Handbook of Rural, Remote, and very Remote Mental Health 9811566305, 9789811566301

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Timothy A. Carey Judith Gullifer Editors

Handbook of Rural, Remote, and very Remote Mental Health

Handbook of Rural, Remote, and very Remote Mental Health

Timothy A. Carey • Judith Gullifer Editors

Handbook of Rural, Remote, and very Remote Mental Health With 40 Figures and 67 Tables

Editors Timothy A. Carey Institute of Global Health Equity Research University of Global Health Equity Kigali, Rwanda

Judith Gullifer Turner Institute for Brain and Mental Health School of Psychological Sciences Monash University Clayton, VIC, Australia School of Psychology Charles Sturt University Bathurst, NSW, Australia

ISBN 978-981-15-6630-1 ISBN 978-981-15-6631-8 (eBook) ISBN 978-981-15-6632-5 (print and electronic bundle) https://doi.org/10.1007/978-981-15-6631-8 © Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

When we first started to conceptualize this book, we were motivated to encourage, debate, and reimagine the way in which we define and discuss the influence of geography, as well as our construction of mental health in the context of this geographical influence for rural, remote, and very remote, or RRvR (we explain this terminology below), locations. In particular, we were interested in the potential impact this reimagining might have on the RRvR communities that are implicitly included in current deliberations. We wanted to provide an opportunity for an exploration of mental health beyond the dominant biological discourses as well as a context within which that exploration could occur. We have deliberately promoted and encouraged a psychological lens throughout this handbook, but it has been our unwavering intention that the principles and ideas that are expressed should be equally applicable and relevant to all mental health professionals who work in RRvR areas. And beyond mental health professionals, we acknowledge the role of all RRvR mental health workers who have a diverse range of backgrounds, training, and experiences, not least because of the difficulty in recruitment and retention traditionally associated with these geographic locations. To create a handbook such as this, we invited authors from a wide range of professional and academic backgrounds to take up the challenge of thinking beyond the status quo. All authors were provided with a basic chapter template and an invitation to reimagine mental health beyond the traditional medical and biological discourses and the conversant individualized treatments that are formulated to address disruptions to psychological and social functioning. From this approach, we think the result has been a wonderful kaleidoscope of interesting and diverse perspectives on the challenges of addressing mental health distress in RRvR communities. Authors differed not only in their perspectives, but also in the extent to which they felt comfortable questioning and breaking down some of our existing ideas and practices. Some chapters, therefore, will be more provocative than others. One of the immediate results of our approach has meant that this handbook does not have some of the usual features that you might expect to encounter such as a consistent, agreed upon, and unified view of mental health. Each chapter presents a unique perspective of the topic under discussion and, therefore, we do not deliver the usual links summarizing various chapters. v

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To further orient you to the nuances of this handbook, we want to highlight the importance of language. We think language is powerful. Language enables the sharing of ideas through written expression and communication. It is a cultural, social, and psychological phenomenon through which people shape discourses and construct power. We are therefore advocating use of the term “Rural, Remote, and very Remote: RRvR” instead of “Rural and Remote.” We provide a rationale for this in the book; however, in brief, given that many of the greatest disparities and inequities occur in very remote settings, we find it unacceptable that this geographical demarcation is subsumed under the term “remote” in most scientific and academic publications as well as policy documents. Because of this practice, the needs and demands of very remote locations remain virtually invisible. Advocating for a change in terminology is our attempt to highlight this important issue. Conversely, we highlight that throughout the book, terms such as patients, problems, and psychology are used. Terms, which arguably can be conceptualized as often being used in a disempowering manner. These terms have been used, rather than avoided, to allow scrutiny and reflection within the context of this handbook and the opportunity we wanted to create for reimagining what is familiar and, perhaps, unquestioned. We also acknowledge the important work in this area by the newly formed Australian Consumer Peak Alliance, established at the end of 2019, in addressing the ways words can be used to disempower people living with what is commonly (and we believe inappropriately) labelled “mental illness” and also challenging language use that is not aligned with personal agency and autonomy. Just as control, engagement, and genuine choice are important for RRvR communities, so too are they crucial for people living with problems that might be considered to be a “mental illness.” Thus, at times, the language used in this book may be unsettling or jarring for some readers. When this occurs, we would propose that the jarring arises from a clash between the words you are reading and existing assumptions and beliefs you hold about mental health in RRvR areas. If this occurs for you, and you find ideas, concepts, or words giving you reason to pause, stop, and think, then we consider we have done our job in providing opportunities for you to reflect upon your values, beliefs, and ideas. What you do with that opportunity, only you can determine. Consequently, throughout the book, there are references to terms such as “treatment” and “problems,” which reflect the dominant discourse of many of the current, often individualized, approaches to mental health. There are, however, also discussions of rural mental health and well-being in communities which often offer different ways of considering psychological and social functioning. Our aim was that this handbook should examine mental health across the spectrum of care including topics such as the social determinants of mental health. Given the lack of an RRvR mental health or social and emotional well-being (or both) workforce in many RRvR communities, this is especially pertinent. As this book has taken a considerable amount of time to produce, we acknowledge more recent initiatives in Australia that might not be as fully represented in the handbook as they perhaps should be. We commend the work, for example, arising from the recommendations from the Senate Affairs Committee Review of rural

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mental health, The Fifth National Mental Health and Suicide Prevention Plan, and the Orange Declaration that would further add to the arguments made in this book. We also acknowledge the important work on Aboriginal and Torres Strait Islander social and emotional well-being and landmark initiatives such as the Uluru Statement from the Heart and the establishment of a Senior Advisory Group by the Hon Ken Wyatt Chaired by Professors Marcia Langton and Tom Calma. With that, as you embark on your reading on this handbook, we would like to reiterate our invitational challenge to you. Are you daring and bold enough to begin to reimagine the way in which we collectively construct and address mental health in RRvR areas? May this handbook be the beginning of a journey to new horizons that are more humane, more respectful, and profoundly more constructive in helping all the citizens of RRvR localities live the lives they would wish for themselves. Scope of the Book It is important to emphasize that this book will have a distinctly Australian flavor. While we (co-editors TAC and JG) have varying amounts of international experience, the research and professional context we know best is RRvR Australia. Moreover, our professional networks include mostly Australian researchers and clinicians. Therefore, to broaden the relevance of this text, we have sought expert, international authors from Canada, New Zealand, the United Kingdom, and the United States to write specifically about their context. We have also, wherever possible, highlighted important principles of practice rather than specific programs or interventions, because principles are more likely to be transportable than particular services (Carey, 2018). The handbook, therefore, may be broadly applicable to RRvR settings in high-income countries (HICs) but may, perhaps, be less relevant for low- and middle-income countries (LMICs). In fact, a useful avenue for future research and inquiry would be to investigate the extent to which lessons learned in LMICs with regard to reducing health and social inequities are applicable to very remote Australia, where these inequities can be just as severe. TAC is now working at the University of Global Health Equity in Rwanda, so perhaps work of this nature will be able to be completed. We would be delighted to hear from you about your impressions of the handbook – whatever those impressions might be. We would be especially excited to learn of initiatives we are as yet unaware of that are consistent with the approach we are nurturing in this handbook as well as any interest you might have in taking up the invitational challenge we have extended by this work. We wish you all the very best in your efforts to help people in RRvR achieve and maintain the psychological and social functioning they regard as ideal to live the lives they wish to create. March 2021

Contents

1

Rural, Remote, and very Remote Mental Health . . . . . . . . . . . . . . Timothy A. Carey and Judith Gullifer

Part I Context of Rural, Remote, and very Remote Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

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Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Judith Gullifer, Mikaela Cibich, and Timothy A. Carey

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Global Mental Health Perspectives on Rural and Remote Mental Health Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ross G. White, Nargis Islam, and Rosco Kasujja

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4

Indigenous Mental Health in Remote Communities . . . . . . . . . . . . Lewis Mehl-Madrona and Barbara Mainguy

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5

Mental Health Research and Evaluation in Rural, Remote, and very Remote Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Timothy A. Carey

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Recovery in Mental Illness Among Rural Communities Keith Sutton and Anton Isaacs

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Professional Ethics in Rural Practice: Relational Territory . . . . . . Judi L. Malone

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Part II Professional Practice in Rural, Remote, and very Remote Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Models of Service Delivery and Funding of Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sebastian Rosenberg and Russell Roberts

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Contents

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Integrated Primary Mental Health Care in Rural and Remote Contexts: The Australian Experience . . . . . . . . . . . . . . . . . . . . . . . Robyn F. Vines and Ross Wilson

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Visiting Workforce Carly Sutherland

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Telemental Health in Rural and Remote Contexts . . . . . . . . . . . . . Susan Simpson, Lisa Richardson, and Corinne Reid

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Improving Access to Psychological Services in Remote Australia with a Patient-Led Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sarah Funnell, Timothy A. Carey, Sara J. Tai, and Debra Lampshire

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Multidisciplinary Teams in Rural and Remote Mental Health Mathew Coleman

...

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Improving the Physical Health of Rural People Living with Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Russell Roberts

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Part III Role of Different Professions in Rural, Remote, and very Remote Mental Health Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Rural and Remote Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lewis Mehl-Madrona and Patrick McFarlane

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General Practitioners Mary Emeleus

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Rural and Remote Mental Health Practice: Nursing Roles . . . . . . Josephien Henriette Rio

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Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Judi L. Malone

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Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jane Maidment

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Peer Work in Rural and Remote Communities and Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fay Jackson, Tim Heffernan, Mark Orr, Robert Butch Young, Cherie Puckett, and Susan Daly Critique of Psychiatry in Rural and Remote Communities . . . . . . Lewis Mehl-Madrona, Patrick McFarlane, and Kate Mulrenin

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Contents

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Maintaining Control: The Importance of Self-Care to Effective and Enduring RRvR Mental Health Service Provision . . . . . . . . . . . . . Timothy A. Carey and Judith Gullifer

Part IV Important Areas of Practice in Rural, Remote, and very Remote Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Suicide and Self-Harm: It’s Everyone’s Business . . . . . . . . . . . . . . Sarah Jane Lutkin and Beryl Buckby

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Substance Abuse in Rural and Remote Areas . . . . . . . . . . . . . . . . James H. Bray, Brittany Zaring-Hinkle, and Jessica K. Perrotte

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Quality Use of Psychotropic Medicines in Rural and Remote Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tobias Speare, Alice Gilbert, Marcus Tabart, and Danny Tsai

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Providing School-Based Mental Health Services in Rural and Remote Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R. Elizabeth Capps, Kurt D. Michael, J. P. Jameson, and Kasey Sulovski

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Social and Emotional Well-Being: “Aboriginal Health in Aboriginal Hands” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pat Dudgeon, Chontel Gibson, and Abigail Bray

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Working with Rural Families: Issues and Responses When a Family Member Has a Mental Illness . . . . . . . . . . . . . . . . . . . . . . . Andrea Reupert, Rochelle Hine, and Darryl Maybery

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Supporting Communities Susan Letvak

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Environmental Impacts on Mental Health . . . . . . . . . . . . . . . . . . . S. E. L. Burke

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Addressing Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S. E. L. Burke

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Depression and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lisa Curtin, Stephanie E. Moss, and Susan E. Keefe

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Low Prevalence Psychiatric Disorders in Rural and Remote Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Noel Collins

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Contents

Promotion and Prevention of Mental Health Problems in Rural and Remote Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jennifer Bowers

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Future of Rural, Remote, and very Remote Mental Health . . . . . . Timothy A. Carey and Judith Gullifer

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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About the Editors

Professor Timothy (Tim) Carey is a scientistpractitioner who is a researcher, teacher, trainer, and clinician. He is currently the director of the Institute of Global Health Equity Research and the Andrew Weiss Chair of Research in Global Health at the University of Global Health Equity in Rwanda. Tim has worked as a clinical psychologist in rural and underserved communities in both Scotland and remote Australia. He has been elected for two terms as a director on the board of the Australian Psychological Society (APS) and has also served two terms as the vice president of the APS. As a director of the APS, he chaired the Regional, Rural and Remote Advisory Group as well as the Division of Psychological Research Education and Training and was also a member of the Indigenous Psychologists Advisory Group. He has a Ph.D. in clinical psychology, an M.Sc. in statistics (with distinction in the dissertation), and a postgraduate certificate in biostatistics as well as tertiary qualifications in teaching (preschool and special education) and is a graduate of the Australian Institute of Company Directors. Prior to his current role, his most recent academic appointments have been professor and director of Flinders University’s Centre for Remote Health and professor of clinical psychology in health equity at Charles Darwin University in Alice Springs, Australia. Tim has served on national grant funding bodies as well as university Human Research Ethics Committees and teaches research methods at undergraduate and postgraduate levels. He has also secured research income as a chief investigator on competitively funded research projects. For Tim, it is a scientific attitude rather than the scientific method that is paramount. A central focus of Tim’s work is the importance of control to health and well-being and xiii

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About the Editors

recognition of internal conflict as an a-diagnostic explanation of psychological distress. He is also very interested in different cultural explanations of psychological distress and the importance of control cross-culturally. He has pioneered clinical innovations such as patientled appointment scheduling and patient-perspective care. He has developed an efficient and effective cognitive therapy called the Method of Levels (www. methodoflevels.com.au) as well as a smartphone app called MindSurf. While working in the National Health Service in Scotland, Tim led a program of practicebased research that resulted in a reduction in the waiting time to access psychological services from 15 months to less than 2 weeks using the patient-led model of appointment scheduling he had developed. He is a Fulbright scholar who has over 150 publications including books, book chapters, and peer-reviewed publications. Tim also has a blog on Psychology Today called In Control, which has had over 1,000,000 views. He is currently working on a book explaining the application of a theory of control to understanding health inequity. He lives in Kigali (the capital of Rwanda) with his family and feels both humbled and privileged to have the opportunity to live and work in such an extraordinary country and to be able to contribute to efforts to eradicate global health inequities.

Professor Judith Gullifer is the Director of Education in the School of Psychological Science at Monash University. She held the inaugural position of Associate Dean (Partners and Quality) at Charles Sturt University and was also the foundation Associate Dean (Academic) in the Faculty of Business, Justice and Behavioural Sciences at Charles Sturt University. Judith has spent over a decade dedicated to education and research in the higher education sector. She has been active in the teaching and supervision of undergraduate and postgraduate students. Judith has been the recipient of the Charles Sturt University Vice Chancellors Award in Teaching Excellence and the Australian Psychological

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Society’s Early Career Teaching Award. Judith completed her Ph.D. investigating students’ perceptions of plagiarism at Charles Sturt University and has maintained that commitment as the current Co-Chair of the Asia Pacific Forum on Educational Integrity (APFEI). Judith is a registered psychologist with a background in professional counselling in rural and remote Australia. She manages a small virtual, parttime practice, mentoring and coaching senior leaders. She has held various positions with the Australian Psychological Society, having been appointed to the Board of Directors in 2016 for her expertise in working in regional, rural, and remote Australia. She was a founding member of the Rural, Regional and Remote Advisory Group to the National Board of Directors and the convener of the Australian Psychological Society Rural and Remote Interest Group. In January 2017, Judith became the Executive Manager and Head of the Australian Psychological Society’s Training Institute where she oversaw the professional education and training of psychologists and other cognate professions.

