The Role of Clinical Psychology in Rural Mental Health
Services: Defining Problems and Developing Solutions
CLINICAL
PSYCHOLOGY
PSYCHOLOGY:
AND
SCIENCE
MENTAL Published
HEALTH
AND PRACTICE
JAMESON
• V14
N3,
& BLANK
SEPTEMBER
2007
Original
XXX
Blackwell
Malden,
Clinical
CPSP
©
0969-5893
2007 American
Psychology:
USA
Articles
Publishing
Psychological
Science
IncRURAL
andAssociation.
Practice
by •Blackwell
Publishing
on behalf of the
American Psychological Association.
John Paul Jameson, Department of Psychology, University of Pennsylvania
Michael B. Blank, Center for Mental Health Policy and Services Research, Department of
Psychiatry, University of Pennsylvania
Rural areas of the United States continue to struggle
to provide residents with adequate access to quality
mental health care. Problems with adequately defining
rurality for research and policy purposes, a shortage
of qualified personnel, a lack of integration between
primary-care and specialty mental health services, and
stigma associated with mental illness have contributed
to the mental health service crisis in rural areas. The
assertion is made that psychologists can help to alleviate
these problems through specialized training for rural
service, the utilization of technology for service delivery,
the dissemination of empirically supported treatments,
and grassroots advocacy. Furthermore, the advantages
and disadvantages of prescription privileges for psychologists and the unclear status of subdoctoral providers
are discussed in terms of potential impact on rural areas.
Finally, psychologists are encouraged to direct research
efforts toward the development and implementation of
novel solutions to the service problems in rural areas.
Key words: mental health services, psychologists,
rural environments. [Clin Psychol Sci Prac 14: 283–298,
2007]
INTRODUCTION
Throughout our history, the United States has enjoyed
portraying itself as a rural nation. Our songs speak of
Address correspondence to John Paul Jameson, Department of
Psychology, University of Pennsylvania, 3720 Walnut Street,
Philadelphia, PA 19104-6241. E-mail: jjameson@psych.upenn.edu.
the majesty of our mountains and the fruitfulness of our
planted plains, our literature relates stories of hardships
of farming and the loneliness of the frontier, and our
artists give renditions of wide open spaces and the
simplicity of country living. Even today, we pride ourselves on our independence and frontier spirit, although
only approximately 20% of Americans live in rural areas
(United States Bureau of the Census, 2001).
Despite our heritage as a rural society, individuals in
rural areas today can be characterized as a vulnerable population. Rural residents are more likely to live in poverty,
lack health insurance, report poor health, have a chronic
health condition, and be unemployed (see Wagenfeld,
2003, for a review). As a population, rural inhabitants
earn less income and include a higher proportion of the
elderly. Additionally, rural areas lack the social and health
services necessary to accommodate its inhabitants.
Services that do exist have been described as fragmented
and inconsistent (Fox, Blank, Kane, & Hargrove, 1994).
This is especially true of mental health care in rural areas.
Empirical research on mental health care in rural areas
is scarce, and the research that does exist paints a bleak
picture of the available services. Furthermore, research
conducted on rural areas, including many of the studies
cited in this article, has often been limited to sampling
rural areas in one particular geographic region of the
country. The generalizability of many studies can be
questioned for this reason. That said, the prevalence
of mental illness in rural areas does not appear to differ
from rates seen in nonrural areas, based on results from
the National Comorbidity Study and the Epidemiologic
Catchment Area Study (Kessler et al., 1994; Robins
© 2007 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association.
All rights reserved. For permissions, please email: journalsrights@oxon.blackwellpublishing.com
283
& Reiger, 1991). The purpose of the present article is to
provide an overview of the mental health care problems
in rural areas, offer suggestions for the amelioration of the
problems faced, and help direct future research efforts.
Issues of Definition: What Is Rural?
Defining rurality is an issue that invariably arises in any
discussion of rural problems. Wagenfeld (2003, p. 33)
described the consideration of definitions of rural as “a
surprisingly difficult task.” This task should not be taken
lightly: The method by which rural is defined can have
far-reaching impact on the application of policy. The
definitions of rural most commonly used in research are
those supplied by the U.S. Census Bureau, the Office of
Management and Budget (OMB), and the United States
Department of Agriculture (USDA). All of these methods
rely on population as the central metric of determining
what is rural and what is not. Each of the definitions has
advantages and disadvantages, and none are completely
adequate to delineate all areas that most would consider
to be rural. Furthermore, there is not complete overlap
of areas using these definitions. For example, Ricketts,
Johnson-Webb, and Taylor (1998) reported that in 1990,
37.3% of individuals living in OMB-defined nonmetropolitan areas were categorized as urban dwellers
by the U.S. Census Bureau and 13.8% of individuals in
OMB-defined metropolitan areas were defined as rural
dwellers by the census.
The USDA (United States Department of Agriculture
Economic Research Service, 2003) provides what is
probably the most popular method for defining rural among
researchers (Blank, Fox, Hargrove, & Turner, 1995;
Wagenfeld, Goldsmith, Stiles, & Manderscheid, 1993).
The USDA uses urban–rural continuum codes to indicate
a county’s degree of rurality. The coding scale assigns a
designation on a scale of 1 (most urban) to 9 (most rural).
Counties coded 1–3 are considered metropolitan, whereas
counties coded 4–9 are considered nonmetropolitan.
Metro counties are designated based on population;
nonmetro counties are designated based on population
and proximity to urban areas. There is good reason for
its popularity; to an extent, one can infer the influence
of urban areas on rural areas using this system, an
important consideration when evaluating the availability
of mental health services. However, this definition has
serious shortcomings as well. Perhaps the most damning
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
flaw is that codes are assigned at the county level, limiting
the ability to precisely demarcate rural areas. This is
particularly problematic for large western counties, in
which inhabitants can live minutes or hours from a large
city and inhabit the same county. An illustrative example
of this problem is Coconino County in Arizona. Coconino
County contains the city of Flagstaff, and is coded as
a 3 (metropolitan county with a population fewer than
250,000). However, residents of the sparsely populated
northern reaches of this county must travel 150 miles to
Flagstaff!
Established methods of defining rural are plagued by a
number of difficulties. Rurality is certainly a continuous
variable, and attempts to label it as categorical will
probably always be problematic. None of the methods
take into consideration the economic base, values, or
perceptions of inhabitants as to the rurality of their area.
Alternative methods have been derived to take into consideration some of these factors. For example, Hewitt
(1989) recommended a categorization system for rural
counties that considers counties’ economic bases for the
study of health care availability, but this method has
not gained widespread acceptance by researchers at this
point. It is doubtful that a consensus will ever be reached
on a definition that fully captures the demographic,
cultural, and economic aspects of rurality, but efforts to
incorporate these features should be undertaken if research
on rural areas is to accurately reflect its subject.
The Services Crisis in Rural Mental Health
One of the most serious issues facing mental health
care in rural areas today is the difficulty in recruiting and
retaining qualified personnel to provide services to
individuals in need. There is a well-established shortage
of qualified mental health professionals in rural areas
(Goldsmith, Wagenfeld, Manderscheid, & Stiles, 1997).
Additionally, the increase of mental health professionals
in rural areas was minimal during the 1990s, despite a
substantial increase in population. According to a report
published by the United States Department of Health
and Human Services, nearly three-fourths of counties
with populations between 2,500 and 20,000 lack a
psychiatrist and approximately half are without a master’slevel or doctoral-level social worker or psychologist
working in health care and residing within the county
(Holzer, Goldsmith, & Ciarlo, 1998). Furthermore,
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inpatient facilities are virtually nonexistent in rural
communities: Wagenfeld et al. (1993) found that only
13% of nonmetropolitan counties had inpatient facilities,
and none of the most rural counties had such services.
