
were “delighted” with their job and 29.3% were
“pleased.” Twenty-six percent (n � 32) indi-
cated they were “mostly satisfied” with their
current job and 13% were mixed about their
satisfaction. Fewer numbers were dissatisfied,
with 5.7% indicating they were mostly dissatis-
fied and less than 1% (.8%) were either unhappy
or “terribly unsatisfied.” The mean job satisfac-
tion rating for the item assessing overall job
satisfaction was 2.53 (SD � 1.26, range 1 to 7).
An overall index score was calculated by sum-
ming responses on all five items, with higher
scores indicating greater dissatisfaction (mini-
mum score possible � 5; maximum score pos-
sible � 35). In the current study, the range on
the job satisfaction index was 5 to 19, with a
mean score of 12.72 (SD � 4.51).

Perceived Opportunities

Responses to open ended questions revealed
themes, which are reported in Table 4. When

Table 3
Descriptive Statistics for Educational Training (N � 123)

Educational training program preparation
area:

Degree of agreement percent of sample (frequency)
Strongly disagree Disagree Neutral Agree Strongly agree

Client of diverse ethnic/racial backgrounds .8 (1) 9.7 (12) 14.5 (18) 50.8 (63) 22.6 (28)
Gay, lesbian, or bisexual clients 4.0 (5) 21.0 (26) 25.8 (32) 37.1 (46) 9.7 (12)
Geriatric/older clients 6.5 (8) 23.4 (29) 24.2 (30) 35.5 (44) 8.9 (11)
Children/adolescents 4.0 (5) 8.9 (11) 16.1 (20) 38.7 (48) 30.6 (38)
Clients with disabilities 1.6 (2) 21.0 (26) 25.0 (31) 34.7 (43) 16.1 (20)
Clients with substance abuse issues 1.6 (2) 20.2 (25) 21.8 (27) 37.9 (47) 16.1 (20)
Clients dealing with bereavement 1.6 (2) 12.1 (15) 23.4 (29) 47.6 (59) 13.7 (17)
Clients in poverty 3.2 (4) 12.1 (15) 16.1 (20) 44.4 (55) 21.8 (27)
Clients dealing with domestic violence 18.5 (23) 16.9 (21) 28.2 (35) 34.7 (43) 18.5 (23)
Depressive disorders 0.0 (0) 5.6 (7) 11.3 (14) 39.5 (49) 36.3 (45)
Martial/relationship concerns 0.0 (0) 8.9 (11) 18.5 (23) 43.5 (54) 27.4 (34)
Sexual offender treatment 26.6 (33) 34.7 (43) 21.0 (26) 15.3 (19) 15.3 (19)
Anger management 3.2 (4) 16.9 (21) 32.3 (40) 32.3 (40) 12.9 (16)
Parent Training 1.5 (2) 18.5 (23) 28.2 (35) 33.1 (41) 16.1 (2)

Note. Percentages do not add up to 100 because some respondents chose not to respond.

43RURAL MENTAL HEALTH PRACTICE

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

given the opportunity to express benefits asso-
ciated with practicing in a rural environment,
the most commonly occurring topics include
freedom and flexibility in their personal prac-
tices; this theme typifies practitioners’ enjoy-
ment of the freedoms associated with general
practice as well as the utilization of creative
techniques in their direct work with clients. One
respondent said, “I love the flexibility of my
work schedule. . . . I enjoy creating my own
niche (early childhood mental health) in the
community and being recognized as someone to
contact for challenges related to this.” Another
commented,

I like my peers/coworkers. I enjoy feeling part of a
team that provides quality counseling services to the
community. I like being able to provide assessments to
engage people in our services; I get satisfaction in
helping individuals feel grounded in beginning the
treatment process.

A third stated, “I get to be a part of making a
difference in the lives of families.” These prac-
titioners relish their role in the community.
Their visibility permits an awareness of individ-
ual families and an ability to make a difference,

and they use the resultant respect to collaborate
with other professionals to provide the most
effective multimodal treatment. Interestingly,
two of these sample responses contradict as-
pects of rural practice frequently discussed in
the literature. The first respondent, for example,
introduced the notion of “creating a niche” in
her community with young children. As dis-
cussed earlier, the literature on rural practice
typically emphasizes the need for clinicians to
equip themselves with generalist skills to meet
the varying demands of their underserved area.
Yet this clinician was able to identify a specific
area of need and adapt to meet it. The second
participant’s response stresses the value of
working with a team. Again, the literature on
rural practice focuses on clinicians often lacking
support of colleagues who may be miles away.
However, it is worth noting that an earlier study
examining mental health counselors in rural
Kansas (Kee et al., 2002) found that rural prac-
titioners who had greater social support were
less likely to suffer the effects of burnout. It
appears our sample captured an example of a
clinician with nurturing collegial relationships,