Contributors

Jennifer Bowers Rural and Remote Mental Health Ltd, Adelaide, SA, Australia Abigail Bray Indigenous Studies, University of Western Australia, Crawley, WA, Australia James H. Bray Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA Beryl Buckby James Cook University, Townsville, QLD, Australia S. E. L. Burke Australian Psychological Society, Melbourne, VIC, Australia R. Elizabeth Capps Department of Psychology, Appalachian State University, Boone, NC, USA Timothy A. Carey Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda Mikaela Cibich College of Medicine and Public Health, Flinders University, Alice Springs, NT, Australia College of Education, Psychology, and Social Work, Flinders University, Bedford Park, SA, Australia Mathew Coleman Rural Clinical School of WA, University of Western Australia, Albany, WA, Australia Noel Collins Rural Clinical School of WA, University of Western Australia, Albany, WA, Australia Lisa Curtin Appalachian State University, Boone, NC, USA Susan Daly Health, New South Wales, Sydney, NSW, Australia Pat Dudgeon Indigenous Studies, University of Western Australia, Crawley, WA, Australia

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Contributors

Mary Emeleus Australian Society for Psychological Medicine, Crows Nest, NSW, Australia College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia Sarah Funnell Centre for Remote Health, Flinders University, Adelaide, SA, Australia Chontel Gibson School of Health and Rehabilitation Science, University of Queensland, Sydney, NSW, Australia Alice Gilbert Top End Health Service, Northern Territory Government, Darwin, NT, Australia Judith Gullifer Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia School of Psychology, Charles Sturt University, Bathurst, NSW, Australia Tim Heffernan NSW Consumer Peer Workforce Committee, Woolloomooloo, NSW, Australia Rochelle Hine Monash University School of Rural Health, Warragul, VIC, Australia Anton Isaacs Monash Rural Health (Tralagon and Warragul), Monash University, Traralgon, VIC, Australia Nargis Islam Independent Academic and Clinical Psychologist, Oxford, UK Fay Jackson Vision In Mind, Brunswick Heads, NSW, Australia J. P. Jameson Department of Psychology, Appalachian State University, Boone, NC, USA Rosco Kasujja Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda Susan E. Keefe Appalachian State University, Boone, NC, USA Debra Lampshire Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand Susan Letvak Adult Health Nursing, The University of North Carolina at Greensboro, Greensboro, NC, USA Sarah Jane Lutkin James Cook University, Townsville, QLD, Australia Jane Maidment School of Language, Social and Political Science, University of Canterbury, Christchurch, New Zealand

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Barbara Mainguy Center for Family Medicine, Eastern Maine Medical Center, Bangor, ME, USA School of Social Work, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA Judi L. Malone PAA Psychologists’ Association of Alberta, Edmonton, AB, Canada Darryl Maybery Monash University School of Rural Health, Warragul, VIC, Australia Patrick McFarlane Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA Lewis Mehl-Madrona Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Department of Psychiatry, University of Vermont, College of Medicine, Burlington, VT, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA Kurt D. Michael Department of Psychology, Appalachian State University, Boone, NC, USA Stephanie E. Moss Appalachian State University, Boone, NC, USA Kate Mulrenin Private Practice, Bar Harbor, ME, USA Mark Orr Flourish Australia, Sydney Olympic Park, NSW, Australia Jessica K. Perrotte Department of Psychology, Texas State University, San Marcos, TX, USA Cherie Puckett Clinical Operations West, Murrumbidgee Local Health District, New South Wales Health, Wagga Wagga, NSW, Australia Corinne Reid Executive Division, Victoria University, Melbourne, Australia Andrea Reupert Krongold Clinic, Faculty of Education, Monash University, Clayton, VIC, Australia

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Contributors

Lisa Richardson School of Psychology and Exercise Science, Murdoch University, Murdoch, WA, Australia Josephien Henriette Rio Mental Health-Central Australia Mental Health Services, Alice Springs, NT, Australia Yorke and Northern Local Health Network, SA Health, Kilkenny, Australia Russell Roberts School of Management, Charles Sturt University, Bathurst, NSW, Australia Sebastian Rosenberg Centre for Mental Health Research, Australian National University, Canberra, ACT, Australia Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia Susan Simpson School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia St John’s Hospital, NHS Lothian, Livingston, Scotland, UK Tobias Speare Centre for Remote Health, Flinders University, Alice Springs, NT, Australia Kasey Sulovski Department of Psychology, Appalachian State University, Boone, NC, USA Carly Sutherland The University of Adelaide, Adelaide, SA, Australia Keith Sutton Monash Rural Health (Warragul), Monash University, Warragul, VIC, Australia Marcus Tabart Central Australia Health Service, Northern Territory Government, Alice Springs, NT, Australia Sara J. Tai School of Psychological Sciences, University of Manchester, Manchester, UK Danny Tsai Centre for Remote Health, Flinders University, Alice Springs, NT, Australia Robyn F. Vines Bathurst Rural Clinical School, School of Medicine, University of Western Sydney, Sydney, NSW, Australia Ross G. White Institute of Population Health, University of Liverpool, Liverpool, UK Ross Wilson Bathurst Rural Clinical School, School of Medicine, University of Western Sydney, Sydney, NSW, Australia Robert Butch Young NSW Woolloomooloo, NSW, Australia

Consumer

Peer

Workforce

Committee,

Brittany Zaring-Hinkle Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA

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Rural, Remote, and very Remote Mental Health Timothy A. Carey and Judith Gullifer

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Distinctive Features of Service Delivery in RRvR Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Abstract

While the prevalence of mental health problems in rural, remote, and very remote (RRvR) settings compared with metropolitan settings is approximately the same, access to services is much poorer. Consequently, the efficient resolution of mental health difficulties is often compromised in nonurban settings. Not only is access to services difficult in more rural locations, the range of health professionals available to residents in RRvR contexts is usually limited. People in RRvR settings, for example, may have access to health professionals who provide psychiatric and case management services but not have access to health professionals who provide alternative psychological and social programs. Thus, the availability of evidence-based programs and services is less than ideal for people living outside metropolitan settings. Furthermore, although people who live in cities have access to specialist mental health services, these services are frequently unavailable to people living in RRvR locations. Moreover, even though T. A. Carey (*) Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda e-mail: [email protected] J. Gullifer Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia School of Psychology, Charles Sturt University, Bathurst, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_1

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T. A. Carey and J. Gullifer

the Western biomedical model of (mental) health is dominant in nonmetropolitan Australia, it could be seen to be particularly unhelpful because of the high proportion of Aboriginal and Torres Strait Islander Australians living in RRvR locations who prefer to understand psychological distress from the perspective of social and emotional wellbeing, rather than as a biomedical disorder and illness. In many ways, a social and emotional wellbeing approach would be more closely aligned to a biopsychosocial model than the way in which the current biomedical model is applied in which psychological problems are understood as illnesses analogous to physical illnesses. The social and emotional wellbeing perspective is also compatible with a social determinants of health model which provides another important component of effective service provision for underserved populations. In this chapter, we define the scope of this handbook and outline the current state of RRvR mental health, thereby laying the foundation for the key areas to be explored in detail throughout the book.

Rural, Remote and very Remote (RRvR) Mental Health needs reimagining: are you ready to take up the challenge?

Introduction Robust and resilient mental health is perhaps our greatest resource. Throughout history, creative and motivated minds have been capable of astonishing achievements. The ancient Egyptian Pyramids and the Great Wall of China provide clear examples of human ingenuity from antiquity that still exist today. More recently, we have figured out how to send people into space, we have erected buildings that are testament to engineering brilliance, we have choreographed patterns of movement of exquisite beauty, and we have learned to overcome deadly illnesses. Of course, we should not forget that our powerful minds are also capable of great atrocities. The horrors of two World Wars, along with, for example, the 1994 Genocide Against the Tutsi, are relatively recent and painful reminders of how extreme our awfulness can be. Despite the hideousness of some acts, they still provide evidence of the profound consequences we can realize when we are focused and determined. Sometimes, great achievements, particularly in the arts, can arise from troubled minds, much like the Phoenix rising from the ashes. People such as Vincent Van Gogh, Sylvia Plath, Robin Williams, and Virginia Woolf all made wonderful contributions to the arts, but all eventually ended their own lives. The tragic ends to these famous people’s lives are poignant reminders that, rather than being the wellspring of great artistic accomplishments, tormented minds are more commonly a source of misery, despair, and disruption, not only for the individual but also for their family, close friends, and community. It may well be the case that the impact of psychological distress reverberates most strongly in small communities such as in RRvR locations, compared with the anonymity and invisibility that can exist in metropolises.

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In small communities, people are often interconnected in ways not replicated in large cities. People are generally much more aware of each other’s day-to-day business and can be quick to notice when daily functioning falters. While this inescapable “community gaze” can be of benefit in terms of offering support at an early stage, it can also introduce problems in terms of perceived stigma and fear of being ostracized. Despite our cleverness and ingenuity at making remarkable progress in technology and physical health, we still have tremendous difficulty solving the problems of a troubled mind. Even more fundamentally, there is still no widely agreed definition or standard of what a troubled mind is. Evidence suggests that, globally, we are having negligible impact on the occurrence of mental health conditions. A recent editorial in The Lancet (2017, p. 1083) reported that there was little improvement in the prevalence of mental health problems between 1990 and 2016, and, in 2016, “major depressive disorders ranked in the top ten causes of ill health in all but four countries worldwide.” It does not seem to be the case that cures and remedies similar to those we have developed in other fields of health are anywhere on the horizon for achieving sustained psychological wellness. The area of greatest development for the treatment of psychological distress in the twentieth century has been unequivocally chemical, rather than psychological or social. “Development,” as we are using the term here, should not be regarded as being synonymous with “progress.” There has been, without a doubt, a great deal of activity in the production of new and, seemingly new, chemical compounds to administer to people diagnosed with mental health problems. This activity has resulted in the profits of pharmaceutical companies rising astronomically, to make them some of the most successful companies in the world. Unfortunately, there has not been a commensurate increase in the evidence of effectiveness of these psychotropic agents. While pharmaceutical interventions have been helpful for some people, there is persuasive evidence that long-term outcomes, even for people with severe psychological problems, are worse than they were before these treatments were introduced (Whitaker 2010). Even with less serious psychological troubles, the picture is grim, with the prevalence of depression, for example, increasing 1000-fold since the introduction of antidepressants (Healy 2004). In fact, the entire profile of depression, in terms of such things as age of onset, frequency of relapse, and so on, changed once treatment by antidepressant medication became the standard (Whitaker 2010). There is compelling evidence that the benefits of medication for psychological and social problems have been wildly exaggerated, and the harms have been drastically minimized (Healy 2012). A comprehensive and systematic study of institutional corruption suggests that the misinformation regarding psychotropic medication may have arisen from the relationship between the American Psychiatric Association and the pharmaceutical industry (Whitaker and Cosgrove 2015). From a big picture perspective, the harm done in this instance of institutional corruption arises from a very simple fact. Our society over the past 35 years, has organized itself in response to a narrative told by American psychiatry that was, in so many of its details, misleading. Our understanding of the biology of mental disorders, our use of psychiatric

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There is good evidence that we need a new approach to the conceptualization and treatment of psychological problems. It could be argued that this is most urgently needed in RRvR locations more than anywhere else because access to services is so problematic in these settings. Although the rates of psychological problems have been assessed as similar between urban and RRvR locations, timely access to effective services is much poorer, which makes the impact of psychological problems in RRvR contexts much greater (Department of Health 2017). People in RRvR towns and communities are not able to seek out a range of different services or specialty clinics that are available to their metropolitan counterparts. So it is critical that, with regard to the options we offer, we get better at getting it right the first time. This book is part of our effort to get it right. We have designed this book to emphasize the psychological and social aspects of conceptualizing and “treating” psychological problems. The ubiquitous portrayal of psychological problems as medical maladies has persisted for far too long. In order to consider an individual’s functioning holistically, it is of course necessary to also include biological frameworks. Our position, however, is that biology, has been afforded a much greater role in a person’s psychological functioning than is appropriate or helpful. For instance, we are still largely in the dark in terms of identifying how genetic or neuronal characteristics translate into actual behavior. It is also time that psychosocial considerations be given at least equal priority when trying to develop a better understanding of an individual’s overall psychological wellbeing. This is not a binary proposition of an “either/or,” “this or that,” situation. The process of living is undoubtedly influenced by genetic, biochemical, and physiological factors as well as psychological and social factors. Programs of research need to focus on understanding the ways in which these different aspects of functioning affect, and are affected by, all the other aspects of functioning. Substantial progress will never be realized, while fields of study such as epigenetics, neuroscience, and psychology proceed in isolation from the other interrelated fields (Carey 2013a, 2015). Placing biology as the first term in the biopsychosocial model (Carey et al. 2014) was never intended to ascribe primacy to biological factors. Humans are, first and foremost, psychological and social creatures. Nomenclature aside, whatever biological, biochemical, or indeed genetic anomalies seem to be associated with psychological distress, the chasm between an individual’s biochemical and genetic profile, and the way this translates into daily functioning, has still not been clarified (Carey 2015). Perhaps that translation will never be explained while we continue to slice human functioning ever more finely, maintaining separate and distinct research programs in each of these realms, policy directives, and funding streams for apparently disconnected features of being human.

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It is the “daily living” by individuals within their social networks and communities that must be understood and enriched. To arrive at an understanding that will be helpful, the perspective of the people living with what is commonly described (incorrectly) as “mental illness” must be prioritized (we use quotations marks in this chapter when we use the term “mental illness” to emphasize the metaphorical nature of the words). In fact, it may be that “people living with mental illnessperspective care” is a more appropriate and effective alternative in service design than the current “people living with mental illness-centered care” model (Carey 2017a). By failing to honour the priorities, values, and beliefs of people identified as patients, the phenomenon of inappropriate care has become a global scourge (Carey 2017a) costing health systems billions of dollars annually. The perspective of people in the role of patient is paramount in providing care that is appropriate, effective, and efficient. We now recognize, for example, that even the category of depression does not capture a discrete, homogenous syndrome. Fried and Nesse (2015) investigated the symptom profiles of 3703 people who were diagnosed as being depressed at the beginning of the STAR*D study, identifying a total of 1030 unique symptom clusters of which 83.9% (864 profiles) were endorsed by less than six people. Profiles endorsed by only one person made up 48.6% (501) of the total. To provide appropriate healthcare to someone requesting assistance for alleviation of their psychological difficulties, it is necessary to understand the person holistically within the context of the social life they are forging for themselves. While there has never been any evidence for the chemical imbalance explanation of low mood (Healy 2004, 2012), there is good evidence that the strength of a person’s connections with various aspects of their life, such as meaningful relationships and a fulfilling occupation, influences their ability to achieve contentment and satisfaction (Hari 2018). The importance of healthy connections resonates with the Aboriginal and Torres Strait Islander concept of social and emotional wellbeing (SEWB) which will be mentioned later in this chapter and in other chapters throughout this book. This chapter provides an overview of mental health in predominantly Australian RRvR contexts. As such, it will introduce a range of topics that will be explored in more depth in subsequent chapters. It is worth emphasizing that several themes will be repeated throughout the book. Lack of access to services, for example, is a feature of RRvR locations that will be highlighted in many of the chapters. It is imperative to find ways of improving access to appropriate interventions and healthcare that do not compromise the quality of those services. An important guiding principle, whenever any RRvR initiative is being considered, is that we should expect the standard of healthcare in RRvR contexts to be at least as high as the standard regarded as satisfactory in metropolitan centres. Interventions may need to be delivered differently because of the way in which locations vary; however, the standard of service delivery should not differ (Carey 2018). There is an important equity principle here for practitioners that is often ignored. We strongly subscribe to, and promote, the attitude that the expanded scope of practice required in many RRvR contexts requires advanced skills, knowledge,

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and general expertise for clinicians to function effectively and be of benefit to the community or communities being served. There often appears to be a perception that clinicians in RRvR contexts are less skilled than their metropolitan counterparts. While any sort of competitive comparison is unnecessary and unhelpful, it remains the case that the effective delivery of services and programs in RRvR localities requires clinicians who are comfortable with uncertainty, unpredictability, flexibility, and responsivity to different, often more complex presentations, with the ability to reflect on and address the different ethical and professional issues that arise from these.