Although the situation is not quite as bleak with regard
to primary-care providers, approximately one-third of
counties with a population of less than 2,500 do not
have a physician practicing general medicine within their
boundaries. Based on this finding, it has been surmised
that one-third of the most rural counties lack any health
professionals available to address mental health problems,
and a much greater percentage of these counties lack any
kind of specialty mental health services (Gamm, Stone,
& Pittman, 2003). One implication of such shortages is
that individuals in need of treatment for mental health
problems must travel great distances in order to obtain
services. Greater travel distances for mental health and
substance abuse treatment have been associated with
reduced outpatient visits and increased likelihood of
expensive hospitalization (Fortney, Booth, Blow, Bunn,
& Cook, 1995; Fortney, Owen, & Clothier, 1999).
Hargrove (1991) has proposed several reasons why
clinical psychologists may favor more urban environments
for employment and practice. He argues that because
of increased specialization in doctoral programs, clinical
psychologists are not well prepared to handle the wide
scope of clients with a wide range of problems that are
encountered in rural areas. Additionally, psychologists
in rural areas are often quickly moved to administrative
or supervisory roles. This may reduce the attractiveness
of rural employment, as individuals in these positions
often cease to directly provide services to patients.
The reduced patient contact hours may be evaluated as a
negative, in that many doctoral-level psychologists may
see providing direct care as their primary role. Moreover,
mental health care in rural areas is dominated by the
public sector, which may have difficulty compensating
psychologists at a rate competitive with private urban
service providers. As such, social workers increasingly
provide services in community service organizations that
have been traditionally associated with psychologists.
Finally, the argument has been made that the cultural
richness that students become accustomed to during
their graduate training (especially in larger programs in
urban areas) cannot be matched by rural areas. Additionally,
DeLeon, Wakefield, and Hagglund (2003) suggest that
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
job satisfaction may be lower for psychologists in rural
areas because of cultural barriers and a lack of respect for
their professional judgment, thereby making it difficult
to retain their services. All of these reasons may contribute to the general absence of psychologists in rural
areas, although we could locate no attempts to systematically study the reasons psychologists tend to be attracted
to urban areas.
Individuals residing in rural areas in need of mental
health treatment often turn to informal sources of care.These
sources include self-help, family, spouses, neighbors, friends,
and religious organizations (Blank, Mahmood, Fox, &
Guterbock, 2002; Fox, Merwin, & Blank, 1995). However, we have not examined the effectiveness of such interventions (Fox et al., 1995). More research must be conducted
to determine whether these informal sources represent an
effective alternative to specialty mental health care.
In addition to the shortage of specialty mental health
professionals in rural areas, there is evidence that the
providers who do practice in rural areas experience
very high rates of burnout. In a study conducted by Kee,
Johnson, and Hunt (2002), 192 full-time, master’s-level
licensed professional counselors and licensed master’slevel psychologists practicing in nonmetropolitan areas
of Kansas completed the Maslach Burnout Inventory
(Maslach & Jackson, 1981). Results indicate that 65% of
the counselors surveyed experienced at least moderate
levels of burnout, indicating a greater degree of burnout
than in a normative sample. Emotional exhaustion
was the most prevalent form of burnout, with 69.3% of
respondents experiencing at least moderate levels.
Burnout was predicted by a lack of social integration
with other professionals, a lack of guidance and advice
from authoritative sources, and the absence of reliable
support from others for assistance. These findings suggest
a lack of collaborative efforts between mental health
professionals in rural areas. This comes as no surprise,
given the overall scarcity of professionals in these areas.The
opportunities for support among co-workers in rural
areas seem to be as rare as the providers themselves. The
authors recommend incorporating these issues into training
programs. Additionally, the authors advocate creating
opportunities for greater peer collaboration and support
through retreats and professionally led support groups,
but caution that funding is in short supply. As such,
programs like these may not be economically feasible.
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Lack of Integration With Primary-Care Providers
The integration between primary-care professionals (such
as general practice physicians and nurses) and specialty
mental healthcare providers is often seen as low in
rural areas, and a great deal of research has lent credence
to this assertion. Based on findings from Geller (1999),
primary-care physicians in rural areas see themselves
as playing a larger role in the provision of mental health
care than do primary-care physicians in urban areas.
However, these findings resulted from a focus group
conducted with physicians in the rural Midwest, so their
generalizability to other rural primary-care providers is
questionable. Research also suggests that rural primarycare practitioners treat more cases of depression without
consultation with or referral to a specialty provider than
do their urban counterparts (Hartley, Korsen, Bird, &
Agger, 1998; Lambert & Agger, 1995). However, these
providers acknowledge a number of constraints on their
ability to provide mental health services (Hartley et al.,
1998). A study of largely rural primary-care practitioners
revealed that a majority thought that a lack of knowledge
about treatment, a lack of time, patients’ refusal of
treatment, and the unavailability of a specialist consultant
hindered their ability to treat depressed patients at least
somewhat. Despite the acknowledgment of these
barriers to primary-care treatment, the practitioners also
cited several impediments to providing depressed patients
with referrals to specialty mental health care providers.
A majority of practitioners perceived a lack of available
services, the physical distance of specialty services,
issues with reimbursement for specialty services, patient
unwillingness to use specialty services, and long waits
for appointments as moderate or major hindrances to
providing services. The willingness of primary-care
physicians to treat depressed patients or provide them
with referrals was not directly associated with the local
supply of specialty mental health providers, but practitioners who were confident in their ability to treat
depression were more likely to treat patients. The
authors suggest increasing the availability of continuing
education programs to improve practitioners’ knowledge
and competence in the treatment of depression, especially in isolated areas where specialty care may be unavailable. Such programs could be integrated into existing
continuing education programs such as Area Health
Education Centers.
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
Additionally, primary-care physicians often seem reluctant
to diagnose mental disorders. In a nationwide survey,
Rost, Smith, Matthews, and Guise (1994) found that
approximately half of physicians in primary-care settings
deliberately misdiagnose depression. These physicians cited
uncertainty about the diagnosis, problems with reimbursement for services if a diagnosis of depression is given,
and fear that the patient may not be able to obtain health
insurance in the future as the most common reasons
for purposefully misdiagnosing depression. Instead, they
often give diagnoses of fatigue/malaise, insomnia, or
headache to depressed patients. The authors suggest
that the rates of deliberate misdiagnosis found in the
study are likely an underestimate of the actual prevalence
of this practice because of the survey methods used. In
addition to the moral and ethical questions that this
common practice raises, there may be implications for
treatment as well. Patients receiving an alternative diagnosis
may be much less likely to be referred to a mental health
services provider or to seek out specialty treatment,
representing a further disconnection between primarycare and specialty mental health services. Furthermore,
they may be less likely to receive appropriate prescriptions
from their primary-care provider. However, the extent to
which misdiagnosis affects treatment seeking and treatment outcome is not known.
Anecdotal evidence also supports the notion that
primary-care physicians see the treatment of mental
illness as a difficult issue in terms of practicality and
maintaining relationships with patients. For example,
interviews with six rural physicians in Nebraska yielded
several common themes: Depression is common in their
practices; depression is often easily recognized, but difficult
to diagnose with precision; depression can be treated
effectively, but requires the cooperation of the patient to
mange; and depression is important to treat, but difficult
to manage because of constraints on time and resources
(Susman, Crabtree, & Essink, 1995). The apparent recognition of these issues by physicians is important; they may
also see a need for increased integration with specialty
mental health care. As noted by Lambert and Hartley (1998,
p. 966), “Organizations cooperate with each other when
it is in their interests to do so.” It is certainly in the
interests of the populations served by rural physicians
and specialty mental health services to have these institutions collaborate to increase the quality of care they receive.
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Individual and Social Factors as Barriers to Treatment
Rural dwellers have long been characterized as having a
strong sense of community and extended social networks,
and rural communities are often seen as places where word
travels fast and everybody knows everybody. Although
the empirical basis of these beliefs is open to debate,
individuals in rural areas often do cite social stigma
and lack of privacy as reasons not to seek help for mental
distress. Social stigma has been associated with several
factors detrimental to the treatment and rehabilitation
of the mentally ill. High perceptions of stigma have been
associated with low self-esteem and low quality-of-life
ratings in seriously mentally ill patients, as well as greater
withdrawal from social interactions after treatment (Link,
Struening, Neese-Todd, Asmussen, & Phelan, 2001; Perlick
et al., 2001; Rosenfield, 1997). Additionally, stigma has
been associated with reduced life satisfaction (Rosenfield,
1997). Clearly, stigma associated with mental illness plays
a significant role in the lives of the mentally ill.