Table 4
Themes Related to Work and Living Location

Open-ended questions Participant themes

What do you like about your job? Making a difference
Freedom, flexibility, autonomy
Diversity of clients and client issues
Coworkers
My family is close by

What do you dislike about your job? Salary/benefits
Funding/resources/clients lack insurance
Overworked
Agency problems and politics
Travel, distance, driving

What do you like about where you live? “I was born here”
Peace and quiet
Live away from clients
Landscape
Rural people/rural lifestyle
Few city problems (low crime, less light pollution, clean water and air, etc.
It’s “close enough” to conveniences
Close to family/friends
Low cost of living

What do you dislike about where you live? Limited access to stores (especially book stores), services, and professional
opportunities

Little diversity
Conservative community
Lack of privacy
Driving distances

44 HASTINGS AND COHN

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

and in this clinician’s case, these relationships
significantly enhanced her satisfaction with her
rural position.

Other positive qualities related to residing in
rural environments that emerged in the research
pertained to familial ties to the community,
stunning vistas, a negligible cost of living, and
appreciation of small town culture. As one re-
spondent commented, “I have lived here for 34
years, have made many friends, and I feel at
home here. There’s a less stressful lifestyle. I
have a supportive community of friends, and
it’s beautiful!” Another remarked,

People in the community seem to know one another
better than in a larger city. This can lend itself to
looking out for one another. The area is mountainous
and very picturesque. I share the values of the locals
and the appreciation for simplicity.

Small town culture is characterized by a
sense of community responsibility, individual
agrarian values, commonality of religion, and a
general fund of knowledge regarding one’s
neighbors. Several respondents commented on
leaving doors unlocked at night and enjoying
scenic commutes to work that do not involve
heavy traffic or interstates.

Perceived Challenges

Many of the reported benefits of rural work
can also be some of the greatest impediments,
such as intrusions into privacy. One respondent
commented, “There’s a lot of gossip among the
staff because everyone knows everyone.” An-
other stated,

A lot of the staff have not worked anywhere outside of
here, so their experiences with a variety of clients and
issues is limited, as is their exposure to new tech-
niques, and so forth This also lends to them knowing
personal histories of clients and their families, which
can sometimes lead to prejudgment of the clients.

Other challenges included inadequate fund-
ing, resources, and insufficient compensation.
One of the primary concerns included the per-
vasive tedium of duties not associated with pro-
viding direct care to clients, such as travel time,
paperwork, and battling managed care and state
mental health reforms. “The limitations of the
job are that there is too much work and not
enough licensed staff to go around. Over-
whelmed caseloads make you feel like you can-
not always provide quality when you are push-

ing nonsensical state paperwork,” noted one
respondent.

In order to maintain self-care and competence
in a general practice, professionals engage in
consultation and collaboration with their col-
leagues. However, because of insufficient sup-
port in rural areas, many are not receiving this
type of support or the only assistance is by
individuals without the appropriate training.
One respondent stated, “There is a tremendous
amount of paperwork. The work duties and ex-
pectations are increasing. In short, there are less
people doing more work than in the past. I wish
that I felt more supported by administration.”

Additional responses noted difficulties with
lack of privacy, inability to freely express di-
vergent opinions, and suspicion associated with
nonindigenous practitioners (“outsiders”). Poor
economic growth is associated with limited re-
sources, limited convenience, and limited profes-
sional opportunities. These factors exacerbate
existing social problems, including widespread
substance abuse, insufficient mental health care,
and poor access to medical care.

Implications and Future Research

The findings from the current study have
implications for individuals who are interested
in working in rural settings. Because of the
special demands of practicing in a rural setting,
mental health practitioners interested in rural
work need to find opportunities to acquire both
knowledge and experience in order to practice
professionally in a rural environment.

The results from this study provide insight
into whom to recruit to work in rural settings.
Individuals who have strong boundaries but are
able to balance the demands of the fluid nature
of privacy in a rural area may be best suited to
rural practice. Further, individuals with a strong
sense of self and who value autonomy may be
best suited for rural practice. In order to keep
practitioners in rural areas, facilities may have
to provide greater opportunities for receiving
supervision from appropriately credentialed su-
pervisors, peer mentoring, consultation, diver-
sity in work-related tasks, and opportunities for
self-care.

An unexpected finding in this study was the
age range of participants. The largest repre-
sented group consisted of people ages 51 to 60
(32.0%). If this is an accurate reflection of the

45RURAL MENTAL HEALTH PRACTICE

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

mental health work force in some rural areas,
then within the next 10 years, a significant pro-
portion of providers will be nearing retirement.
Thus, there may be additional opportunities for
new professionals to establish homes and ca-
reers to meet the needs of an underserved pop-
ulation. Mental health agencies may benefit
from considering the age distribution of their
work force to ensure adequate service delivery
in the future. Further, agencies likely will need
to be active in recruiting counselors to work in
rural areas. Highlighting the benefits of rural
work, including overall job satisfaction of coun-
selors, collaboration with colleagues, and op-
portunities to utilize creative, innovative ap-
proaches to counseling will likely be attractive
to potential candidates.