Distinctive Features of Service Delivery in RRvR Areas There are a number of features which are distinctive to the provision of effective and efficient mental health services in RRvR contexts. We will briefly describe some of the more important features – however, this is by no means an exhaustive list. The features discussed here are general in nature and might apply, to a greater or lesser extent, to most or all RRvR contexts. There may also be other characteristics, however, more specific to particular locations. You will learn about some of these in later chapters of the book. Starting with what is not distinct: The astute reader will notice that many of the issues that are discussed in this text are not unique to RRvR settings. Problems of stigma, for example, are not constrained by geography. Furthermore, the current Western biomedical conceptualization of mental health and social emotional wellbeing is just as inappropriate in the city as it is in the country, and the Aboriginal and Torres Strait Islander concept of socialand emotional wellbeing is universally applicable. While dilemmas regarding ethical and professional boundaries may be more common in RRvR locations, they still require attention and careful consideration in metropolitan centres. It is the impact, not the issues themselves, that is most affected by rurality. There is a greater range of service options in more densely populated locales; thus lack of access to these services is likely to have a greater impact in less densely populated areas. Similarly, while battling stigma is never an easy task, in small close-knit communities where anonymity is virtually impossible, the impact of stigma may reverberate far more strongly than in urban settings. The universal nature of many of the difficulties inherent in providing timely access to effective and efficient services means that if this problem can be solved in RRvR locations, there is every chance that there will be valuable lessons for improved service provision in metropolitan contexts. As you read the chapters in this Handbook, it may be important to pay more attention to the impact any particular issue might have in RRvR settings, rather than the issue itself. Organization of mental health services. Living in RRvR Australia has many exceptional quality of life benefits, but there are existing challenges with accessing appropriate mental health services. As a rule, the further the distance from a capital city, the fewer publicly funded services and private health practitioners. Public mental health services still tend to be linked to hospital systems, governed by the

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different State governments, which may differ in their service provision across Australia. This creates challenges for continuity of care when access is needed. These services include the public hospitals that provide mental health services during a situational crisis or an acute episode of “mental illness.” Communitybased services are managed through local teams that exist to help bridge the gap between hospital services and community living. Mental health community support services are a range of government and nongovernment organizations that provide additional support to individuals living with severe and debilitating “mental illness” in the community. Integration between these range of sectors (government, nongovernment, and private) varies across locations. Private mental health services may be delivered by psychiatrists, psychologists, or other mental health professionals who work in the community. These services can be subsidized by a government rebate through the federally funded Medicare system if the individual obtains a referral from a general practitioner (GP) or through private health insurance. This subsidized government service has, however, received criticism because of the limited number of sessions that an individual can claim. An individual who is referred by a GP is entitled to government rebates for ten sessions in a calendar year. While ten sessions are ample for many people, this number falls drastically short for people with complex mental disorders who may need many more sessions. A recent innovation under Medicare has been the introduction of telehealth items which provide one way of making services more accessible. It is crucial, however, that telehealth services should not be seen as an alternative to faceto-face services for people in RRvR settings. Telehealth does not suit all people who wish to access mental health services. Moreover, if policy and other decision-makers genuinely believe that telehealth services are equivalent in quality to face-to-face services, then there is no need to restrict them to RRvR people seeking mental health services. People residing in the affluent and well-resourced suburbs of major cities who are psychologically troubled should also be able to access mental health treatment over the phone (as we have seen with COVID-19). In 2015 the Australian Government established Primary Health Networks (PHN) across Australia. These networks were established to improve the coordination of care when and where individuals may require it, by working directly with GPs and other healthcare providers. The role of PHNs was expanded to plan and commission primary mental healthcare services. This new model of mental healthcare in Australia is based on the delivery of grant funding to PHNs to deliver a range of activities which include: • Commissioning of evidence-based clinical mental healthcare services; • Developing and commissioning low-intensity psychological interventions for people with mild “mental illness,” integrating the use of technology where appropriate; • Phasing in the implementation of approaches to deliver services for people with severe and complex mental health issues; • Establishing assessment processes and referral pathways for individuals with “mental illness” to receive the clinical services required;

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• Developing and commissioning region-specific services to provide early intervention to support children and young people with, or at risk of, “mental illness”; • Developing and commissioning strategies to target the needs of people living in RRvR areas and underserviced populations; and • Developing evidence-based regional suicide prevention plans and commissioning services to enable a planned and flexible approach to suicide prevention. The greatest change to delivery of mental health services with the introduction of the PHN model is the commissioning of services through the use of the available workforce. The capacity of this model to deliver effective services in the Australian context has been challenged (Coopes 2017), with several barriers to equity identified by Henderson and colleagues (Henderson et al. 2018). They argue that commissioning tends to disadvantage populations most in need of service provision, including Aboriginal and Torres Strait Islander Australians and RRvR communities. Diverse contexts. A common adage in RRvR contexts is “if you’ve seen one remote community, you’ve seen one remote community.” The term “rural and remote” covers a staggering array of communities of different sizes, ethnicities, and purposes. In fact, one of our purposes in using the term “RRvR” is to bring into the spotlight very remote communities. It is often the case that the term “remote communities” is used when, actually, what is being referred to is a “very remote community.” In 2004, a landmark paper defined “remote health” as a distinct health discipline (Wakerman 2004). The definition offered was: Remote Health is an emerging discipline with distinct sociological, historical and practice characteristics. Its practice in Australia is characterised by geographical, professional and, often, social isolation of practitioners; a strong multidisciplinary approach; overlapping and changing roles of team members; a relatively high degree of GP substitution; and practitioners requiring public health, emergency and extended clinical skills. These skills and remote health systems, need to be suited to working in a cross-cultural context; serving small, dispersed and often highly mobile populations; serving populations with relatively high health needs; a physical environment of climatic extremes; and a communications environment of rapid technological change. (Wakerman 2004, p. 213)

A moment’s reflection will reveal that this definition depicts very remote rather than remote health. Alice Springs, for example, is regarded as a remote community, according to standard Australian geographical classifications. It has a large teaching hospital and many GP practices. It could be argued, in fact, that the health services in many remote towns are not so different from the health services in rural or even regional locations. For example, according to the Modified Monash Model, Broken Hill (in New South Wales) has a remoteness classification of 3, Mackay (in Queensland) has a remoteness classification of 2, Alice Springs in the Northern Territory has a classification of 6, and Ampilatwatja, Anmatjere, Papunya, and Yuendumu (all in the Northern Territory) all have classifications of seven (7). Alice Springs, however, as a remote town, would be far more similar to Mackay and Broken Hill than to the very remote communities of Ampilatwatja, Anmatjere, Papunya, and Yuendumu. It is in very remote communities that the greatest challenges to service delivery exist.

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Some very remote Aboriginal and Torres Strait Islander communities, for example, may have only a few hundred people and can become inaccessible in wet weather. In these communities, English may not be the main language spoken. Furthermore, traditional cultural and healing practices, along with traditional beliefs about illness and wellbeing, may be preferred over Western biomedical approaches. “Rural and remote,” however, also refers to mining towns and small tourist economies. Larger communities that might be the centre of wine growing districts or sheep, wheat, or other farming enterprises are also included. These communities often have distinct “cultures” that range from families who have lived in the area for generations to fly-in fly-out workers for a large mining enterprise. “Rural and remote” additionally covers all parts of Australia including coastal, inland, island, desert, and rainforest. It is imperative, however, that very remote Australia is not left out of our considerations or assumed to be included with remote Australia. In fact, it is somewhat ironic that, in carving out “remote health” as a distinct and important specialty, the incorrect nomenclature was adopted by Wakerman (2004). “Remote area nurses” (RANs), for example, who can be proud and fiercely territorial of their professional identity, are, in fact, “very remote area nurses” (vRANs). It is very remote health where the inequities and needs are greatest. Perhaps it is the current invisibility of very that contributes to this disparity. Hence, from our perspective, it is RRvR. A large proportion of Aboriginal and Torres Strait Islander Australians. With increasing remoteness, the proportion of Aboriginal and Torres Strait Islander Australians also increases. Aboriginal and Torres Strait Islander Australians constitute 3% of the Australian population with approximately 80% living in regional and metropolitan areas (Australian Government 2017). Although only approximately 14% of Aboriginal and Torres Strait Islanders live in “very remote” locations, they comprise 45% of the population in these areas. The health and social disparities and general disadvantage experienced by Aboriginal and Torres Strait Islander Australians therefore has a large impact in these locations. While there have been recent initiatives to provide Aboriginal and Torres Strait Islander peoples with greater influence and control over their lives, it is still not clear that the spirit of selfdetermination has been fully embraced. To solve long-standing problems, however, in RRvR locations, it is imperative that Aboriginal and Torres Strait Islander peoples not only have seats at the political table but are seated at the head of the table. The promise of the landmark Apology to Aboriginal and Torres Strait Islanders by the Australian Psychological Society (described in more detail below – Carey et al. 2017) still seems to be some way from being realized. A lack of specialist services. Due to their small and often dispersed populations, very remote locations frequently cannot support the presence of specialty clinics such as an eating disorders clinic, an anxiety clinic, or a service specifically for people who might attract a diagnosis of borderline personality disorder. Mental health professionals in RRvR locations, therefore, are often required to have an expanded scope of practice with the commensurate skills and knowledge to function effectively. This can be problematic when the professionals recruited to services in RRvR locations are often young and inexperienced.

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The importance of primary care. Primary care services are often the bedrock of health service delivery in RRvR locations, and all mental health professionals need to be skilled at working in them. Due to workforce shortages, those working in primary care centres in RRvR locations need to acquire expertise in a number of areas including the provision of individual therapy, education, and prevention initiatives and also the evaluation of programs and services. An important area of expertise of psychologists that is frequently overlooked by decision-makers in primary care settings is their research and evaluation skills. Training programs also need to recognize the importance of primary care and provide extensive training to psychologists and all workers working in RRvR in the philosophy and multidisciplinary practice of this area of health services and systems. The relevance of the social determinants of health. Consideration of the social determinants of health is pivotal to effectively addressing the social and emotional wellbeing of people wherever they may live but especially in RRvR locations. The social determinants of health perspective has a specific organizing principle as well as consequent interventions. The principle that underpins this perspective is the organizing principle of “control and social engagement” (Marmot 2006, 2015). While the interventions arising from the social determinants of health model such as education, employment, and housing, attract most of the attention, it is actually the impact these interventions have on the organizing principle of “control and social engagement” that is pivotal. “Employment, for example, will promote wellbeing when it increases the degrees of freedom a person has in their life and improves their ability to control the things which matter to them. If someone’s employment interferes with their ability to control their life, however, through perhaps degrading or stressful conditions, then wellbeing will not be improved. Similarly, housing will enhance wellbeing if it improves a person’s ability to control important aspects of their life. If, however, the person experiences an influx of large numbers of relatives and they are then held accountable for damage to the property, wellbeing might move in the opposite direction from what is desired” (Carey 2013b, p. 190). This emphasis regarding the fundamental importance of “control” to successful social living, once again points to the essential relevance of self-determination. From this perspective, self-determination could be regarded as much more basic than other human rights (Carey 2017b). Self-determination is an inherent property of the way in which humans are designed, in the same way that digestion, neuroplasticity, and cell regeneration are features of our design. The applicability of the concept of “social and emotional wellbeing.” Given the high proportion of Aboriginal and Torres Strait Islander people living in RRvR locations, a challenge for mental health professionals is to embrace a SEWB approach to psychological functioning. SEWB is the preferred model of psychological and social functioning for Aboriginal and Torres Strait Islander peoples. As outlined at the beginning of this chapter, the Western biomedical approach to mental health problems has overridden First Nations understandings across the globe, with a consequent homogenization of the way in which psychological functioning is conceptualized and addressed (Watters 2010). Rather than considering psychological distress as a medical problem, Aboriginal and Torres Strait Islander people focus

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on the strengths of an individual’s connections in seven domains: connection to mind and emotions; connection to body; connection to family and kinship; connection to country; connection to culture; connection to spirit, spirituality, and ancestors; and connection to community (Gee et al. 2014). In light of this focus of Aboriginal and Torres Strait Islander peoples, the widespread and long-standing allegiance to the Western biomedical model and provision of mental health services (to Aboriginal and Torres Strait Islander peoples) have not always been helpful and, in some instances, have been harmful. In recognition of the inappropriateness of some of the services that have been provided, the Australian Psychological Society (APS) developed and delivered a landmark apology to Aboriginal and Torres Strait Islander peoples in 2016. The APS apologized for: • Psychologists’ use of diagnostic systems that do not honor cultural belief systems and world views; • The inappropriate use of assessment techniques and procedures that have conveyed misleading and inaccurate messages about the abilities and capacities of Aboriginal and Torres Strait Islander people; • Conducting research that has benefitted the careers of researchers rather than improved the lives of the Aboriginal and Torres Strait Islander participants; • Developing and applying treatments that have ignored Aboriginal and Torres Strait Islander approaches to healing and that have, both implicitly and explicitly, dismissed the importance of culture in understanding and promoting social and emotional wellbeing; and • Psychologists’ silence and lack of advocacy on important policy matters such as the policy of forced removal which resulted in the stolen generations (Carey et al. 2017). To demonstrate a tangible recognition of these errors, the APS made a commitment to a new way of working with Aboriginal and Torres Strait Islander peoples which would be characterized by: • • • • •

Listening more and talking less; Following more and steering less; Advocating more and complying less; Including more and ignoring less; and Collaborating more and commanding less (Carey et al. 2017).