Many studies (but not all) have found social stigma
associated with mental illness to be higher in rural areas
than in nonrural areas. A survey of adults by Hoyt,
Conger, Valde, and Weihs (1997) found higher perceived
stigma associated with mental health care in rural
areas than in nonrural areas. Furthermore, the degree to
which stigma was perceived predicted willingness to
seek treatment for mental health problems. Individuals in
rural areas also perceive a lack of privacy for primary-care
treatment of mental illness (Fortney et al., 2004). Stigmas
associated with mental illness in rural areas have legal
consequences as well: A study conducted by Sullivan
and Spritzer (1997) indicates that seriously mentally ill
individuals residing in rural areas have a greatly inflated
chance of being detained without criminal charges while
awaiting inpatient treatment. However, not all research
suggests that stigma and resulting utilization are worse in
rural areas than in nonrural areas. A study of seriously
mentally ill patients found that rural patients were more
likely to receive treatment and less likely to list stigma as
a barrier to treatment than their nonrural counterparts
(Kessler et al., 2001). Deductively, these findings run
counter to those of Dottl and Greenley (1997), who found
that seriously mentally ill patients in rural areas had greater
levels of general pathology and lower involvement in
vocational activities. The contrary findings may be due
to differences in geographical locations of the sampled
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
population, as well as small sample sizes of seriously
mentally ill patients in rural areas. Furthermore, access to
care does not necessarily equate to effective care in rural
areas, especially considering the lack of well-trained service
providers and adequate healthcare facilities (Wagenfeld,
2003). Additionally, findings indicate that seriously
mentally ill patients tend to migrate from rural areas to
medium-size, low-income urban areas (Dembling,
Rovnyak, Mackey, & Blank, 2002). The shifted burden
on these urban treatment centers may also account for
the low treatment rates in rural areas.
In addition to the social stigma associated with mental
illness, rural dwellers often do not recognize the need for
treatment. In a large study of rural Southerners, 90% of
individuals who screened positive for a mental disorder
had not sought treatment one month after receiving the
diagnosis and an educational intervention (Fox, Blank,
Berman, & Rovnyak, 1999). This is not due to ignorance
of treatment availability: All participants in the study were
provided with referrals to nearby services. Of the individuals
who screened positive for a disorder and did not seek
treatment, approximately 81% reported that they did not
feel the need for treatment. Furthermore, of the individuals
who screened positive and discussed the screening with a
friend or family member, only 13% reported receiving
encouragement to seek treatment from the significant
other. In fact, the data from this study suggest that
individuals who were accompanied by a significant other
when they received information about the disorder
for which they screened positive were less likely to seek
help than those who received this information alone
(however, this difference did not reach statistical significance). The finding suggests that the denial of need for
treatment may even be reinforced by social contacts in
rural areas.
ADDRESSING THE MENTAL HEALTHCARE PROBLEMS OF
RURAL AMERICA
Clearly, there is not one answer to the problems of
mentally ill individuals living in rural areas. The factors
contributing to the plight of these individuals are numerous:
The attitudes of rural people, the lack of integration
among social institutions, lack of well-trained personnel,
and the physical geography of rural areas all play roles as
barriers to adequate mental health services. However,
the situation is not hopeless. Psychologists are well
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positioned to make a significant impact on the problems
faced by rural America through clinical work, research,
and training. The following section details contributions
that can be made by psychologists to help alleviate the
mental healthcare difficulties in rural areas.
Training for Rural Service
If the manpower shortage in rural areas is to be successfully addressed, training in graduate school and beyond
must be tailored to fit the needs of rural practitioners.
Hargrove and Breazeale (1993) have outlined a training
model for psychologists who consider these distinct
needs. They caution that specialization is not suitable
for rural practitioners, as specialized services are rarely
sought and practitioners often must treat a wide variety
of clients. Therefore, the skills required for general
practice should be stressed above specialization in a few
disorders or methods of treatment. A second recommendation given by this model is the need for increased administrative training. Administrative training is not provided
in many PhD programs despite the high likelihood of
doctoral-level psychologists assuming such duties. A third
change recommended by this model is the need for
increased integration with other healthcare professionals,
such as social workers, primary-care physicians, and
administrators. The authors recommend teaching
trainees to work with and establish relationships with these
healthcare professionals to provide more comprehensive
care to patients.
The issue of recruiting and retaining psychologists for
work in rural areas is also worth examining. Incorporating specialized training for rural work is important, but
has little value if trainees cannot be convinced to ply
their trade in these needy areas. Paramount to this effort
is the need to make positions in rural areas as attractive
as possible. Hargrove and Breazeale (1993) have made
several recommendations for improving new graduates’
perceptions of rural work. First, there is a need to increase
practica and internship opportunities in rural areas
(Hargrove & Breazeale, 1993; Murray & Keller, 1991). It
is believed that internship sites in particular have a great
deal of influence on the location of new psychologists’
first jobs, and placing individuals in rural internships
would increase the likelihood of their working in a rural
setting after internship. However, the current shortage of
doctoral psychologists in rural areas may greatly hinder
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
the establishment of new internships and practica.
Additionally, Hargrove and Breazeale have recommended
the creation of a program similar to the National Health
Service Corps to place psychologists in high-need areas.
This program uses the incentive of loan repayment to
encourage physicians, nurse practitioners, dentists, and
physician’s assistants to work in areas with inadequate
health services. However, there are no demonstrations of
the effectiveness of such a program for psychologists.
Hargrove (1991) describes the University of Nebraska–
Lincoln Clinical Psychology Training Program as a
moderately successful model for training doctoral-level
psychologists for rural service in terms of training and
job placement. The program offered a rural specialty
track, in which coursework, research training, and
clinical experience were tailored for individuals interested in rural work. The curriculum included seminars
in community psychology and rural communities, the
clinical component required that trainees be placed in
rural settings and complete a three-month placement in
a rural facility, and the research component required
that the dissertation topic was relevant to rural issues.
Otherwise, the rural track did not differ from the general
clinical psychology track. Of the 24 students examined,
33% remained in rural areas after completing the program.
Unfortunately, this particular rural training program no
longer exists. However, other psychology training programs
also have developed a rural specialty, including the
University of Mississippi, the University of Wyoming,
the University of South Dakota, the University of Iowa,
the California School of Professional Psychology at Fresno,
and Washington State University (Hargrove & Breazeale,
1993). Still, the schools that provide such a specialty
represent a very small proportion of the doctoral training
programs in the United States.
Telehealth
The use of new technologies such as broadband Internet
and videoconferencing can potentially have a large impact
on the delivery of services to rural areas. The term telehealth
is used to describe the use of communications technology
in the educational, clinical, training, administrative, and
technological aspects of health care; telemedicine is used to
describe the aspects of telehealth involved in patient care
(Stamm & Peredina, 2000). The methods of telehealth
delivery vary widely: Telephone consultations, Web site
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288
access, email, store-and-forward technology, videoconferencing, and virtual reality programs all represent
approaches that have been used to varying extents (Stamm,
2003). Interest in the use of telehealth systems in behavioral
health care is growing rapidly; at one point, it was estimated
that the literature on telehealth was doubling approximately
every six months (Stamm, 1998). In fact, telemedicine
now has a journal dedicated to the topic ( Journal of Telemedicine and Telecare, founded in 1995).
Telehealth has the potential to address a number of
problems faced by rural caregivers. First, the use of
telehealth gives patients in remote areas increased access
to services. Assessment, psychotherapy, crisis, intervention, psychoeducation, medication consultations, and case
management can be conducted from great distances, often
through videoconferencing when economically feasible.
Research suggests that patients are generally happy using
telehealth services. One study of adults and children in
Kentucky reported that 98% of recipients of consultations
were at least as satisfied with the remote consultation
as with an in-person consultation (Blackmon, Kaak, &
Ranseen, 1997). Furthermore, participants reported
little discomfort associated with using the videoconferencing equipment.