In the future, researchers may want to exam-
ine two areas regarding what individuals find
attractive about rural practice and what helps
individual stay in rural practice. Jameson and
colleagues (2009) surveyed graduate students
and found that, in theory, graduate students
indicated that there were not necessarily op-
posed to practicing in a rural area. Thirty-five
percent of respondents had a mildly, moder-
ately, or strongly positive attitude toward work-
ing in a rural setting. In actuality, however,
practitioners may be less inclined to select a
rural area than a suburban or metropolitan set-
ting. For example, Mills and Millsteed (2002),
in exploring rural practice in Australia, reported
that both recruiting and retaining practitioners
(occupational therapists, primary care physi-
cians, and psychologists) has been especially
difficult in rural settings. Therefore, it may be
helpful to understand what aspects of rural life
are appealing or attractive for potential practi-
tioners. The current study clarified what people
value once they are in a rural setting as well as
indicating that, in general, practitioners are sat-
isfied with their job; in the future, it may be
helpful to understand what practitioners find
attractive about the rural setting before they
enter rural practice. Further, additional study
may help determine whether students who are
trained in rural psychology work and stay in
rural areas.

An additional area of research within the area
of rural practice is to understand the impact of
stressors on the rural clinician. If the clinician
must be ever vigilant for potential boundary
crossings and dual relationships, how does this

vigilance influence the practitioner’s overall
sense of well-being and security? Moreover, if
the clinician is in a “fish bowl” and something
“goes wrong” personally or professionally, how
do those stressful events impact the rural prac-
titioner? Is the effect of the stress different from
that experienced by practitioners in a metropol-
itan area in which he or she can more easily fade
into the masses? Future research could compare
levels of stress and burnout among rural mental
health providers versus those in more metropol-
itan areas.

There are a number of limitations to the cur-
rent study. In general, the majority of the par-
ticipants were quite satisfied with their job, so it
is possible that individuals who were not satis-
fied may have been less likely to respond. Ad-
ditionally, given that some participants were
recruited from listservs, it is possible that the
overworked and overburdened practitioner may
not have had resources (e.g., time or energy) to
complete the survey, thus minimizing the chal-
lenges reported concerning rural practice.
Moreover, given the potential difficulties and
risk of burnout in rural practice, individuals
who are highly dissatisfied may move to urban
areas and therefore would not have been in-
cluded in this research. Additionally, this re-
search sample was comprised of practitioners in
the central Appalachian region. Although the
sample provides a snapshot of mental health
practitioners in this area of North America,
samples from other regions may appear quite
different on some important dimensions. Be-
cause of the breath of rural practice, the ability
to generalize the current findings to all areas of
rural practice may be limited.

Conclusions

In the current study, practitioners’ views of
the benefits and challenges of rural mental
health practice show many trends, primarily
that, often, the very aspects of the area that
make it most appealing can also lead to many
challenges in providing mental health services.
For example, although some participants com-
mented on the easy-going nature of rural life
and the peace and quiet they enjoy, others noted
the difficulty of accessing resources such as
bookstores, the performing arts, and museums.
Findings also indicated that practitioners need
to have experience that allows them to practice

46 HASTINGS AND COHN

T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

competently with clients ranging across the life
span and thus will need to have exposure, ex-
perience, and training to treat a variety of con-
cerns. Additionally, results indicated that these
training experiences may not be available in the
graduate programs, and, therefore, students may
have to make special efforts to seek out oppor-
tunities for rural practice.

Practitioners who enter training programs
that place emphasis on working within a devel-
opmental framework and focusing on preven-
tion and psychoeducation may be especially
well-suited for rural practice. Training pro-
grams would assist their students by incorporat-
ing more information about rural practice, es-
pecially regarding rural cultural norms and
boundary negotiation, and providing training
experiences serving rural populations. In addi-
tion, programs could help clinicians in training
develop skills to assess the needs of small com-
munities in order to identify any special areas of
practice that would benefit those communities.

Finally, the potential for therapists to make a
significant impact in rural settings appears to be
increasing. In our sample, large numbers of
practitioners will be retiring within the next 8 to
10 years, exacerbating the long-standing short-
age of rural providers. Early career counselors
and graduate students who have not considered
rural practice may want to explore the possibil-
ities of working in these underserved areas.

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Andrews, F. M., & Withey, S. B. (1976). Social
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Aten, J. D., Mangis, M. W., & Campbell, C. (2010).
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ol
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ss
oc
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ti
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e
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it
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al
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ed
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bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
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548.

Received November 27, 2012
Revision received March 15, 2013

Accepted March 18, 2013 �

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49RURAL MENTAL HEALTH PRACTICE

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pe
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on
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us
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of
th
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in
di
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du
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us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.