The challenge for all rural mental health practitioners, but perhaps even more so for psychologists working in RRvR locations, is to reflect the sentiment of the apology in their daily practice with Aboriginal and Torres Strait Islander peoples. Difficulty in accessing ongoing education and professional development for mental health practitioners. The geographic isolation of many RRvR locations can make access to ongoing education and professional development prohibitively expensive for mental health professionals. Whereas attending a one-day professional

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development workshop in a city can be relatively straightforward for a health professional who lives in that city, to attend the same workshop from a RRvR location will often require a minimum of three days to enable travel to and from the workshop venue. The travel involved adds enormously to the expense of attending the workshop, as does finding suitable accommodation in the city. Furthermore, whereas a private practitioner in the city will forfeit one day’s income to attend the workshop, an RRvR private practitioner will forgo at least three day’s income. The range of appropriate supervisors to facilitate regular and ongoing professional reflection and development can also be very limited in RRvR settings. Moreover, for those who require professional supervision and support, it may impede their progress to formalize professional requirements. Professional development provided via the Internet such as webinars provide more cost-effective options for mental health professionals in RRvR locations. Even though the range of these alternatives recently has been driven by the rapid adaptation to COVID-19, they are still in development to be appropriate for online platforms. The suitability of the modality very much depends on the information being disseminated. Some types of skill building, for example, is likely to be more effective in face-to-face learning formats with the instructor and the learner actively interacting in the same physical location. There is at least a double disadvantage, therefore, for mental health professionals in RRvR locations. A large part of the professional workforce in RRvR locations are younger, less experienced professionals who, arguably, have the greatest professional development needs. So, the current situation is that, generally, those with the greatest needs have the most limited and most expensive options with regard to ongoing professional development. The presence of ethical and professional challenges. As mentioned earlier, ethical and professional challenges exist in all mental health treatment contexts. Given the nature of small, close-knit, RRvR communities, however, the presence of these challenges is especially relevant, and their impact can be far more problematic. For example, a mental health professional’s child might be in the same class at school as the child of a client. Perhaps these children become friends and want to play at each other’s house on the weekend. They might even request to have a “sleep over” at each other’s house. What should a mental health professional do in this situation? Or, perhaps the mental health professional discovers that, in the tennis club he has just joined, one of his team members is a client he has recently seen. It is likely to be the case that it is impossible to avoid these challenges; however, it is entirely possible to minimize their impact. Mental health professionals need to be clear about their role and its associated boundaries and responsibilities, as well as the ethical code of their profession. Accessing regular supervision to discuss and reflect on current ethical and professional challenges is also likely to be helpful. It can also be interesting to reflect on the different relationships other health professionals have with the people to whom they provide services in RRvR locations. Medical practitioners, for example, might actually move to RRvR communities because of the opportunity to know their patients more closely than they otherwise would in a city. Family practices are established in which the one medical practitioner might provide

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health services to an entire family. Furthermore, the medical practitioner’s child might be on the same soccer team as the child of a patient or indeed a child who is a patient. It would be difficult to argue that the work of a mental health professional is necessarily any more private and intimate than the work of a medical practitioner. A medical practitioner, for example, might conduct a pap smear in the morning and then, in the afternoon, drive her daughter to her ballet lesson where the teacher is the patient from the morning’s procedure. Or, perhaps a prostate examination is performed on a patient who is the president of the running club of which the medical practitioner is an active member. Given these scenarios, perhaps there are lessons that mental health professionals can learn from other health professionals regarding a more nuanced and sophisticated approach to codes of ethical and professional conduct. The highest standards of conduct are unquestionably important; however, there may be different ways of maintaining these standards in different contexts to ensure the same high quality of care is provided. A lack of evaluation of programs and services. A scarcity of programs and services being routinely evaluated seems to be a feature of mental health services generally and is not simply a feature of the RRvR mental health landscape. In RRvR settings, however, where choices are so limited, the impact of an ineffective service can be extremely serious. A recent review of programs and services for Aboriginal and Torres Strait Islander people (Hudson 2016) reported that, of the 1082 programs identified, only 88 of them had been subjected to any kind of evaluation. While this situation is serious enough, it is probably of even greater concern that, “of those programs that were evaluated, few used methods that actually provided evidence of the program’s effectiveness” (Hudson 2016, p. 1). Although not all of these programs and services were delivered in RRvR locations, many of them were, and the lack of systematic evaluation contributed to an unacceptable amount of duplication and waste. The report revealed, for example, that the small community of Roebourne in Western Australia had more than 400 government-funded programs delivered by 67 local service providers even though the population of the community is only 1150 (Hudson 2016, p. 2). Similarly, with a population of 300 people, Toomelah in New South Wales had more than 70 service providers delivering programs and services (Hudson 2016, p. 2). Anecdotal information indicates that the poor coordination and integration of services and lack of evaluation are not restricted to programs and services for Aboriginal and Torres Strait Islander people but are endemic throughout RRvR Australia and indeed in metropolitan contexts as well. Of course, not all of these programs and services will have a specific mental health focus, but a great number of them will be, directly or indirectly, addressing psychological wellbeing. If one considers that evidence-based healthcare is an ongoing process involving the best available evidence, the context in which the care is delivered, client preferences, and the professional judgment of the health professional (Pearson et al. 2012) – the challenges of providing evidence-based healthcare in RRvR contexts become apparent. While there is generally strong evidence for many mental health treatments and interventions, the varying contexts of RRvR settings mean that the application of this evidence is not always straightforward. Furthermore, current

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evidence suggests that client preferences are typically ignored, overlooked, or misrepresented in many healthcare decision-making situations (Carey 2017a). Finally, due to the nature of many RRvR settings, there may be numerous factors influencing the judgment of a mental health professional, such as varying knowledge of important local social networks and relationships. There are strong indications therefore that, due to the complexity of these demands, mental health service delivery in RRvR contexts may not be considered to be “evidence-based healthcare” in a general sense. Even the way in which evidence is understood raises difficulties for the application of evidence-based mental healthcare in RRvR locations. Evidence needs to be considered broadly to include evidence of feasibility, appropriateness, and meaningfulness as well as evidence of effectiveness (Pearson et al. 2012). When evidence is understood to involve these four components, the importance of context as well as culture is clear. Many of the problems of “knowledge transfer” highlighted by recent initiatives such as “translational research” and “implementation science” may have arisen because of the way in which traditional research has been separated from clinical practice. Given the paucity of evaluations occurring in RRvR contexts, as well as the difficulties of implementing evidence-based mental healthcare in these settings, there is a strong suggestion that ongoing monitoring and evaluation should become a routine habit for RRvR mental health professionals. Ongoing monitoring and evaluation can emphasize a learning approach to the provision of services whereby the outcomes important to service recipients are accommodated, and interventions are continually monitored and adjusted as necessary to ensure continued effectiveness (Carey et al. 2019). Advocating for policy change to ensure that evaluation is a specified requirement of all government-funded mental health services and programs, along with the development of partnerships between service providers and expert evaluators, would be one way of promoting high-quality service delivery of mental health programs for RRvR residents (Carey et al. 2019).

Concluding Comments and Recommendations Working in RRvR locations can be challenging and taxing. It can also be immensely rewarding and enriching. The scope of practice and opportunities that exist in RRvR contexts is unmatched in metropolitan settings. What’s more, the breathtaking beauty of many RRvR places can add an unparalleled dimension to one’s quality of life. The price to pay for living in these areas and experiencing this beauty, however, is the long-standing health and social inequity that RRvR residents, which are inclusive of mental health practitioners, are forced to endure in their day-to-day lives. It is time for change. It is time that policy- and other decision-makers began to introduce the necessary reforms that will bring about tangible improvements in the inequities that exist. The Take-Home Messages below provide a small number of specific recommendations that will be discussed further throughout this Handbook. By paying

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close attention to the wealth of information provided by the talented and knowledgeable experts who have contributed chapters to this Handbook, we will propose a way forward for people who live in RRvR towns and communities, to enable them to enjoy the same standards of mental health services that metropolitan citizens take for granted.

Take-Home Messages Mental health services in RRvR locations: • Need to address the social determinants of health with a particular emphasis on the organizing principle of “control and social engagement”; • Would benefit from approaching psychological distress from the perspective of social and emotional wellbeing rather than the Western biomedical model of illness; • Should consider what is acceptable in metropolitan settings as a benchmark for the types of services offered to RRvR residents and, for example, should see innovations such as telehealth and Internet services as adjuncts to enhance, rather than to replace, effective service provision; and • Need to ensure that services are routinely evaluated through establishing ongoing outcome monitoring and feedback as a routine feature of their design.

References APS. Apology to aboriginal and Torres Strait islander people from the Australian Psychological Society. 2017. https://www.psychology.org.au/getmedia/dc5eb83c-9be9-4dce-95ec232ac89e1d14/APS-apology-ATSI.pdf. Accessed 1 Apr 2018. Australian Government. Closing the gap: prime Minister’s report 2017. Canberra: Commonwealth of Australia; 2017. Carey TA. Mental health: integration is the key to the revolution. Lancet. 2013a;382(26):1403–4. Carey TA. Defining Australian indigenous wellbeing: do we really want the answer? Psychother Polit Int. 2013b;11(3):182–94. Carey TA. Global mental health and neuroscience: different synergies might be needed. Lancet Psychiatry. 2015;2(6):489–90. Carey TA. People living with mental illness-perspective care: A new paradigm for health services and systems. Melbourne: Routledge; 2017a. Carey TA. Self-determination is NOT a basic human right. Psychology Today. 2017b. Retrieved on 7 May 2020 from https://www.psychologytoday.com/gb/blog/in-control/201707/self-determina tion-is-not-basic-human-right Carey, TA. Same principles, different practices: the distance for geographic parity in health is not so great after all. JBI database of systematic reviews and implementation reports. 2018. https://doi. org/10.11124/JBISRIR-2017-003827. Carey TA, Mansell W, Tai SJ. A biopsychosocial model based on negative feedback and control. Front Hum Neurosci. 2014;8:article 94. https://doi.org/10.3389/fnhum.2014.00094. http://jour nal.frontiersin.org/Journal/10.3389/fnhum.2014.00094/abstract

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Carey TA, Dudgeon P, Hammond SW, Hirvonen T, Kyrios M, Roufeil L, Smith P. The Australian Psychological Society’s apology to aboriginal and Torres Strait islander people. Aust Psychol. 2017;52:261–7. Carey TA, Fauth JM, Tremblay GT. Rethinking evaluation for improved health outcomes: Implications for remote Australia. Am J Eval. 2019;1–21. https://doi.org/10.1177/1098214018824040 Coopes A (2017) Commissioning no cure for Australian health equity. Croakey: Independent, indepth social journalism for health. https://www.croakey.org/commissioning-no-cure-for-austra lian-health-equity/ Accessed 21 Sep 2020. Department of Health. The fifth National Mental Health and suicide prevention plan. Canberra: Commonwealth of Australia; 2017. Editorial. Life, death, and disability in 2016. Lancet. 2017;390(September 16):1083. http://www. thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)32465-0.pdf Fried EI, Nesse RM. Depression is not a consistent syndrome: an investigation of unique symptom patterns in the STAR*D study. J Affect Disord. 2015;172:96–102. Gee T, Dudgeon P, Schultz C, Hart A, Kelly K. Aboriginal and Torres Strait islander social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, editors. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd ed. Canberra: commonwealth of Australia; 2014. p. 55–68. Website for book: https://www.tele thonkids.org.au/our-research/early-environment/developmental-origins-of-child-health/aborigi nal-maternal-health-and-child-development/working-together-second-edition/; website for chapter: https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/work ing-together-second-edition/wt-part-1-chapt-4-final.pdf. Hari J. Lost connections: uncovering the real causes of depression – and the unexpected solutions. New York: Bloomsbury; 2018. Healy D. Let them eat Prozac: the unhealthy relationship between the pharmaceutical industry and depression. New York: New York University Press; 2004. Healy D. Pharmageddon. Berkeley: University of California Press; 2012. Henderson J, Javanparast S, MacKean T, Freeman T, Baum F, Ziersch A. Commissioning and equity in primary care in Australia: Views from Primary Health Networks. Health Soc Care Comm. 2018;26(1):80–89. https://doi.org/10.1111/hsc.12464 Hudson S. Mapping the indigenous program and funding maze. Sydney: The Centre for Independent Studies; 2016. Marmot M. Health in an unequal world: social circumstances, biology and disease. Clin Med. 2006;6(6):559–72. Marmot M. The health gap: the challenge of an unequal world. London: Bloomsbury; 2015. Pearson A, Jordan Z, Munn Z. Translational science and evidence-based healthcare: a clarification and reconceptualization of how knowledge is generated and used in healthcare. Nurs Res Pract. 2012:792519. https://doi.org/10.1155/2012/792519. Wakerman J. Defining remote health. Aust J Rural Health. 2004;12:210–4. Watters E. Crazy like us: the globalization of the American psyche. New York: Free Press; 2010. Whitaker R. Anatomy of an epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Broadway Books; 2010. Whitaker R, Cosgrove L. Psychiatry under the influence: institutional corruption, social injury, and prescriptions for reform. New York: Palgrave Macmillan; 2015.

Part I Context of Rural, Remote, and very Remote Mental Health

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Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts Judith Gullifer, Mikaela Cibich, and Timothy A. Carey

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How Do Social Determinants Influence Mental Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Are the Social Determinants of Mental Health in RRVR Locations? . . . . . . . . . . . . . . . . . Access to Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social-Political Exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Importance of Secure Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is Rurality a Social Determinant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Country Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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J. Gullifer (*) Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia School of Psychology, Charles Sturt University, Bathurst, NSW, Australia e-mail: [email protected] M. Cibich College of Medicine and Public Health, Flinders University, Alice Springs, NT, Australia College of Education, Psychology, and Social Work, Flinders University, Bedford Park, SA, Australia e-mail: Mikaela.cibich@flinders.edu.au T. A. Carey Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_2

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Abstract

The important influence of the social determinants of health on the physical health status of individuals and communities is well established. Factors such as employment, education, and housing all make decisive contributions to the physical health a person enjoys. What is not as readily recognized is that the social determinants also have a very strong impact on a person’s mental health. The ability of a person to live a contented and satisfying life has a lot to do with the conditions and circumstances in which they live, work, play, and age. Crucially, these social determinants are likely to affect people differentially with greater or lesser impacts in rural, remote, and very remote (RRvR) locations. Of particular importance in developing a nuanced understanding of the contributions the social determinants make to a person’s mental state is appreciating the fundamental significance of control. Also crucial is a recognition of the inadequacy of linear cause-effect models and the necessity to incorporate bidirectional, mutually influencing models for a more sophisticated understanding of how people function within the environments they inhabit. After describing the way in which the social determinants might be considered in RRvR areas, the chapter concludes with an illustration of the way in which a case conceptualization might occur if the social determinants are thoroughly and genuinely incorporated.