Researchers also have investigated the attitudes of rural
dwellers toward the use of telemedicine. A telephone survey
conducted by Rohland, Saleh, Rohrer, and Romitti (2000)
found that two-thirds of individuals in rural midwestern
communities were willing to receive mental health
services through live two-way audio and video transmission.
Individuals who were not willing to use the telemedicine
approach to treatment most often cited concerns about
confidentiality and the impersonal nature of the telemedicine
approach. However, the authors caution that the rates of
acceptance in this study may overestimate the willingness
of rural individuals to use telemedicine for mental health
services, because those interviewed were not necessarily
in need of services and therefore might be less reluctant
to report discomfort utilizing them.
There is a great need for the assessment of telemedicine effectiveness to determine whether it represents a
viable alternative to traditional treatment. Many studies are
currently underway to help answer this question (Stamm,
2003). One recent randomized control trial compared the
effectiveness of medication consultations for depressed
patients done in person or through videoconferencing
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
(Ruskin et al., 2004). Results indicate that both groups
improved on measures of depression, and improvement
did not differ between groups. Furthermore, dropout
rates, medication adherence, and measures of patient
satisfaction did not differ between groups. Treatment
in the telemedicine condition was found to be more
expensive than the in-person condition, but this difference disappeared when costs associated with psychiatrists’ travel were considered. However, the patients in
this study were located in nonrural areas. The results may
not generalize to a rural population. Furthermore, it is
not known if similar results would be achieved with
psychotherapy.
A particularly interesting telemedicine system in development is the use of computerized therapy programs.
Generally, these refer to therapy interventions presented
on a computer rather than through face-to-face contact
with a therapist. One such program, Beating the Blues, has
shown substantial promise. The program creates a
personalized therapy regimen based on patients’ input.
Anxious and/or depressed patients in primary care have
shown greater improvement than treatment-as-usual in a
large randomized control trial (Proudfoot et al., 2002).
Furthermore, completion rates were similar to those found
in studies of face-to-face therapy. Use of the Beating the
Blues program has also been well received by professionals
in community mental health environments (Van Den Berg,
Shapiro, Bickerstaffe, & Cavanagh, 2004). However, this
program is not without limitations. First, a physician or
mental health professional must be available to give the
initial diagnosis and to review the outputs produced by
the program after each session (e.g., ratings of suicidal
ideation). Second, a dedicated private room is highly
preferred for the system, which is problematic for clinics
short of space. Third, studies of the program have been
conducted primarily with patients residing in urban areas
of the United Kingdom; generalization to rural areas of
the United States is not assured. Despite these limitations,
the development and implementation of programs such
as Beating the Blues could prove an advantageous extension
of telehealth in rural areas.
Additionally, the use of technologies as a supplement
to therapy has shown great promise. A study conducted
by Newman, Kenardy, Herman, and Barr-Taylor (1997)
compared the effectiveness of a four-session computerassisted cognitive–behavioral therapy (CBT) regimen with
JAMESON & BLANK
289
a more traditional 12-session CBT regimen for panic
disorder. Individuals assigned to the computer-assisted
CBT condition used a palmtop computer loaded with
CBT software for 12 weeks and received weekly faceto-face therapy for only the first four weeks. Although
patients in the traditional CBT condition were slightly
more likely to demonstrate clinically significant change
at posttest, these differences disappeared at six-month
follow-up. Furthermore, there was no difference between
conditions in patient satisfaction. These results have since
been replicated in a similar multisite study (Kenardy et al.,
2003). While studies of computer-assisted interventions
have been limited mainly to the treatment of anxiety
disorders, their use for the treatment of other disorders
warrants the attention of researchers. There are numerous
advantages to using computer-assisted interventions, and
these advantages are likely to be especially appreciated
in rural areas. First, they appear to be significantly more
cost-effective than traditional face-to-face therapy.
While clinics wishing to adopt these technologies would
certainly incur initial costs of the hardware and software,
computer-assisted therapy has been estimated as costing
approximately one-third less than 12-session CBT for panic
disorder (Kenardy et al., 2003; Newman et al., 1997).
Second, the reduced patient contact time may make it
possible for clinicians to increase their caseloads without
sacrificing quality of care.
An additional advantage of using telehealth systems is
the potential increase in professional collaboration among
rural mental health professionals. Telehealth systems
enable caregivers in isolated areas to interact with other
professionals. Interactions include consultations, grand
rounds, and supervision. These contacts could be important
in keeping rural mental health professionals abreast of
developments and issues in the field, increasing the quality
of care they are able to offer to their patients through
consultations with specialists, and aiding the obtainment
of continuing education credits required by most state
licensing boards. In addition to these obvious benefits
of greater contact with other professionals, the increased
integration can potentially help shield caregivers from
the high rate of burnout found among mental health
professionals in rural areas (Kee et al., 2002).
There are several challenges to the implementation
of telehealth in rural areas (Stamm, 2003). The economic
feasibility of telemedicine for mental health has been
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
brought into question (Werner & Anderson, 1998). For
example, Stamm (1998) estimates that a videoconferencing unit can range in cost from $1,000 to $50,000
with additional costs for technical support and access
to communications networks (e.g., Internet service).
Considering the proliferation of technology since that
writing, it is likely that costs now are much lower. Other
researchers have argued that limits in economic resources
should not alone determine whether a service that increases
access to care should exist (e.g., Chen, Blank, & Worrall,
1999). Furthermore, reimbursement for services provided
through telemedicine has not gained total acceptance
yet, although that acceptance is growing (Stamm, 2003).
The remote care provided by telemedicine systems also
raises problems with licensure. Stamm (2003, p. 149) points
out the following licensure dilemma: “. . . should the
provider of care be licensed in the state from which he
or she originates or in the state to which the care goes?”
These issues have not yet been adequately addressed by
the legal system. A final barrier to the implementation of
telehealth systems is the comparatively weak technological
infrastructure of rural areas. Many rural areas may not yet
be equipped with technologies capable of transmitting the
large quantities of data required for use of devices such as
videoconferencing units. Although the magnitude of this
problem almost certainly decreases as time passes, this may
be an issue for years to come, especially in the most
sparsely populated areas of the country. Despite these
criticisms, telehealth systems seem to hold great promise
for increased accessibility and quality of care in rural areas.
The Dissemination of Empirically Supported Treatments to
Rural Clinics
The previous sections detail some possible solutions to
the mental health service problems of individuals in rural
areas. However, they are at best long-term solutions.
Changes to training programs or the implementation of
telehealth systems are not likely to happen overnight,
and the effect of these changes may take years or decades
to feel. However, the dissemination of empirically
supported treatments (ESTs) to rural clinics may be the
most helpful in the short term. A particularly promising
application of ESTs to rural clinical practice exists in
their utilization in community mental health centers
(CMHCs), which have served as the cornerstone of
specialty mental health care in rural areas since their
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290
inception. As with telephone lines, cable television, and
more recently broadband Internet connections, rural areas
are generally among the last to benefit from advances
in technology. The lack of published research on the
effectiveness of ESTs in rural areas suggests (but does
not demonstrate) that the dissemination of ESTs has
followed this familiar trend, especially in locally funded
organizations. Arguments can be made that the utilization
of ESTs in rural CMHCs may have a positive impact on
the issues previously described, namely, personnel shortages, lack of integration with primary care, and stigma
associated with mental illness.
Although treatment outcome research has yielded
therapies that have been shown to be efficacious across
multiple studies, researchers have cautioned that the
promising results may not readily generalize to clinical
settings such as rural CMHCs (Borkovec & Castonguay,
1998; Chambless & Hollon, 1998; Goldfried & Wolfe,
1998; Westen, Novotney, & Thompson-Brenner, 2004).
In recent years, however, investigators have made attempts
to demonstrate the effectiveness of empirically supported
treatments in clinical settings, with some success (e.g.,
Addis et al., 2004; Wade, Treat, & Stuart, 1998; see
Chambless & Ollendick, 2001, for a review). There is
good reason for feelings of guarded optimism in response
to these studies, as generalization from laboratory findings
to clinical practice is a crucial first step in gaining
widespread acceptance of these treatments in areas that
may need them the most.