Introduction The social, economic, and environmental conditions in which people grow, live, work, and age are commonly known as social determinants and influence physical and mental health. In the 1980s, the landmark Whitehall I study demonstrated that there was a strong association between British civil servant employment level and mortality rates from a range of causes (Marmont and Shipley 1984). Since the Whitehall I study, there has been a growing body of research demonstrating that inequality in social determinants impacts on physical and mental health across all levels of the social hierarchy (WHO 2014). According to the Australian Institute of Health and Welfare (2016), there is clear evidence that health and illness are not distributed equally within the Australian population. The Australia’s health 2016 report outlines how variations in health status generally follow a gradient, with overall health tending to improve with improvements in socioeconomic position (Kawachi et al. 2002). The less favorable the social, economic, and environmental conditions a person is exposed to, relative to others in their society, the poorer their physical and mental health will be. There are, however, some exceptions to this general rule. Wilkinson and Pickett (2017), for example, report that health problems that do not demonstrate a social gradient, such as breast and prostate cancer, seem to be unaffected by inequality in the way that health problems such as heart disease and infant mortality do.

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While there are a number of important conditions included as social determinants which can affect health in a variety of ways, Marmot (2006) crucially identified control and social engagement as an organizing principle of these social determinants. This principle could be expressed simply as “control” in terms of the extent to which people are able to engage with their social environment and also the extent to which this is understood as a control process. Marmot (2006) is unambiguous in the importance he places on control with regard to health. According to Marmot (2006), “changing social conditions to ensure that people have the freedom to lead lives they have reason to value would lead to marked reductions in health inequalities.” (p. 559). Marmot’s (2006) views here are consistent with other authorities such as Pearlin’s theory of how social stress and disadvantage may proliferate over the course of an individual’s life span (Pearlin et al. 2005). The importance of control to the social determinants of health should be considered in these discussions. Indeed, it has been proposed that control could provide the foundations for a genuine and functional biopsychosocial model of health (Carey et al. 2014) and even provide the basis for a conceptually cohesive definition of health (Carey 2016) as well as a patient-perspective model of healthcare (Carey 2017). In this chapter, we provide an overview of the influence of the social determinants in mental health in rural, remote, and very remote (RRvR) areas. We begin by examining how social determinants influence mental health. Then, we describe the social determinants of mental health in RRvR communities. Finally, we highlight points of intervention for researchers and clinicians to reduce the presence and influence of unequally distributed social determinants in RRvR communities.

Distinctive Features Understanding the impact of the social determinants on mental health is important for RRvR practice and research because they guide points of entry for prevention and intervention. We will begin with a general discussion of how the social determinants influence mental health and then move to a description of the key social determinants for mental health and how they may be experienced by people in nonurban locations. Given there is a lack of research that investigates the influence of social determinants in RRvR areas specifically, much of the conceptual and theoretical work presented is drawn from reviews on social determinants more generally (Baum 2015; Marmot and Bell 2012; WHO 2010, 2014). However, we draw on the available evidence from RRvR locations where it is available.

How Do Social Determinants Influence Mental Health? Broadly, the mechanisms through which social determinants influence health (and mental health) have been described as social causation (i.e., social position determines health), social selection pathways (i.e., health determines social position), and life course perspectives (WHO 2010). Although bidirectionality is at times

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considered in these models, it appears that linear, cause-effect causality continues to be proposed to understand these complex relationships. The social causation perspective suggests that social position influences health through mediating factors. Material factors (e.g., housing, physical working conditions), behavioral factors (smoking, diet, physical exercise), psychosocial factors (e.g., stressors, social support), and the health system itself are argued to be the main mediating factors that play a role in how social determinants influence health (WHO 2010). Regarding social selection, many researchers have concluded that social selection is a less important determinant of health inequities (Goldman 2001; WHO 2010). However, considering the possible bidirectionality between social determinants and mental health is still useful. Employment, for example, can influence mental health, but mental health problems can lead to unemployment (WHO 2014). The life course perspective indicates that exposure to specific circumstances during critical periods in a person’s life can have a greater or lesser impact on health outcomes later in life and also that risk can “accumulate” over a life course (WHO 2010). In turn, it is suggested that interventions should be appropriate for each stage of life while also prioritizing giving children the best start in life possible. A recent report by the World Health Organization neatly summarizes how interventions to improve mental health can be targeted to different life stages (WHO 2014). Yet, while the inclusion of a life course, developmental perspective highlighting identifiable critical periods is plausible, this approach also maintains a linear, causeeffect model without due consideration of bidirectional explanations. John Dewey (1896) may have been the first person to articulate problems with the linear, stimulus-response, cause-effect approach to understanding behavior. More specifically to his argument, Dewey (1896) challenges the linear approach by proposing a circuit metaphor in the following terms: “What we have is a circuit, not an arc or broken segment of a circle. This circuit is more truly termed organic than reflex, because the motor response determines the stimulus, just as truly as sensory stimulus determines the movement” (p. 363). Despite this early recognition of the problems with the linear cause-effect approach to understanding human behavior, we continue to search for, and apply, linear causal models, thus making the concept of linear causality applied to human behavior exceedingly difficult to challenge. Part of the problem may be that conventional approaches to learning about the human behavior rely on conceptual or statistical mechanisms in models of causation that are founded in the scientific method of independent and dependent variables. The model of control, however, described by perceptual control theory (Powers 2005), relies on a functional mechanism and, consequently, endorses Dewey’s proposal of a circuit model of understanding, rather than linear causality. The circuit model would best explain how social determinants are multifactorial and complex and do not fit neatly into a linear model, hence reinforcing the difficulty that psychology has in trying to best meet these complex problems in a discipline that is dominated by linear causal models of explanation. In order to move beyond the individualized focus of factors that impact on mental health, the social determinants’ framework challenges the traditional medical model of mental health to consider and recognize societal conditions in therapy. Johnson

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and Sampson (2019a) argue that practitioners working in mental health have an opportunity to take into account the impact of societal conditions when considering individual well-being. In order to do so, practitioners must remain abreast of developments within their areas of expertise and also the broader paradigms that inform practice. The challenge for practitioners is knowing how to integrate broader frameworks, such as a social determinants approach to mental health, alongside dominant models that tend to focus on the individual and tend to draw on linear models of causality as outlined. This challenge is further amplified in RRvR locations.

What Are the Social Determinants of Mental Health in RRVR Locations? When discussing how social determinants may influence mental health in RRvR locations, it is first important to highlight that there is an unequal distribution of the impact of social determinants (and in turn mental health) between and within RRvR areas. As an illustration of the considerable heterogeneity of RRvR communities, Fraser et al. (2002), for example, reviewed the research relating to the mental health of rural Australians and highlighted that while some rural towns are flourishing (e.g., coastal areas transformed by tourism or retirees) this is not the case for all rural towns (e.g., drought-prone farming land) (see also Kotey 2015). In many developed countries, there is population growth in coastal, picturesque, rural towns as well as large inland regional centres that are not dependent on agriculture and mining. Conversely, population decline continues in inland agricultural regions and mining towns. A study in four local government areas (a declining agriculture region, declining mining community, growing exurban area, and growing regional city) in two Australian states (New South Wales and Victoria) surveyed residents about their mental health as well as other indicators of their well-being. Participants in the two areas that were experiencing growth reported being happier and more satisfied with life and also reported fewer mental illness symptoms than participants in the declining regions. These reported differences were partly explained by whether the region was in growth or decline even after controlling for demographic characteristics (Fraser et al. 2005). The high variation between RRvR communities means that we cannot make broad generalizations regarding the social determinants that all RRvR communities experience. Furthermore, there is a small, but growing, body of research that investigates RRvR locations in developing countries, meaning that our conclusions to date are largely based on RRvR areas in developed countries. Another consideration is that not all people within a discrete RRvR area will be exposed to the same conditions. Even within towns, conditions can vary greatly. This variation is because the social determinants a person is exposed to are not only influenced by their location (i.e., rurality) but also by many other factors that can vary within rural areas and can interact with rurality (e.g., race, gender, education, income, etc.). For example, Johnson and Sampson (2019b) propose a framework that

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integrates social determinants into a case formulation model in order to identify idiosyncratic contextual factors that may contribute to understanding the underlying factors of the person’s mental health. Johnson and Sampson (2019b) propose the following vulnerability factors when trying to understand the unique rural context in which a person resides: membership of a socially stigmatized or disadvantaged group (whether on racial, sexual, gender, religious, age-related, physical, ability/ disability, or other grounds); the normalization of discrimination within that social context; the variability of workplace conditions (availability of work, impact of technology and automation, wages and conditions, casualization of work); and socioeconomic considerations (such as the impact on housing affordability and education). As such, it is important for clinicians or researchers to actively engage with local knowledge regarding the distribution of the social determinants in the RRvR community within which they work (see section “Practice Implications” for further discussion). With this variation between and within RRvR areas in mind, we will explore further how these social determinants can influence the mental health of residents of RRvR communities.

Access to Services Access to mental health services in RRvR areas can be a barrier to timely and effective care. For example, a qualitative study of mental health practitioners in four Victorian regional towns with varying suicide rates found that accessibility of services, including mental health services, provides the strongest links with mental well-being (Collins et al. 2017). Accessibility is not only influenced by the local availability of services but also other factors such as stigma; whether the available services are culturally appropriate (Westerman 2014); the lack of anonymity; the presence of rural “gossip networks” (Aisbett et al. 2007); prohibitive wait lists; low affordability; and the lack of public transport. For example, focus groups conducted with African-Americans living in the rural south of the USA revealed that stigma was one of the most significant barriers to help-seeking within the community (Haynes et al. 2017). Other focus groups in two rural towns in the USA found that the cost of health insurance and the lack of transport to health services were perceived as major barriers by residents (Hege et al. 2018). The trend may be similar in Australia where the National Survey of Mental Health and Well-being found that mental health service utilization was lower in rural compared to urban areas (Taylor et al. 2005).

Employment Data from countries including Australia, England, and Kenya suggest that – similar to urban areas – there is a mental health advantage to being employed in RRvR areas (Fragar et al. 2010; Musyimi et al. 2017; Riva et al. 2011). A study analyzing data from the Health Survey for England found that being employed is associated with

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better mental health in both rural and urban areas but that this effect was more pronounced for rural areas (Riva et al. 2011). However, there can be unique challenges faced by rural job seekers. The overwhelming majority (90%) of the long and more recently unemployed participants from two rural towns in Scotland identified that too few appropriate job opportunities was a significant barrier to work (Lindsay et al. 2003). Other challenges for the rural workforce include industrial restructuring, skill mismatches, poor transport infrastructure, and a lack of job search services (Lindsay et al. 2003). As mentioned earlier, it is also important to be aware of the two-way relationship between employment and mental health: poor mental health can reduce prospects for employment, in turn reducing income, leading to reduced access to material resources (e.g., food and shelter) and psychological resources (e.g., sense of belonging, self-esteem), thereby increasing the risk of mental health challenges (WHO 2014).

Social Capital Social capital is closely related to social support and describes how people benefit from being connected to others. There is evidence to suggest that lower morbidity and increased life expectancy correlate with the extent and degree of connectedness to family, friends, and others in the community; however this is not always consistent (Kawachi et al. 2002; Pearce and Davey Smith 2003). Generally, the more socially connected a person feels, the better their mental health. This is also true in rural communities (Galloway and Henry 2014; Hamano et al. 2011). There is sometimes a (mis)perception that people living rurally are more connected with their local community than people living in urban areas. While some data – such as the Canadian Community Health Survey (Romans et al. 2011) – supports this presumption, social inclusion in rural communities is not guaranteed. During focus groups, members of a remote Scottish community discussed the exclusionary reactions (e.g., verbal abuse, petitions to be removed from the community, gossip) that can occur when they have disclosed mental illness (Parr et al. 2004). Social capital is a resource for resilience, a protective factor for good mental health, and a resource for the formation of networks that can further improve access to economic opportunities, such as work, assistance with family support, travel to access health services, and friendship.

Social-Political Exclusion Social disadvantage (broadly construed) is both a cause and consequence of mental illness, once again highlighting the inadequacy of linear cause-effect models (see Horwitz and Scheid 1999). That is, mental illness, in all its forms, can be conceptualized as intrinsically social. For example, in the mental health literature, social exclusion can result from a number of factors that are socially derived such as fear, misunderstanding, stigma, and discrimination. Subsequently, those living with

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mental illness are often excluded from participating fully in society because of these factors. Contributing further to this situation is that people with mental illness are also more likely to have smaller social networks than the general population with these networks declining further as the duration of their illness increases over time. Cappo (2002) refers to social exclusion as community members not participating fully in the social, economic, political, and cultural systems in which they reside. Social inclusion, on the other hand, is where members of society feel valued, their diversity respected, and their basic needs are met, enabling them to participate with dignity. The importance of community, therefore, cannot be underestimated for those living with a mental illness. In larger geographic centres, community organizations can enable social inclusion through their business practices. These organizations rely on the community to work collaboratively with them in order to enable service delivery. For example, peer support and consumer networks are important in recovery processes. Services such as self-help groups, consumer networks, telephone support services, and consumer-friendly centres are important for both the person living with a mental illness and their family and careers. The challenge for RRvR communities is providing timely and ongoing access to community-based services as previously indicated. While the literature has demonstrated the effectiveness of models of assistance provided to community members, these services decline in more remote locations. The benchmark Whitehall I study demonstrated the link between social exclusion and ill health. Conversely, greater levels of community participation, social support, and trust in others in the community have been associated with a reduced experience of psychological distress (Berry and Rickwood 2000).

Importance of Secure Housing It has been claimed by Thomson et al. (2009) that safe, affordable, and secure housing is associated with better health, which in turn impacts on people’s participation in work, education, and the community. From this perspective, housing can be considered to be a vital social substrate for mental health. Access to safe and secure housing also influences relationships, familial or social (Baker et al. 2014). Thus, there is a relationship between health and quality of housing: as the likelihood of living in unaffordable, unsuitable, or insecure housing increases, health worsens. Once again, this is another two-way relationship, in that poor health can lead to unsuitable choices in housing. A lack of secure housing is also associated with weakened social networks due to the instability of being able to form lasting bonds. The impact of insecure housing can affect relationships contributing to the eventual breakdown of these partnerships and further impact on the lack of community participation. Consequently, living and parenting alone or homeless, coupled with limited income, have all been shown to have a negative effect on mental health. Unfortunately, these are common outcomes for people who are discharged from inpatient care or the criminal justice systems into an unsupportive and alienating society. This leaves people vulnerable to neglect, abuse, homelessness, and the

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“revolving door syndrome,” where they enter cycles of admission, discharge, and readmission to hospital. Clearly, this is not a conducive context for recovery (AIHW and Harrison 2015; Baker et al. 2014). Less research, however, has focused on RRvR areas. A study by Jones et al. (2014) explored the factors that contribute to housing problems for people with mental health and substance use issues in rural areas. They interviewed 40 people of which 39 reported a mental illness diagnosis, and of these 27 also reported having problems with alcohol or other drugs at some stage in their life. All interviewees were supported by government support payments. More than half of the participants were living in private rental accommodation, with the remaining participants residing in public housing. Their research revealed a range of problems experienced by the participants which are listed below (Jones et al. 2014): • • • • •

Unavailability of affordable accommodation Lack of permanent accommodation Poorly maintained accommodation Poor access to services and transport Isolation from social and support networks

A range of contributing factors that impacted on participants obtaining unsuitable/unstable housing were also identified by Jones et al. (2014) such as the impact of the cyclic nature of mental health; comorbid substance use; and housing issues, which in turn exacerbates mental illness. Other factors included relationship and family breakdown; poor history with housing services or real estate agencies; and a lack of knowledge of services and agency supports. The researchers also found protective factors that enabled the participants to move out of unsuitable/unstable housing such as obtaining a stable income and ongoing employment; a solid social network, particularly family networks; and agency support, such as drug and mental health services. It can be argued, however, that many of the factors discussed above may equally apply to individuals living in both urban and rural areas. Unique factors that appear to be more prevalent in RRvR areas include poor access to essential services (such as housing, mental health, drug and alcohol services, etc.), limited access to transport, and sometimes nonexistent public transport. Social networks are argued to be paradoxically both an asset (such as family networks) and a hindrance (e.g., the “community grapevine” sharing poor rental history) to obtaining support with finding housing.

Is Rurality a Social Determinant? Although rurality can influence the social determinants to which a person is exposed (e.g., employment opportunities), the literature regarding the impact of rurality is mixed. Evidence exists that rurality alone does not have a strong influence on mental health. This conclusion is reached through two observations: mental health differs

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greatly between RRvR areas and statistical analyses that separate the effect of uniquely rural factors from other social determinants which find that rural factors alone account for a very small amount of variation in mental health. As indicated, results however may differ greatly between studies that have sought to investigate differences in mental health between urban and nonurban locations. While some studies find that there is no difference in mental health between urban and rural areas (Weich et al. 2005), many other studies find that people living in rural areas have better mental health than their urban counterparts (Nepomuceno et al. 2016; Paykel et al. 2000; Riva et al. 2011; Romans et al. 2011). Other data – particularly suicide research – suggest that people (particularly men) living in rural areas have worse mental health than their urban counterparts. If rurality was a strong predictor of mental health, we would expect less variation between rural towns. As such, this variation suggests that there are other important factors aside from rurality that influence RRvR mental health. When differences between urban and rural residents’ mental health have been found, researchers have sought to understand whether these can be explained by uniquely rural factors. A study of rural communities in New South Wales measured the effect of demographic variables (e.g., age, gender), predisposition factors (e.g., personality, education), recent difficulties and support (e.g., adverse life events, employment), rural-specific variables (e.g., infrastructure and service accessibility, drought-related worry), and rural characteristics (e.g., remoteness category, population change over time) on well-being and mental health (Kelly et al. 2010). Results showed that once the demographic, predisposition, recent difficulties, and support variables were accounted for, rural factors and remoteness exposure made a minor contribution to the variance in current well-being (2%) and psychological distress scores (1%). These findings suggest that the largest contributors to well-being are not rural-specific factors but rather other social determinants (e.g., stressful life events, social support). It may be that adverse life events are more frequent in nonurban than urban environments, thereby attributing rural-specific factors in the non-rural factors, but – as the authors of the research suggest – the lack of significant association between well-being and district-level variables (e.g., remoteness score) would suggest this is not the case (Kelly et al. 2010). Another example comes from data collected during the Australia-wide National Survey of Mental Health which showed that the difference in risk of suicide between males in rural compared to urban areas reduced by one third (to nonsignificance) when country of birth and socioeconomic status were accounted for (Taylor et al. 2005). Rather than unique rural determinants influencing mental health, it seems that rurality interacts with general social determinants (e.g., employment status) to explain mental health status.

Practice Implications The World Health Organization’s report on the social determinants of mental health suggests ten principles and actions to improve mental health: proportionate universalism (interventions to support mental health are universal but relative to

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disadvantage); actions across sectors; life course approach; early intervention; healthy mind and healthy body; prioritize mental health; avoid short-termism; mental health equity in all policies; knowledge for action at the local level; and country wide strategies (WHO 2014). Risk and protective factors for mental health act at multiple levels including country, community, family, and individual. This multilevel framework can be applied to prevention and intervention strategies to improve mental health. When considering practice implications of implementing any action on social determinants, we must have a good understanding of how a range of factors interact (behavioral, clinical, policy, systems, occupational, and environmental determinants of health) (Dean et al. 2013).

Country Level Interventions such as policy changes that address structural inequalities are likely to be the most effective as they can influence the social processes that determine the unequal distribution of social determinants (WHO 2014). When designing or advocating for these kinds of interventions, it is important to focus on the social processes that determine the unequal distribution of social resources, not just the social resources themselves. Only addressing their unequal distribution in society will affect the outcomes achieved (WHO 2010). This is because it is relative social deprivation rather than absolute social deprivation that influences health, including mental health (Picket and Wilkinson 2010). Clinicians and researchers working in RRvR mental health should advocate for fairer public policy and interventions that address the unequal distribution of social determinants factors. As we indicated earlier, RRvR communities and localities vary in important ways. Attending to the distinctiveness of individual locations, however, will not lead to lasting change. Australia’s first National Rural Health Commissioner, Professor Paul Worley, suggests that focussing on differences will not translate into changes in policy (Carey et al. 2019). In order to affect policy reform, it is important to be able to understand and articulate the commonalities across these differences. The importance of recognizing underlying commonalities behind the superficial differences has clear implications for the social determinants of health. While it is clearly beneficial to focus on specific determinants, for interventions to be ultimately effective, it will be necessary to ensure that the concept of control, as the underlying principle, informs and is reflected in the different programs and services that are developed and provided in any particular town or community. Proportionate universalism is an approach that can target initiatives within a universal health model. It recognizes that, across the health gradient, a range of responses are required to address different levels of disadvantage within the population, as opposed to solely targeting the least disadvantaged groups. Within this approach, action is proportionate to the needs of the community and the levels of disadvantage within that community. The goal is to narrow the disadvantage in health inequity by addressing the burden of disease across a number of determinants. The challenge is in weighting how the determinants of health and burden of disease

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are proportionately considered in the identification of priority populations. There is a dearth of information in the literature to provide guidance on this issue. In examining the types of public health approaches in Ontario, Canada, Lu and Tyler (2016) found that current public health approaches addressed priority populations along a spectrum that ranges from a health equity approach at one end to a burden of disease approach at the other. According to Lu and Tyler (2016), the health equity approach proposes that the determinants of health are at the heart of health inequities and priority populations should be identified based on the criteria of relative social disadvantage. At the other end of the spectrum, they found that the burden of disease approach identifies priority populations based on their relative contribution to overall population disease burden. What the approaches have in common is that they both draw on epidemiology and surveillance data, and both may be augmented with local engagement and other processes. Local engagement and other appropriate and useful augmentative processes are especially important since unstable projections of population morbidity and whether or not there will be a compression of morbidity in later life or a “pandemic of chronic disease” complicate the task for policymakers (Manton 1982). Planning for different demand scenarios, therefore, remains challenging. A key lesson from past literature is that global health agendas tend to move between “technology-based medical care and health interventions” (Solar and Irwin 2010, p. 4) and problematize health disparity as a social phenomenon. If health disparity is framed as a social phenomenon, then we need to consider the principles of social justice. By doing so, the focus will shift to health equity. Framing health disparity within broader social justice and health equity discourse, a human rights framework is arguably the appropriate approach for ensuring health equity, primarily being the responsibility of the state (Solar and Irwin 2010). Theoretical traditions that have tried to explain the causation of health inequity draw upon the following: social selection/mobility, social causation, and life course perspectives. Central to these three explanatory mechanisms is the concept of “social position.” Diderichsen et al. (2001) developed a framework for conceptualizing a model of health inequity which identifies how the following three factors influence health outcomes: • Social contexts (the influence of social relations or the structure of society in assigning individuals to different social positions) • Social stratification (which results in differential exposure to poor health conditions and differential vulnerability of health conditions and right resources) • Differential consequences (of ill health for those more disadvantaged as well as economic and social consequences) In a paper commissioned by the World Health Organization (Solar and Irwin 2010), the relevance of the Diderichsen model was proposed as a framework for consideration. Solar and Irwin (2010) drew heavily from Diderichsen and colleagues’ model and suggested multiple policy entry points along a continuum. The “action-oriented” framework of health inequities enables policymakers to identify

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the intervention point in these underlying processes in order to target health inequities effectively. The model developed proposes three core components: socioeconomic and political context; structural determinants of health inequities; and the intermediary determinants of health. The WHO conceptual framework for action enables policymakers to distinguish between the processes underlying social stratification and the intermediary determinants of health that are caused by stratification that leads to inequities in health. The framework further enables the identification of where policy interventions can address the causes of health inequities, which are grounded in an evidence-based framework. The WHO Commission on Social Determinants of Health (2010) further emphasized the need for understanding the diversity of sectors and their key goals because policies for health equity may involve very different sectors with very different goals. Policies for education, labor market, traffic, and agriculture are not primarily put in place for health purposes. Conceptual frameworks should make clear which types of actions are needed to enhance their “side effects” on health, but also do it in such a way that these sectors with potentially different scientific traditions find it relevant and useful.

Community Level There is an increasing recognition that a broad range of structural, cultural, social, economic, and environmental factors shape an individuals’ opportunities and barriers to positive mental health. Environmental influences or constraints that impact on an individual’s behavior are considered important determinants of health and health inequities. The importance of geographical location for assessing and addressing health needs to continue to be recognized, with an individual’s residential postcode understood to be a stronger predictor of their health outcomes than their genetic code. For example, a range of external pressures such as climate change, changing economic conditions, and natural disasters impinge on the well-being of the whole community. Furthermore, the affordable availability of healthy food sources and access to safe local environments that encourage physical exercise are important for community well-being. Particular cultural groups in the community may also be affected by such things as the way in which they are accepted or ostracized and stigmatized by the rest of the population. Along with poor physical environments, the job opportunities available in certain communities may restrict income levels, which can in turn also impact on mental health (Wan and Su 2016). Health outcomes for RRvR communities tend to deteriorate the greater the geographic distance from metropolitan areas (Roufeil et al. 2014). The prevalence of risk factors for chronic diseases also tends to be higher for individuals living in RRvR regions, with higher rates of cigarette smoking, alcohol consumption, and obesity recorded. There also tends to be a greater risk of serious motor vehicle accidents outside of major city boundaries. Furthermore, RRvR communities have been described as slowly dwindling with a decreasing sense of autonomy and social cohesion (Holden and Bourke 2014).

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Moving beyond individual indicators of poor mental health, external factors such as social exclusion, powerlessness of community members to articulate or advocate for their needs, and a large portion of the community recognized as being of low socioeconomic status, along with other indicators of social or economic stress, can impact on an individual’s mental health (Wan and Su 2016). Arguably, while these factors may equally relate to individuals residing in metropolitan cities, the lack of access to services and geographic distance from resources make the RRvR experience more challenging. The challenge of providing adequate health services (let alone mental health services) for RRvR communities has been attributed as a causal mechanism for the disparity in health outcomes for RRvR community members. As reported by Roufeil et al. (2014), on average, RRvR communities have limited access to a range of goods and services (including mental health services) and educational and employment opportunities. As a result of these inequities, there has been a significant focus in Australia on policy initiatives, research, and funding for RRvR health and mental health service delivery. There has also been a focus on recruitment and retention of a rural health/mental health workforce. Yet, most of these initiatives tend to focus on service provision by an RRvR health workforce which conversely targets individualized treatment of mental health presentations and not on addressing the social determinants that impact on the prevalence of presentations. Although it is indisputable that health services should provide treatment at least equivalent to those treatments and programs delivered (and expected) in metropolitan areas, the social determinants that impact on health outcomes of rural individuals and communities are not easily addressed by a treatment-focused health system. Community level interventions can provide protective factors that reduce peoples’ vulnerability to unequal social determinants of mental health. Gaining local, contextual, and cultural knowledge to understand the unequal social determinants that influence mental health in the rural area in which a health professional practices is paramount (WHO 2014). Community interventions for mental health promotion have focused on strengthening protective factors (such as having a supportive family and employment with a sense of autonomy) and by reducing the impact of potential risks to mental health (e.g., a family history of mental health issues or financial stress) (Brown and Cochrane 2000). Based on WHO (2014), the following questions can guide a deeper understanding of the context of RRvR communities which, in turn, can assist with addressing the impact of social determinants: • Are there certain groups who experience poorer mental health? What social determinants may lead to this? • What are the local, social, economic, and environmental stressors? • What local social, economic, and environmental factors help protect or buffer the population against poor mental health? • What services are locally available to reduce inequities in the social determinants that influence mental health? What services are locally available to address poor mental health directly?

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Strategies can be embedded in local community policy and decision-making and work to assist RRvR communities which address the social determinants that underpin poor mental health. Strategies may aim to improve social participation and inclusion (e.g., strengthening community networks, increasing sense of belonging), addressing unhelpful social norms (e.g., stigma of accessing mental health services; Haynes et al. 2017), and/or providing education and support (e.g., improving mental health literacy, parental skill support). In order to successfully enact many of these strategies, the collaborative input of community members is critical. Working in RRvR requires a sound understanding of community development principles. Community development is a process where community members are supported by local professionals or local agencies to identify and take collective action on issues which have been identified as important to them (Gilchrist 2019). Community development in RRvR empowers local members and creates stronger and more connected communities. The knowledge and skills required to implement community development processes are important for health professionals working in RRvR communities who want to address health inequities and may be a point of difference in the skillset of those professionals working in metropolitan regions. For instance, when delivering and designing services and programs, professionals working in RRvR should do so in consultation with the communities they aim to serve, and they should ensure that their initiatives are based on a formal needs analysis. In many metrocentric initiatives, there may not be the level of consultation required, resulting in high levels of unmet mental health needs. As a result, communities are left with a haphazard, ad hoc arrangement of services and programs that are not based on a discernible strategy which creates duplication and waste in some areas and considerable unmet needs in others (National Mental Health Commission 2014). Crucially, there is also little research regarding community preferences for different service models and, in particular, the role for telehealth. It is currently unclear whether or not telehealth is a viable and acceptable longer-term solution for service gaps or whether this, in itself, complicates the development of a local mental health workforce.