As discussed previously, rural areas suffer from a severe
shortage of mental healthcare professionals. Therefore,
service providers in these areas must adopt strategies to
administer effective treatments in a time-efficient manner
if they hope to compensate for understaffing and insufficient funding. The characteristics of empirically supported treatments lend themselves to be included in such
strategies; they are typically short in course in comparison to more traditional treatment options. Additionally,
patients who successfully complete these treatments
tend to maintain improvements for substantial periods of
time (e.g., Stuart, Treat, & Wade, 2000). If this holds true
in rural treatment centers, the so-called revolving door
phenomenon may be diminished. Furthermore, empirically based treatments are often manualized in great detail.
This feature may lead to effective training in a relatively
short period of time with manageable costs.
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
A second problem that has been identified in rural
mental health services is lack of integration with primary
care. The successful implementation of ESTs in rural
mental health facilities may help to diminish some of the
concerns expressed by primary-care providers, thereby
increasing integration between primary care and specialty
mental health care. Primary-care physicians in rural areas
may be more willing to collaborate with specialty mental
health service providers if there is an understanding that
state-of-the-science treatments are to be employed.
Mental health providers who are able to discuss treatment with physicians in terms of expected outcomes and
treatment success may overcome some of the cultural
differences that have been identified between physicians
and therapists (see Bray, Enright, & Rogers, 1997, for a
review). Furthermore, primary-care workers may have
better success convincing needy patients to seek out
these services if they are able to make a compelling
argument based on empirical findings.
The social stigma associated with mental disorders
is a third obstacle to treatment in rural areas. The perceived
stigma, coupled with the lack of encouragement from
loved ones to seek out treatment, paints a very bleak
picture for individuals in need of help in these areas.
However, evidence suggests that clients consider decisions
informed by clinical research as a very favorable method
for deciding on a treatment strategy (O’Donohue, Fisher,
Plaud, & Link, 1989). Despite this evidence, practitioners
rarely give a rationale of any kind for the treatment
strategies they develop; in cases where a rationale is
provided, clinical research is rarely cited (O’Donohue,
Curtis, & Fisher, 1985). The ability of practitioners to
tell prospective clients that a particular treatment works
based on empirical evidence may alleviate some of their
concerns.The medical model that serves as the philosophical
basis for efficacy trials may also help clients view their
problems as being common and treatable rather than a
sign of weakness or a personality flaw, therefore reducing
the perceived stigma associated with mental disorders.
One of the greatest challenges to the dissemination
of ESTs is mental healthcare providers’ perception of
manualized treatments (Kendall, 2002). Because most ESTs
have been manualized, it is important to understand
how practitioners feel about using manuals in practice
and training. Manuals likely represent the stepping-stone
from the development of ESTs to their utilization in
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clinical settings, and their use has been recommended to
facilitate learning the principles of the treatments (Moras,
1993). While the use of manuals to improve training has
not been well researched, a study by Addis and Krasnow
(2000) suggests that attitudes toward the use of treatment
manuals in practice among doctoral psychologists are
mixed. In their survey, approximately one-third of
respondents reported they were not clear or only somewhat clear on what a treatment manual was. Only 6%
reported using manuals often or exclusively in their
practices, and 47% reported never using manuals at
all. Additionally, one-fifth of respondents had negative
experiences with manuals; slightly less than half reported
neutral experiences, and slightly more than one-third had
positive experiences. Interpreting these results in terms
of rural practitioners is difficult, as geographic location
of the practice was not a variable used in the analysis.
A similar study of rural providers would be helpful in
designing strategies to make the use of manualized ESTs
more palatable in their practices.
The impact of implementing empirically supported
treatments in rural CMHCs is potentially profound. ESTs
seem particularly well suited for use in areas facing
personnel shortages, a lack of integration with other
community services, and a hesitant client base. However,
initial groundwork must be laid before any significant
course of action can be designed, tested, or applied.
Furthermore, the input of rural mental health service
providers on the front line is essential if any initiative is
to succeed in practice. They are uniquely able to provide
insight to immediate needs based on the types of patients
they see, potential barriers, and financial and structural
feasibility of EST implementation. Additionally, providers
logically should play the major role in directing future
research efforts regarding the dissemination of ESTs
to rural settings, because they are the ones who would
potentially provide the services. If ESTs are to play a
significant role in helping to solve the mental healthcare problems faced by rural communities, collaboration
between researchers and clinicians is imperative.
The Rural Psychologist as a Grassroots Advocate
The role of the psychologist in the rural community should
not be limited to providing patients with treatment and
services. Perhaps even more so than their urban counterparts, the rural psychologist should have an active voice
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
in the community. Psychologists in rural communities
have the deck stacked against them: Barriers to quality
care are numerous, and suspicion of “shrinks” is high.
Psychologists may be seen as stuffy, overly intellectual
elitists as well. This perception (right or wrong!) does
little to instill a sense of partnership and trust with the
community. To be more effective in treating individuals
in rural communities, psychologists must effectively
combine their role as a mental healthcare provider with
their role as concerned community member. This can
include reaching out to community leaders such as
ministers, school administrators, business owners, and local
government officials, as well as community organizations
(Rotary Club chapters, chambers of commerce, Kiwanis
Club chapters, women’s organizations, state cooperative
extension service offices, etc.). Furthermore, education
and awareness programs may be designed for the community as a whole. Talks at local schools or community
centers may provide community members with access to
information that they would not normally receive.
Crucial to these efforts is balancing an air of professionalism with the ability to recognize and relate to the
needs of the community and the audience (see Fox et al.,
1994, for a thorough discussion). The subject matter of
community education and awareness initiatives should
be carefully tailored to the segment of the community
that they are intended to reach (e.g., a presentation on the
impact of the farm crisis on the mental health of farming
communities to a cooperative extension service group,
or a discussion of the economic impact of depression
for a talk at the chamber of commerce; Kendall, 2002).
Additionally, the presentation of scientific data to community groups should be informative and insightful,
but care should be taken not to dilute the messages one
hopes to convey with unnecessary detail about methodology
or statistical analysis. Even manner of dress may impact
the effectiveness of such advocacy efforts. Although these
considerations seem arbitrary, they may seriously impact
the perceptions that rural community members develop
of mental health care and its representatives. Cues from
the culture of the community should be taken seriously
if advocacy efforts are to influence community acceptance.
Cultural competence and sensitivity are important
considerations if linking the community members to the
mental health service system is to be an achievable goal; this
includes developing local knowledge, an understanding
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of belief systems and values unique to each community
(Hill & Fraser, 1995). Furthermore, behavior outside of
practice does not go unnoticed in a rural community. Rural
individuals may not as readily separate professional behavior
from private behavior, and there is often little anonymity.
Rural psychologists must also be prepared to offer
services to their patients above and beyond what might
be expected of clinicians operating in more populated
areas. This may be especially important for seriously
mentally ill (SMI) patients. SMI patients in rural areas are
less likely to receive case management, day treatment,
and home visits from care providers (Sullivan, Jackson,
& Spritzer, 1996). Furthermore, rural SMI patients are
more likely than urban patients to be jailed without
criminal charges while waiting for a bed at an inpatient
facility (Sullivan & Spritzer, 1997). Psychologists may
wish to enlist family members or spouses to actively
participate in treatment in order to help compensate for
the lack of services. This may include psychoeducational
interventions for family members. While these interventions vary widely in content, they often share similar
goals: helping families cope with the illness, improving
medication adherence, improving communication between
the patient and family, and improving problem solving.
Such interventions have been shown to reduce relapse
and hospitalization of patients with bipolar disorder,
schizophrenia, major depression, and other disorders (see
McFarlane, Dixon, Lukens, & Lucksted, 2003, for a
review). While most research has examined the effectiveness of family psychoeducation with individual families,
success has been seen with multifamily group formats
as well (e.g., Dyck, Hendryx, Short, Voss, & McFarlane,
2002), thereby reducing the time commitment necessary
to implement such services. Such interventions are
necessary to help compensate for the shortage of specialty
services (e.g., inpatient facilities) in rural areas.