Individual Level Control. The importance of control was mentioned earlier. The extent to which a person is able to control the things that are important to them is a well-established decisive element in the link between social position and mental health. If a person has a low ability to cope through poor access to services, is unemployed or in precarious employment, has unstable housing, and has a lack of education, they are likely to feel less control over their lives in comparison to someone who has more security and stability in those areas identified as social determinants. An individual’s perception of control may negatively impact on their help-seeking behavior, with a subsequent low rate of mental health service use in RRvR localities (Vines 2017). Additionally, barriers that tend to be omniscient in RRvR communities are poor

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access to healthcare services; limited choice of healthcare provider (and of those, only a few may offer services funded by public health); long waiting lists; and the stigma associated with help-seeking (Vines 2017). Stigma, related to mental health, remains a strong deterrent in help-seeking, particularly in RRvR communities. Vines (2017) has argued that contributing to the stigma of help-seeking is the stoic narrative of RRvR communities and the concern of “small town gossip” should the strict, self-imposed boundary of selfdisclosure be relaxed. The perceived concept of limited anonymity in these communities makes the notion of maintaining control of one’s personal and private business paramount. Paradoxically, it is this strong desire to maintain control over one’s personal information, and that of maintaining family privacy, that further escalates mental health problems and the delaying of help-seeking. On the flip side, lack of adequate mental health service provision and poor funding across RRvR communities mean that appropriate help may not be available until the individual has deteriorated to crisis point. This situation occurs because mental health supports are not accessible to the individual or their families, may not exist in their local area, or are inappropriate to their needs. To further exacerbate their situation, some may have ceased employment or become disconnected from their family and their home. The sense of maintaining control over one’s mental health is embedded in discourses positioning mental health problems as being caused by either internal or external conditions that an individual should have control over. Causal models of human distress are often maintained by models that are linear, situating a direct relationship between the distress that a person experiences and the internal or external conditions that cause it. As previously discussed, Dewey’s (1896) critique of linear, stimulus-response, cause-effect approach resulted in an approach that considered functional models to account for the mutually influencing complexity of the internal and external factors that impact on mental health. Stress. Frequently cited considerations of the relationship between social position and mental health relate to the frequency, duration, and intensity of stressful experiences as well as buffering protective factors (WHO 2014). Stress is also strongly related to control that was mentioned above, and, in fact, stress could be understood as the inevitable consequence of compromised control. Those who are lower on the social hierarchy are likely to live in less favorable conditions and in turn experience more stress. This stress can stem from a higher likelihood of day-to-day stress (e.g., high debt, poor living conditions) as well as a higher frequency of intensely stressful events (e.g., violence). Stress can affect both mental and physical health. Wilkinson and Pickett (2017) proposes an income inequality and support model to explain the situation whereby people who are at the bottom of the income hierarchy are effected by psychosocial stress linked to exclusion, lack of self-respect, and contempt from people around them. Life course approach. A life course approach acknowledges that the experience and impact of social determinants vary depending on life stage and that there is an accumulation of advantage and disadvantage over a life course (Marmont and Bell 2012; Pearlin et al. 2005; WHO 2014). In turn, this approach advocates that

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interventions should be appropriate for different stages of life, and while interventions should be present along the life course, giving every child the best possible start in life will lead to the greatest societal and mental health benefits (WHO 2014). The below key points from WHO (2014) detail life course considerations when working in RRvR communities: • While there is a social gradient to mental health at all ages, social determinants influence people at different life stages in particular ways. • Many mental health challenges manifest later in life but originate early in life (Shonkoff et al. 2012). • Stress in early life can have long-lasting effects on stress response mechanisms. • Protective factors such as secure attachment, social supports, and positive beliefs (e.g., optimism, self-esteem, control) are important in early childhood (Taylor 2010). • Risk factors and protective factors accumulate over time. • The mental health of mothers can affect the infant prenatally as well as after it has been born, and the birth of the infant can affect the mental health of mothers. Maternal education is important here. • In the early years, parental mental health plays a key role with social gradients in socioemotional difficulties being found in children 5 and under. In this phase, parenting support, maternal care, childcare, education, and strengthening strong community ties will be important. • In later childhood, home environments that support education, protective factors against risk taking, and schools as a location for intervention will be necessary to consider. • When a person reaches working age, their own mental health will impact children, family, and communities. Employment and unemployment are particularly important for mental health at this age. Short-term contracts and low control at work versus secure and rewarding work will be particularly influential making the workplace an intervention setting. • When family building is underway, assistance with managing the transition to parenthood may be important for parental and child mental health. Assistance can take a variety of forms such as direct mental health support, support for employment, income and housing conditions, and parental support. • For older people, social isolation is likely to be an important problem. A life course approach is informed by developmental and structural perspectives (Jones et al. 2019). Developmental perspectives emphasize how exposure to social, economic, and environmental conditions during sensitive life stages shifts health trajectories, whereas structural perspectives emphasize how social identity and position within social, economic, and environmental conditions disproportionately allocate risk factors and resources, resulting in altered health trajectories (Jones et al. 2019). Reducing the health disparities we had outlined requires an understanding of the factors that generate the disparities at the country and community level. Life course approaches to the impact of the social, economic, and environmental

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conditions influence frameworks that explain how being exposed at different stages of the life span shapes the health of the individual and the intergenerational influences. These approaches can offer substantial insight into the etiology of health disparities (Jones et al. 2019).

Concluding Comments and Recommendations Understanding the social determinants of health (inclusive of mental health) is important for RRvR policy, practice, funding, and research because they provide an understanding of important circumstances and processes that can contribute to poor mental health and in turn guide points of entry for prevention and intervention. Broadly, the processes through which social determinants influence health (and mental health) have been described through different positions: social selection pathways (i.e., health determines social position); social causation (i.e., social position determines health which determines social position); and life course perspectives (WHO 2010). These different perspectives enable us to move beyond the individualized focus on factors that impact on mental health. The social determinants framework challenges the traditional medical model of mental health to consider and recognize societal conditions in therapy. Risk and protective factors for mental health act at multiple levels including country, community, family, and individual. This multilevel framework can be applied to prevention and intervention strategies to improve mental health. When these conditions are understood, the RRvR context enables a greater understanding of the impact of a range of factors that impact on the individual, such as limited access to mental health services in RRvR areas which can be a barrier to timely and effective care. Accessibility is not only influenced by the local availability of services but also other factors such as stigma, the lack of anonymity, prohibitive wait lists, low affordability, and the lack of public transport. Other factors such as employment, social capital, social exclusion, and safe and secure housing all impact on people’s participation in work, education, and the community. Access to safe and secure housing also influences relationships, familial, or social.

Take Home Messages At the practice level, the impact of the key inequities of the social determinants of health in RRvR populations is complicated by the increasing diversity of these communities and the increased risk of poor mental health outcomes. Coordinating services across the continuum of needs and connecting and integrating social supports and services into mental health provision are essential in order to address the broad range of social determinants that play such an important role in health and well-being. This approach to service provision may not be currently embedded in the

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curriculum of many health professions given the relationship of the science-practitioner model to mental healthcare and the metrocentric approaches which emphasize an individualized emphasis on psychopathology and related treatments. Changing practice to take into account the social determinants can be achieved through various methods among healthcare professionals which may include, but is not limited to, the following: • Understanding the social factors that impact on health-related behaviors and health status to develop more effective treatment plans (see Johnson and Sampson 2019a) • Understanding the importance of assessing and addressing social needs through appropriate referrals to ensure adequate support where available locally or connecting through other mediums (telehealth, phone services, representative agencies, etc.) • Professional development in health promotion and community development strategies that can enable communities to improve living and working conditions • Engaging in research to ensure a RRvR voice is taken seriously regarding the social determinants of health • Ensuring community participation when determining which strategies might be most appropriate in achieving improved health outcomes • Advocating as a resource for local, state, and national policymakers to enable improved health equity for all citizens By working collaboratively with the community, RRvR healthcare professionals can create awareness of the biological, psychological, and social factors that impact on mental health. Furthermore, RRvR healthcare professionals can work with other members of the community to develop an equitable healthcare system that enables better health outcomes for all members of the community. In order to successfully enact strategies to address inequities that are explained through a social determinants of health framework, the collaborative input of community members is paramount. Case Studies

Psychology in Action Working as a healthcare worker working in a local RRvR community creates opportunities to consider the inclusion of social determinants of health when considering the development of a mental health treatment plan. When reviewing the nature, proposed causes, and moderating influences on an individual’s presenting problems, a psychologist can consider the relevant social determinants that can then be integrated into treatment plans. Drawing on a framework developed by Johnson and Sampson (2019a), we would consider the factors described in the table and seek answers to the related questions when developing a case conceptualization (Table 1).

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Table 1 Case formulation utilizing a social determinants of health approach Factors Vulnerability factors

Precipitating factors

Maintaining factors

Protective factors

Questions Is the client a member of a socially stigmatized or disadvantaged group? (racial, sexual, gender, religious, age-related, physical, ability/disability) Does the client live in an RRvR context in which discrimination is normalized? Does the client have stable workplace conditions? (working hours, automation market changes, poor wages and conditions, precarious work, or casualization of work) Does the client come from a background of economic inequality and disadvantage? (low socioeconomic background, declining housing affordability impacted by costs of education) Has the client experienced acts of discrimination, stigmatization, and exploitation? (experiencing specific instances, either subtle or overt, of racism, sexism, ageism, discrimination, harassment, exploitation, prejudice, or violence) Has the client experienced the consequence of political, cultural, or economic developments? (increased stigmatization of a particular ethnicity, religion, race, or nation; altered policies regarding discrimination, social services, racial equality, disability, wages, and conditions) Has the client been exposed to events related to climate change? (fires, droughts, floods, storms) Is there evidence of the client individualizing structural and social issues? (for instance, self-blame for structural disadvantage, being blamed by others, selfsubordination, the medicalization of social problems, over-diagnosis) Lack of assistance in understanding the influence of the social determinants of health Self-perpetuating sequelae (including isolation, lack of material resources including money, housing, healthcare, information, education or time, depletion of psychological resources through chronic disadvantage, reduced sense of efficacy, and powerlessness) Does the client have access to material and practical assistance? (e.g., safety nets, community agencies, social services, access to low cost or pro bono services) Does the client have access to social support including a sense of connection and participation with others? (e.g., opportunities for social relationships, engagement, communality, belonging, acceptance, self-determination, and agency) Is the client engaged with social justice initiatives? (those that minimize inequities, eliminating unfair discrimination and reducing stigma) Does the client have access and opportunity to engage with community supports? (e.g., access to advocates, information, referrals, resources, and community groups) Is the client connected to their cultural group or opportunities to connect with their cultural group? (opportunities to connect with others in one’s cultural group and to practice aspects of one’s culture freely and safely) Does the client have opportunities or access to egalitarian environments? (where justice, equity, mutuality, inclusion, and cohesion are valued)

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Cross-References ▶ Future of Rural, Remote, and very Remote Mental Health ▶ Models of Service Delivery and Funding of Mental Health Services ▶ Multidisciplinary Teams in Rural and Remote Mental Health ▶ Promotion and Prevention of Mental Health Problems in Rural and Remote Context

References AIHW HG, Harrison J. Trends in injury deaths, Australia: 1999–00 to 2009–10. Canberra: AIHW; 2015. Aisbett DL, Boyd CP, Francis KJ, Newnham K, Newnham K. Understanding barriers to mental health service utilization for adolescents in rural Australia. Rural Remote Health. 2007;7(1):624. https://www.rrh.org.au/journal/article/624. Accessed 12 June 2020. Baker E, Mason K, Bentley R, Mallett S. Exploring the bi-directional relationship between health and housing in Australia. Urban Policy Res. 2014;32(1):71–84. Baum F. The social determinants of health inequity. In: The new public health. 4th ed. Victoria: Oxford University Press; 2015. Berry H, Rickwood D. Measuring social capital at the individual level: personal social capital, values and psychological distress. J Public Ment Health. 2000;2(3):35–44. Cappo D. Social inclusion initiative. Paper presented at the Social inclusion, participation and empowerment. Address to Australian Council of Social Services National Congress; 2002. Carey TA. Health is control. Annals of Behavioural Science. 2016;2(1):13. Carey TA. Patient-perspective care: A new paradigm for health systems and services. 2017. London: Routledge. https://doi.org/10.4324/9781351227988. Carey TA, Mansell W, Tai SJ. A biopsychosocial model based on negative feedback and control. Frontiers of Human Neuroscience, 8, article 94. 2014. https://doi.org/10.3389/fnhum.2014.00094. http://journal.frontiersin.org/Journal/10.3389/fnhum.2014.00094/abstract. Carey TA, Fauth JM, Tremblay GT. Rethinking evaluation for improved health outcomes: Implications for remote Australia. American Journal of Evaluation. 2019;1–21. https://doi.org/ 10.1177/1098214018824040. Collins J, Ward BM, Snow P, Kippen S, Judd F. Compositional, contextual, and collective community factors in mental health and Well-being in Australian rural communities. Qual Health Res. 2017;27(5):677–87. https://doi.org/10.1177/1049732315625195. Dean HD, Williams KM, Fenton KA. From theory to action: applying social determinants of health to public health practice. Los Angeles: SAGE Publications; 2013. Diderichsen F, Evans T, Whitehead M. The social basis of disparities in health. In: Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya, Meg Wirth (Eds.), Challenging inequities in health: from ethics to action, vol. 1; 2001. p. 12–23. Oxford University Press. Fragar L, Stain HJ, Perkins D, Kelly B, Fuller J, Coleman C, et al. Distress among rural residents: does employment and occupation make a difference? Aust J Rural Health. 2010;18(1):25–31. https://doi.org/10.1111/j.1440-1584.2009.01119.x. Fraser C, Judd F, Jackson H, Murray G, Humphreys J, Hodgins GA. Does one size really fit all? Why the mental health of rural Australians requires further research. Aust J Rural Health. 2002;10:288–95. Fraser C, Jackson H, Judd F, Komiti A, Robins G, Murray G, et al. Changing places: the impact of rural restructuring on mental health in Australia. Health Place. 2005;11(2):157–71. https://doi. org/10.1016/j.healthplace.2004.03.003.