Ethical concerns often arise in rural practice and
advocacy, most notably the existence of dual relationships. Dual relationships seem to be inevitable in small
communities where services are limited (Schank &
Skovholt, 1997). Overlaps often arise in social relationships,
business and professional relationships, relationships among
clients (e.g., having more than one member of a family
as a client), and psychologists’ families (spouse, children,
or relatives have social or business relationships with
clients). Rural psychologists must use more flexibility in
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
dealing with these relationships than their urban
counterparts if life is to be tolerable. However, it is not
uncommon for rural professionals to experience discomfort in maintaining a professional relationship
while managing a secondary one. Campbell and Gordon
(2003) outline several guidelines for avoiding negative
outcomes resulting from dual relationships: Imagine the
worst-case scenario when deciding if a dual relationship
is potentially harmful; set clear expectations and boundaries
with clients in as many areas as possible; consult often
with other professionals to avoid subjective oversight;
maintain clients’ confidentiality at all costs; and terminate
multiple relationships as soon as possible. Additionally,
Schank and Skovholt (1997) suggest developing a very
clear understanding of state laws and codes governing
ethical behavior before starting practice and maintaining
a fulfilling life outside of practice to prevent exploitation
of clients as strategies that can prevent the negative
outcomes that dual relationships can foster.
The Prescription Privileges Controversy: Increasing Access or
Decreasing Comprehensive Care?
The notion of giving prescription privileges to psychologists
has been the subject of heated debate in the field (see
Heiby, 2002, for a review). Although the following section
is not an attempt to thoroughly rehash the advantages
and disadvantages of the existence of prescribing
psychologists, this highly controversial issue is worth
considering in the context of rural mental health care.
Arguments can be made that giving psychologists
prescription privileges could either help or hinder rural
dwellers in need of treatment. The issue is certainly
complex, and there is no clear evidence that provides a
strong empirical basis for either position. Three questions
should be kept in mind when considering the impact
on rural areas: (a) Would giving psychologists license to
write prescriptions improve access to mental health
services, (b) Would giving psychologists license to write
prescriptions improve the quality of care available, and
(c) Would the impact of prescription privileges on access
and quality differ between a short-term perspective and
a long-term perspective?
Proponents of prescription privileges for psychologists
often argue that this change reflects the changing role
of psychology as a healthcare field (Norfleet, 2002).
Psychologists have recently assumed an increasingly central
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role in hospital settings, and often consult with psychiatrists
and other physicians regarding medications. This requires
at least a working knowledge of medications. Furthermore,
there is a belief that prescription privileges are necessary
for the survival of clinical psychology in the managed care
era. Proponents suggest that third-party reimbursement
for the treatment for mental disorders is increasingly
limited to drug therapy.
A major fear among opponents to prescription privileges for psychologists seems to be that the psychologists
will turn into a group of low-rent psychiatrists. That is,
psychology practice will trade in the behavioral interventions, psychosocial treatments, and talking cures that
have become trademarks of the profession for 15 minute
medication consultations and a strict biological perspective of mental disorders (Albee, 2002). In recognition of
the declining incomes of many psychologists, they suggest
that practicing psychotherapists move away from private
practice and into other areas such as the public sector.
Furthermore, critics wonder what current coursework
and practica requirements will be displaced by psychopharmacology training in graduate programs.
Although no data are currently available on the
long-term impact of prescription privileges on the rural
population, a discussion of the possible outcomes based
on past professional trends might prove useful. First, it is
questionable that rural areas would attract prescribing
psychologists for the same reasons that they do not currently
attract doctoral-level psychologists and psychiatrists.
Furthermore, considering that many doctoral-level
psychologists in rural areas work in administrative roles,
it is not certain that they would play a more significant
role in treatment if they prescribed. Second, individuals
with mental disorders generally seek help from their
primary-care providers at least initially. Therefore, they
initially access a professional with the ability to prescribe
medications. From a patient’s perspective, it might be
difficult to justify seeking treatment from a second
professional who would provide the same services as
the family doctor. Psychologists currently offer a unique
product in mental health care; it is difficult to anticipate
the reaction of the consumer if this product were replaced
with one that could be obtained from other sources.
Third, prescription privileges may create a rift between
psychologists and primary-care providers rather than
increase integration and collaborative care. Primary-care
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
providers may equate referring patients to prescribing
psychologists with a sign of their own professional
limitations regarding the treatment of mental illness.
They may also be uncomfortable referring patients to a
professional who has less training and background in
pharmacology.
Alternatively, prescription privileges may prove to
be a boon to rural mental health care in the long term.
First, the addition of prescription privileges to psychology’s
treatment repertoire may make the field much more
attractive to bright young minds who might otherwise
be considering an MD career track. The increased output
of trained psychologists may weaken the job market in
urban areas, forcing graduates to consider positions in
rural areas, thereby increasing the mental health services
manpower in these areas. Second, the ability to prescribe
may improve the image of psychology as a health profession in the eyes of individuals who would potentially
utilize mental health services. The stigma associated with
mental illness in rural areas might be attenuated if disorders were approached from a biological perspective.
Rural individuals might be more inclined to seek help if
they thought that their problems were physiologically
based rather than rooted in some character flaw or
maladaptive coping strategy. Some support for this
argument can be found anecdotally; it is often said that
rural patients tend to somatize their symptoms (e.g., anxiety
may be described as “a feeling in my gut”). Third, it does
not have to follow that giving psychologists the right to
prescribe will restrict the role of psychologists to
inexpensive medication consultants (Sammons, 2003). If
the standards of therapy coursework and instruction are
upheld in psychology training programs, then traditional
approaches do not have to take a backseat to medication.
The use of medication as a conjunctive treatment
could represent an increase in service quality for patients.
Fourth, although resistance from the medical community
seems to be strong, primary-care providers may come to
appreciate psychologists’ prescription privileges because
of the reduced burden of patients with mental illness on
their practices.
The outcome of this controversy for rural individuals
is unknown. Prescription privileges could be harmful or
helpful; convincing arguments can be made either way.
In the short term, it is doubtful that granting prescription
privileges would have any tangible impact. It may be
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294
years before enough data on licensed prescribers are
collected to determine whether they improve access and
quality of treatment in rural areas. It is recommended
that the activities of psychologists in the states that have
granted prescription privileges be studied with great
care: Comparisons of treatment outcomes and patient
satisfaction between prescribing and nonprescribing
psychologists in rural areas of these states could lend an
empirical basis to either side of this debate. These
comparisons are possible, as the states that have
allowed psychologists to prescribe (New Mexico and
Louisiana) contain large rural populations, perhaps not
coincidentally.
The Role of Subdoctoral Practitioners in Rural Areas
As a profession, psychologists are generally thought of as
possessing some form of doctoral degree, usually a PhD
or PsyD. This belief is evidenced by the membership
requirements of the American Psychological Association
(2005). However, master’s- and baccalaureate-level practitioners are thought to supply most of the mental health
services in many rural clinics (Hargrove & Breazeale,
1993). Despite their regular presence as mental health
service providers, state licensure agencies often reserve
the title of psychologist to those with doctoral degrees
and label subdoctoral professionals as “professional
counselors.” The disenfranchisement of subdoctoral
practitioners in rural areas is potentially very dangerous.
If indeed they provide a substantial amount of services
(which seems to be the case), exclusion from eligibility
for state licensure could set a perilous precedent.
In an age when private insurance companies play a
major role in access to care, treatment provided by
subdoctoral professionals could fall victim to cost-reducing
efforts. One study of professionals in Ohio found no
difference in reimbursement rates between doctorallevel and master’s-level providers (Zimpfer, 1995). However,
this study was conducted over a decade ago and holds
little meaning considering the rapid changes in health
services. The concern that private insurers and public
healthcare assistance programs may exclude subdoctoral
practitioners is especially relevant to rural areas, because
access to doctoral-level providers is severely limited.
Clearly, there will never be enough doctoral-level
psychologists to fulfill the needs of rural America
(Hargrove, 1991). A significant degree of the burden of
PSYCHOLOGY AND RURAL MENTAL HEALTH
•
caring for rural individuals has fallen on and will continue
to fall on subdoctoral professionals. Hargrove and Breazeale
(1993) recommend that research be undertaken to
delineate the clinical skills possessed by master’s-level
professionals from those unique to doctoral service
providers in order to better develop positions in mental
healthcare systems that fit each group’s strengths. In
addition to the recommendation of Hargrove and
Breazeale, professional organizations are urged to advocate
for these professionals to help ensure their continued
service in mental health care. Furthermore, states with
substantial rural populations should be urged to reconsider
what level of training constitutes a psychologist in order
to ensure equitable access to care for rural dwellers. For
some states, this may require revisiting past legislation
(e.g., Minnesota, which licensed master’s-level psychologists
until 1991).
CONCLUSIONS
The plight of providing adequate mental health care for
individuals in rural areas is a complex issue, and the
solutions to the problems faced are not easily definable.
However, psychologists can make significant contributions
toward the alleviation of problems through research,
practice, training, and advocacy. The literature suggests
that research efforts have done a better job describing
problems than creating novel solutions. Solutions that
have been tested and shown promise seem to terminate
with the publication of an article in a scholarly journal.
Efforts have not been focused on disseminating and
funding potentially powerful interventions. This is not to
say that studying the problems with mental healthcare
services in rural areas is an unimportant endeavor;
identifying these problems is crucial to developing solutions. However, research on barriers to services alone
does not, in the end, impact the people in need of services.
A man who has been shot experiences no relief simply
by being told of his wound. For this reason, we urge that
the energies of rural psychologists, both in academia and
in practice, be directed toward collaborative work to
implement strategies for change.
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The Future of Clinical Psychology: Board Certification
clinical
the
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Blackwell Publishing on behalf of the American Psychological Association.
A. J. Finch, Jr., The Citadel
Norma P. Simon, New York
Christine Maguth Nezu, Drexel University
The present article presents the future of clinical
psychology board certification. With the increasing
specialization in the field of professional psychology and
the generic nature of state licensure, clinical psychology as a specialty will develop into a specialty area in a
similar fashion as have specialties in medicine. A brief
history of board certification in professional psychology by the American Board of Professional Psychology is
reviewed and the process of becoming board certified
in either clinical psychology or clinical child and adolescent psychology is discussed.
Key words: board certification, clinical, professional,
specialty. [Clin Psychol Sci Prac 13: 254–257, 2006]
THE INCREASING TRAINING DEMANDS FOR PROFESSIONAL
PSYCHOLOGY PRACTICE
Training in clinical psychology has become increasingly
more time consuming. The most common progression
involves four years of undergraduate education, followed
by two years to obtain a master’s degree, and three to
four years of study at the doctoral level. Next comes the
internship/residency year and most commonly a year of
postdoctoral supervision before the person is eligible for
generic licensure as a psychologist. Individuals seeking a
formal postdoctoral fellowship in a specialty tended
to do so electively. Following licensure most clinical
psychologists enter practice and rarely think about
additional credentialing. Some will seek registration in
Address correspondence to A. J. Finch, Jr., SHSS, The
Citadel, 171 Moultrie Street, Charleston, SC 29409. E-mail:
fincha@citadel.edu.
the National Register of Health Service Providers or seek
to obtain the Certificate of Professional Qualification
(CPQ) offered by the Association of State and Provincial
Psychology Boards. However, few have historically sought
specialty certification in clinical psychology, despite the
fact that Board Certification in Clinical Psychology
has been available for more than 50 years through the
American Board of Professional Psychology (ABPP).
A BRIEF HISTORICAL CONTEXT OF BOARD CERTIFICATION
The initial ABPP specialty boards came into existence in
1947 with the establishment of the American Board of
Professional Examiners in Psychology, which was
developed to ensure that an individual was qualified to
perform the specialties of clinical and counseling
psychology. Industrial/Organizational psychology was
added a year or so later. In 1968, the name was changed to
American Board of Professional Psychology to reflect the
expanding roles performed by professional psychologists.
Since that time, additional specialty areas have been
developed and included under the ABPP umbrella.
These include cognitive and behavioral, clinical child
and adolescent, clinical health, clinical neuropsychology,
forensic, family, group, school, rehabilitation, and psychoanalysis. Industrial psychology has expanded to reflect its
broadening scope in organization and business activities.
Additionally, many professional psychologists seek dual
specialty certifications that reflect their professional
work. Examples of these combinations include clinical
child and forensic certification, clinical and cognitive
and behavioral, counseling and group, or clinical neuropsychology and rehabilitation. This article will focus on
board certification by ABPP in clinical psychology and
clinical child and adolescent psychology.
© 2006 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association.
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254
As has been discussed by several authors (Nelson &
Finch, 2005; Packard & Reyes, 2003), there is a relatively
common progression in the development of a professional field of practice. In the early stages of the profession
there is an apprenticeship model of training during
which the aspiring practitioner studies and works closely
with an established professional in the field. Gradually
the preparation process becomes more formalized and
the need for a more complex and standardized curriculum
develops. Gradually accreditation is established to ensure
professional guidelines for preparation for the profession.
As the field develops and diversifies in its applications,
increased specialization in the practice of the professional
develops. With increased specialization, the need to
establish a process for identifying and certifying specialists
in the various fields develops. The history of medicine is
a good example of this developmental process. The
American Board of Medical Specialties currently lists 24
affiliated specialty boards that offer 38 specialty certificates and 87 subspecialty certificates. Board certification
in the various specialty areas of medicine has developed
and the days of “general or generic practice” have passed.
Given this developmental process in medicine and
other professional fields, why has the development of
specialty certification been so slow in professional
psychology? Is the field too narrow? Given the growing
diversity in professional psychology exemplified by the
growing number of divisions and organizations in the
field, this seems unlikely. Is there a lack of interest in
specialty in professional psychology? The opposite would
appear to be true. Within the American Psychological
Association (APA) there exists the Council for the
Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP), established in 1995 as
the organizational agent to implement the recognition of
specialties. ABPP has always had a mechanism for the
recognition of specialties. Later, the Council of Specialties
was established in 1997 as a joint venture, initially
sponsored by the APA and the ABPP, to represent and
support the development and functioning of recognized
specialties in professional psychology.
Are there any benefits to board certification? If there
are no benefits for seeking board certification, then it
would be easy to understand why it is not more common.
However, there are a number of benefits both for the
individual psychologists and for the public. Board
THE FUTURE OF CLINICAL PSYCHOLOGY
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FINCH ET AL.
certification is a safeguard for the public. With the
increased complexity and specialization in the practice of
psychology, the public cannot be expected to have
knowledge of the requirements for someone to provide
services in a particular area. Board certification by ABPP
is a way to assure the public that psychologists have the
education and experience to practice in a specific area and
that they have been examined by peers in the area.
The advantages of ABPP board certification for the
individual psychologists also would appear to be clear.
First, there are clear financial benefits with a considerable
reduction in liability insurance for the board-certified
psychologists. For military psychologists and those in
the public health service, there is a salary bonus. In
addition, board certification is a credential that facilitates
one’s qualification as an expert witness. Another benefit
of ABPP board certification is increased ease of mobility, as many states recognize ABPP. Similarly, being
board certified by ABPP facilitates obtaining the CPQ.
In addition to these and other benefits, there is the professional growth that occurs as a result of the exam process.
It appears that the time is now for board certification in
professional psychology and that ABPP may have simply
developed at a time when it was not needed. In truth the
role of ABPP has developed with the field. It was developed
before widespread licensure and initially served to
identify trained practitioners in the field. Following the
development of licensure, the role of ABPP drifted to a
more “elitist” position. Although this position was not by
design, nor reality, it reflected the “perception” within
the field. However, those days have passed and the position
has been replaced by one much more in line with the
American Board of Medical Specialties, and ABPP
sees its role as providing examinations for properly
trained psychologists in the emerging specialty areas.
THE EXAMINATION PROCESS
Examination for board certification in clinical psychology
is offered by the American Board of Clinical Psychology
(ABCP) and examination in clinical child and adolescent
psychology is offered by the American Board of Clinical
Child and Adolescent Psychology (ABCCAP). Both are
member boards of ABPP and their examination processes
are similar, as are all examinations under the ABPP
oversight board. Each requires verification of credentials
in the respective area, including licensure as a professional
255
psychologist. If the credentials are accepted, the candidate
enters the second phase of the examination process and
begins preparation of practice samples. The practice
samples include two video samples of professional work
of approximately 50 min each. One sample is an unrehearsed psychological assessment and the other sample is
an unrehearsed intervention. Both samples are to be drawn
from typical clinical practice within approximately six
months prior to the submission. These video samples
should reflect one’s competence and expertise (rather than
exemplary situations) that depict his or her interactive
style with clients drawn from the candidate’s typical
practice. Many candidates seem to want to select unique,
interesting, or unusual cases but both groups prefer cases
drawn from the candidate’s typical practice. Such a
practice sample allows the examination committee an
opportunity to see the candidate at his or her best.
A senior option for the clinical exam practice sample
was developed in 1996 and later adopted by the Clinical
Child and Adolescent Board. Candidates who are 15 or
more years post licensure can elect to submit a practice
sample that reflects their career contributions. Frequently
these senior practice samples include professional publications in clinical psychology, treatment manuals,
program manuals, a summary of professional practice,
etc. The exam itself is identical and the criterion for a
pass is the same for all candidates.
Three specialists serve as the examination committee
and review the samples. Both boards provide scoring
criteria with passing and failing responses. If the practice
samples meet and pass criteria, the candidate enters the
oral examination stage. The oral exam is conducted by
the same three examiners that have reviewed and passed
the practice samples and takes approximately three hours.
During the practice samples review and the oral
examination, the committee is attempting to assess the candidate’s competencies in several domains. There are some
minor variations in how these are described and those
from the ABCCAP will be presented here. The examination
process encompasses the following interrelated domains.
Professional Knowledge
The successful candidate understands patients/clients
within their social context (family, school, and peers)
and their problems with conceptual breadth and depth.
This understanding involves having a definable set of
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
•
constructs or a theoretical orientation of sufficient
complexity to allow a rich discussion that can be justified
from the research and/or clinical literature. Successful
candidates can critically evaluate the research and professional literature and discuss implications for their
practice. They appreciate the limitations of their own competence and appropriately seek consultation, supervision,
and continuing education.
Assessment Competence
The successful candidate chooses procedures appropriate
for the referral needs and characteristics of the patient/
client. They interpret assessment data accurately and
develop conclusions appropriately. Successful candidates
will communicate results in a manner that leads to useful
outcomes for diagnosis and treatment while minimizing
the likelihood of misuse.
Intervention Competence
Successful candidates will effectively manage treatment
contract issues (patient/client goals, boundaries of treatment, payment resources, etc.). They choose procedures
that are appropriate for both the patient/client and the
situation. Interventions are applied and documented
skillfully. Successful candidates will assess intervention
issues in a developmentally appropriate and contextually
relevant manner.
Interpersonal Competence with Clients
The successful candidate relates in developmentally
appropriate ways that enhance the effectiveness of services
and minimize interference or disruption. The candidate
will be aware of patient–therapist interpersonal issues,
personal impact, strengths, weaknesses, and limitations as
professionals—and they consistently manage these factors.
Successful candidates will be sensitive to the welfare,
rights, and dignity of their patients/clients, families,
other professionals, and society as a whole.
Ethical and Legal Standards and Behavior
Successful candidates will demonstrate knowledge of
ethical principles, professional practice standards, recordkeeping requirements, and legal standards. They effectively
apply ethical principles, professional practice standards,
record-keeping requirements, and legal standards in their
clinical practice as well as in unique situations.
V13 N3, FALL 2006
256
Commitment to the Specialty and Awareness of Current Issues
Successful candidates will demonstrate active participation
in the profession. They can thoroughly describe current
issues facing the profession and their implications for
patient/client welfare.
Competence in Supervision and Consultation
Successful candidates will demonstrate awareness of the
activities involved in and the complexities of the supervisory relationship. They also understand the parameters
for consultation and the limitations of their own training
and competence.
Following the completion of the oral exam, all
practice sample material is returned and the candidate is
dismissed without knowledge of the results of the examination. The committee members independently rate the
candidate on each of the domains and assign a pass/fail
rating based on the candidate’s performance during the
oral examination. Two votes are required for a passing
score. Successful candidates are notified by Central Office.
Unsuccessful candidates receive a detailed explanation of
the reasons for the committee’s decision.
THE REWARDS OF PROFESSIONAL ABPP CERTIFICATION
Sharing their professional work and having an opportunity
to discuss their practice with recognized specialists in the
THE FUTURE OF CLINICAL PSYCHOLOGY
•
FINCH ET AL.
area is an experience too rare in professional lives. Most
candidates report that the experience was a rewarding
one and resulted in professional growth. In recognition
of the growth and developmental nature of the process,
successful candidates are granted 10 continuing education credits by ABPP, which is recognized as an approved
provider by APA. As stated in previous publications that
explain the ABPP process (Dattilio, 2002), now, more
than ever, the growth and sophistication of our profession and its position of importance and credibility in the
delivery of mental health, consulting, and behavioral
medicine services demand full participation in a highquality, standardized, board certification process.
REFERENCES
Dattilio, F. M. (2002). Board certification in psychology: Is it
really necessary? Professional Psychology: Research and Practice,
33, 54– 57.
Nelson, W. M., III, & Finch, A. J., Jr. (2005). Board certification in professional psychology: A developmental passage.
The San Francisco Psychologist, December, 5, 11, 13.
Packard, T., & Reyes, C. J. (2003). Specialty certification in
professional psychology. In M. J. Prinstein & M. D.
Patterson (Eds.), The portable mentor: Expert guide to a
successful career in psychology (pp. 191–208). New York:
Plenum.
257
The Present and Future of Clinical Psychology in
Private Practice
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by 2006
Blackwell Publishing on behalf of the American Psychological Association.
Lillian Comas-Diaz, Transcultural Mental Health Institute
This article discusses clinical psychologists’ current
concerns, challenges, and opportunities in private
practice. The future of clinicians in independent practice
is presented within two paradigms, namely, psychology
I discuss clinical psychologists’ concerns, challenges,
and opportunities in private practice. I arrange my remarks
under two paradigms, namely, psychology as a health
profession, and psychology as life enhancement.
as a health profession, and psychology as life enhancement. Finally, the author argues that psychotechnology,
corporate clinical psychology, and psychology as life
enrichment will evolve within the future of clinical
psychological independent practice.
Key words: clinical psychology, independent practice,
life consultant, life trainer, psychotechnology. [Clin
Psychol Sci Prac 13: 273–277, 2006]
INTRODUCTION
I examine how clinical psychology is currently evolving
in private practice in the United States. Additionally,
I speculate how independent clinical psychology will
advance in the future. Most of my observations are based
on anecdotal data acquired during my tenure as 2005
president-elect and 2006 president of the American Psychological Association’s (APA) Division of Psychologists
in Independent Practice. In this capacity, I enjoyed an
“inside” view of clinical psychology in private practice.
Access to numerous online lists discussions, communications with independent practitioners, and input provided
by APA governance groups informed my observations.
Moreover, my experience of over 25 years in the private
practice of clinical psychology grounded my comments.
Address correspondence to Lillian Comas-Diaz, Transcultural
Mental Health Institute, Auburn, NSW 2144, Australia.
E-mail: cultura@starpower.net.
CURRENT CONCERNS OF CLINICAL PSYCHOLOGISTS IN PRIVATE
PRACTICE
Clinical psychologists are trained within the Boulder
Model of scientist-practitioner. However, clinical psychologists in private practice expand this definition by
adding business to the science and practice designation.
Within this context, independent practitioners offer
consumers a choice for psychological services under a
capitalist economy. Clinicians are committed to provide
effective and ethical psychological services t...
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