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Galloway AP, Henry M. Relationships between social connectedness and spirituality and depression and perceived health status of rural residents. Online J Rural Nurs Health Care. 2014; 14(2):43–79. https://doi.org/10.14574/ojrnhc.v14i2.325. Gilchrist A. The well-connected community 3E: a networking approach to community development. Bristol: Policy Press; 2019. Goldman N. Social inequalities in health: disentangling the underlying mechanisms. Ann N Y Acad Sci. 2001;945:118–39. Hamano T, Yamasaki M, Fujisawa Y, Ito K, Nabika T, Shiwaku K. Social capital and psychological distress of elderly in Japanese rural communities. Stress Health. 2011;27(2):163–9. https://doi. org/10.1002/smi.1324. Haynes TF, Cheney AM, Sullivan JG, Bryant K, Curran GM, Olson M, et al. Addressing mental health needs: perspectives of African Americans living in the rural south. Psychiatr Serv. 2017;68(6):573–8. https://doi.org/10.1176/appi.ps.201600208. Hege A, Ball L, Christiana RW, Wallace C, Hubbard C, Truesdale D, et al. Social determinants of health and the effects on quality of life and well-being in 2 rural Appalachia communities: the community members’ perspective and implications for health disparities. Fam Community Health. 2018;41(4):244–54. https://doi.org/10.1097/FCH.0000000000000201. Holden T, Bourke L. Rural community wellbeing. Rural Society. 2014;23(3):208–215. Horwitz AV, Scheid TL. A handbook for the study of mental health: social contexts, theories, and systems. Cambridge: Cambridge University Press; 1999. Johnson L, Sampson E. The ‘missing link’ in case conceptualisation and treatment. InPsych. 2019a;41:1. https://www.psychology.org.au/for-members/publications/inpsych/2019/FebruaryIssue-1/Asocial-determinants-approach. Johnson L, Sampson E. The ‘missing link’ in case conceptualisation and treatment. InPsych. 2019b;41:1. Jones R, Reupert A, Sutton K, Maybery D. The interplay of rural issues, mental illness, substance use and housing problems. J Ment Health. 2014;23(6):317–22. Jones NL, Gilman SE, Cheng TL, Drury SS, Hill CV, Geronimus AT. Life course approaches to the causes of health disparities. Am J Public Health. 2019;109(S1):S48–55. Kawachi I, Subramanian S, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56(9):647–52. Kelly BJ, Stain HJ, Coleman C, Perkins D, Fragar L, Fuller J, et al. Mental health and well-being within rural communities: the Australian rural mental health study. Aust J Rural Health. 2010; 18(1):16–24. https://doi.org/10.1111/j.1440-1584.2009.01118.x. Kotey B. Demographic and economic changes in remote Australia. Aust Geogr. 2015;46(2):183– 201. https://doi.org/10.1080/00049182.2015.1020592. Lindsay C, McCracken M, McQuaid RW. Unemployment duration and employability in remote rural labour markets. J Rural Stud. 2003;19(2):187–200. https://doi.org/10.1016/s0743-0167 (02)00067-0. Lu D, Tyler I. Focus on: a proportionate approach to priority populations. Public Health Ontario. 2016. https://www.publichealthontario.ca/en/eRepository/Focus_On_Priority_Populations.pdf. Accessed 29. Manton KG. Changing concepts of morbidity and mortality in the elderly population. Milbank Mem Fund Q. 1982;60:183–244. Marmot M. Health in an unequal world: Social circumstances, biology and disease. Clinical Medicine. 2006;6(6):559–572. Marmot M, Bell R. Fair society healthy lives: the Marmot review. 2012. Retrieved from http://www. instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review Marmot MG, Shipley MJ. Inequities in death—specific explanations of a general pattern. Lancet. 1984:1003–6. Musyimi CW, Mutiso VN, Musau AM, Matoke LK, Ndetei DM. Prevalence and determinants of depression among patients under the care of traditional health practitioners in a Kenyan setting: policy implications. Transcult Psychiatry. 2017;54(3):285–303. https://doi.org/10.1177/ 1363461517705590.

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National Mental Health Commission. The national review of mental health programmes and services. Sydney: NMHC, 67; 2014. Nepomuceno BB, Cardoso AA, Ximenes VM, Barros JP, Leite JF. Mental health, well-being, and poverty: a study in urban and rural communities in northeastern Brazil. J Prev Interv Community. 2016;44(1):63–75. https://doi.org/10.1080/10852352.2016.1102590. Parr H, Philo C, Burns N. Social geographies of rural mental health: experiencing inclusions and exclusions. Trans Inst Br Geogr. 2004;29:401–19. Paykel ES, Abbott R, Jenkins R, Brugha TS, Meltzer H. Urban-rural mental health differences in great Britain: findings from the national morbidity survey. Psychol Med. 2000;30(2):269–80. https://doi.org/10.1017/s003329179900183x. Pearce N, Davey Smith G. Is social capital the key to inequalities in health? Am J Public Health. 2003;93(1):122–9. Pearlin LI, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: some conceptual perspectives. J Health Soc Behav. 2005;46(2):205–19. Pickett KE, Wilkinson RG. Inequality: an underacknowledged source of mental illness and distress. The British Journal of Psychiatry. 2010;197(6):426–428. Powers WT. Behavior: The control of perception (2nd ed.). New Canaan, 2005. CT: Benchmark. Riva M, Bambra C, Curtis S, Gauvin L. Collective resources or local social inequalities? Examining the social determinants of mental health in rural areas. Eur J Pub Health. 2011;21(2):197–203. https://doi.org/10.1093/eurpub/ckq064. Romans S, Cohen M, Forte T. Rates of depression and anxiety in urban and rural Canada. Soc Psychiatry Psychiatr Epidemiol. 2011;46(7):567–75. https://doi.org/10.1007/s00127-010-0222-2. Roufeil L, Gullifer J, Maybery D. The health challenges facing rural people and communities in Australia: what can psychology offer? Aust J Rural Health. 2014;22(6):271–2. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of, C., Family, H., Committee on Early Childhood, A., Dependent, C, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–46. https://doi.org/10.1542/peds.2011-2663. Solar O, Irwin A. Social determinants of health discussion paper 2 (policy and practice). A conceptual framework for action on the social determinants of health; 2010. Taylor SE. Mechanisms linking early life stress to adult health outcomes. Proc Natl Acad Sci U S A. 2010;107(19):8507–12. https://doi.org/10.1073/pnas.1003890107. Taylor R, Page A, Morrell S, Harrison J, Carter G. Social and psychiatric influences on urban-rural differentials in Australian suicide. Suicide Life Threat Behav. 2005;35(3):277–90. Thomson H, Thomas S, Sellstrom E, Petticrew M. The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007. Am J Public Health. 2009;99 (Suppl 3):S681–92. https://doi.org/10.2105/AJPH.2008.143909. Vines R. Psychology in the bush: a rural reality: preparedness for climate-change-related disasters. InPsych. 2017;39(5):41. Wan C, Su S. Neighborhood housing deprivation and public health: theoretical linkage, empirical evidence, and implications for urban planning. Habitat Int. 2016;57:11–23. Weich S, Twigg L, Lewis G, Jones K. Geographical variation in rates of common mental disorders in Britain: prospective cohort study. Br J Psychiatry. 2005;107:29–34. Welfare, A. I. o. H. Australia’s health 2016: in brief. Cat. no. AUS 201; 2016. Westerman T. Engagement of Indigenous clients in mental health services: What role do cultural differences play? Australian e-Journal for the Advancement of Mental Health. 2014;3(3):88–93. https://doi.org/10.5172/jamh.3.3.88. WHO. A conceptual framework for actions on the social determinants of health. 2010. Retrieved from Geneva. WHO. Social determinants of mental health. 2014. Retrieved from https://apps.who.int/iris/ bitstream/handle/10665/112828/9789241506809_eng.pdf;jsessionid=67EEEABBBA311CD C4AEAC2B49CB607F0?sequence=1 Wilkinson RG, Pickett KE. The enemy between us: the psychological and social costs of inequality. Eur J Soc Psychol. 2017;47(1):11–24.

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Global Mental Health Perspectives on Rural and Remote Mental Health Provision Ross G. White, Nargis Islam, and Rosco Kasujja

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Emergence of Global Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture and Its Impact on Understandings of Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Biopsychosocial Model and the Need to Attend to Cultural Factors . . . . . . . . . . . . . . . . . . . Scaling-Up and Task-Sharing for Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features of Effective Rural and Remote Practice in LMIC . . . . . . . . . . . . . . . . . . . . . . . . . The Context in Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Context in Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications for Rural and Remote Mental Health Work in LMIC . . . . . . . . . . . . . . . . . . . . Training People to Deliver Interventions in Rural Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Utilizing Existing Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical Considerations Associated with International Collaborations . . . . . . . . . . . . . . . . . . . . . . . Case Study from Bangladesh: Shomaj Shongi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study from Uganda: Group Support Psychotherapy for Depression Treatment in People with HIV/AIDS in Northern Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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R. G. White (*) Institute of Population Health, University of Liverpool, Liverpool, UK e-mail: [email protected] N. Islam Independent Academic and Clinical Psychologist, Oxford, UK e-mail: [email protected] R. Kasujja Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_3

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Abstract

Low- and middle-income countries (LMICs) are home to the vast majority of the world’s population. These countries tend to lack adequate resources to meet the mental health needs of their populations. The limited infrastructure for supporting mental health in LMIC tends to be concentrated in urban areas, with remote and rural areas fairing much worse. Particular challenges relate to a lack of highly skilled practitioners to deliver support. Drawing on insights from Global Mental Health, the chapter reflects on innovative and pragmatic strategies that can help to bolster mental health provision in remote and rural parts of LMICs. These include “task-sharing” initiatives which aim to train nonspecialist workers to assume responsibilities which have historically been undertaken by highly skilled practitioners. Issues relating to the training and supervision of nonspecialists are flagged as being central to the success of these initiatives. The chapter highlights the importance of attending to the social and cultural context in which people live their lives. Incorporating local language terms and local explanatory models for distress into interventions is presented as key to maximizing engagement with local communities. Case studies from Uganda and Bangladesh are used to illustrate key points. International collaborations are highlighted as an important vehicle for building capacity for remote and rural mental health provision in LMICs. However, such collaborations will necessitate attention to be allocated to how dynamics of power operate at the meeting space between different epistemologies and the risk that local ways of understanding could be subjugated in such collaborations. While acknowledging the importance of directly addressing distress experienced by people living in remote and rural areas of LMIC, the chapter also recognizes that resilience factors can serve to mitigate against the impact of adversity on these communities. Consideration is given to the importance of harnessing collective strengths, so that “community” can serve as a resource to promote mental health and well-being.

Introduction Statistics from the United Nations (UN) indicate that there is a shift occurring in the distribution of people living in rural versus urban settings. In 1950, 70% of the world’s population lived in rural settings; in 2014, this dropped to 46%; and by 2050, it is estimated that only 34% of the world’s population will live in rural areas (UN 2014). However, in noting this change, it is important to appreciate that since 1950, the number of people living in rural settings across the world has grown with the global rural population estimated to be approximately 3.4 billion people (compared to less than 2 billion people in 1950) (UN 2014). The continents of Africa and Asia are home to nearly 90% of the world’s rural population with 60% and 52% of their respective populations living in rural areas (UN 2014). The vast majority of the countries on these continents consist mainly of low- and middle-income countries (LMIC) (World Bank 2018).

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The infrastructure for mental health in LMIC has been highlighted as requiring attention (The Lancet Series in Global Mental Health 2007, 2011). Historically, mental health in LMIC has not been recognized as a major priority on a policy and resource allocation level, possibly because basic needs such as food, shelter, and the more tangible and visible construct of physical health problems are governmental priorities for managing the needs of such a vast and largely rural-based population (Saraceno et al. 2007). There has also been a reluctance to acknowledge the importance of social determinants of mental health and the extent to which activity relating to diverse policy sectors (education, social welfare, criminal justice, etc.) can impact on mental health. This has meant that investment has tended to be restricted to agencies active in the health sector, which has narrowed the range of models employed to design and deliver services to address emotional distress. Although there is growing recognition of the importance of intersectoral collaboration relating to mental health, the lack of available financial and human resource in LMIC means that people experiencing mental health difficulties in these countries most often lead a life of containment, with no access to positive experiences or relationships with family and community networks, who also report discrimination as a result of a family member experiencing a mental health difficulty (Saxena et al. 2007). This is especially true of rural areas with resource traditionally being invested in urban settings (Saraceno and Dua 2009; Saraceno et al. 2007). In rural settings, there are issues of geographic accessibility and limited resources in terms of availability and retention of trained professionals (Shields-Zeeman et al. 2017).

The Emergence of Global Mental Health Global Mental Health (GMH; The Lancet Series on Global Mental Health 2007, 2011) has been defined as an “area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide.” (Patel and Prince 2010, p. 1976). The overall difficulty in LMIC remains the scarcity of mental health professionals to deliver such interventions to underprivileged communities (Saxena et al. 2007). The Movement for Global Mental Health (http://www.globalmentalhealth.org), which has a membership of around 200 institutions and 10,000 individuals, has been spearheading efforts to bring about change in mental health care over the last 12 years. GMH initiatives place emphasis on the importance of “scaling-up” services in LMIC. According to the WHO (2008), “scaling up in the health sector means doing something in a big way to improve some aspect of a population’s health (and it can relate to) . . . scaling up inputs; outputs (access, scope, quality, efficiency); outcomes (coverage, utilization) or impact (reducing morbidity or mortality)” (p. 1). There have been criticisms in some quarters that GMH is seeking to “scale-up” Western psychiatric systems of care in LMIC, and that the evidence base that is used to justify the scaling-up of particular forms of intervention is not drawn from diverse cultural contexts (Summerfield 2008; Mills 2014; Mills and White 2017). However, rather than being a homogeneous, monolithic enterprise, GMH should be understood as a

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diverse range of activities characterized by collaboration with local stakeholders to generate innovate, pragmatic, and context-sensitive approaches related to mental health and well-being in low-resource settings (White et al. 2017). White et al. (2016) highlighted the need to reach consensus on what the primary objective of GMH initiatives actually are. This was in reaction to the fact that this had largely been constricted to granting people across the world equitable access to mental health services rather than thinking about what these services should be seeking to deliver on. Well-being, as conceptualized by the capabilities approach (CA; Sen 1999; Nussbaum 2002), has been highlighted as an important framework for refining the objectives of GMH (White et al. 2016). Specifically, CA places emphasis on developing an understanding of factors that influence people’s agency and freedom to engage in forms of being and doing that they subjectively value. This includes a focus on cultural norms, beliefs, and practices – including those relating to physical and mental health. For example, Greco et al. (2015) used CA to develop a measure of what constitutes “a good life” for women in rural Malawi. Focus group discussions with the women identified six spheres of well-being: physical strength, inner well-being, household well-being, community relations, economic security, and happiness.

Culture and Its Impact on Understandings of Health and Illness Culture has been defined as “a set of institutional settings, formal and informal practices, explicit and tacit rules, ways of making sense and presenting one’s experience in forms that will influence others” (Kirmayer 2006; p. 133). Cultural factors have been highlighted as influencing the decisions that individuals and groups make about health and illness (Angel and Thoits 1987). Culture is recognized as affecting various levels of understanding how mental health difficulties present and how they should be responded to: “. . .culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given. In sum, because health care is a cultural construct, arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventative interventions” (U.S. Department of Health and Human Services n.d.). There is a need to attend to the implications that cultural diversity has for efforts to build capacity for mental health in low-resource settings (White et al. 2017). The term explanatory model (EM) was introduced by Kleinman (1980) to capture understanding the origins of illness held by cultural groups. Angel and Thoits (1987) state that the structured narratives about health and illness that can emerge from these explanatory models can become “overlearned” by members of cultural groups to such an extent that they are assumed to be objective reality. These narratives, in turn exert a strong influence at a societal level on how people think they should behave (Hacking 1995). A range of interview measures have been developed to elicit

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narratives and explore explanatory models in particular cultural contexts, e.g., Explanatory Model Interview Catalogue (EMIC; Weiss 1997), Short Explanatory Model Interview (SEMI: Lloyd et al. 1998), McGill Illness Narrative Interview – MINI (Groleau et al. 2006), and Barts Explanatory Model Inventory (BEMI: Rudell et al. 2009).

The Biopsychosocial Model and the Need to Attend to Cultural Factors The biopsychosocial model (Engel 1977) has been influential in guiding efforts to build capacity for mental health difficulties in LMIC. A key limitation of the model, however, is that it lacks a “functional architecture” that accounts for the processes by which biological, psychological, and social factors interact to give rise to mental health difficulties (Carey et al. 2014). Furthermore, Babalola et al. (2017) contend that for the model to be truly “holistic,” it needs to be sensitive to the diverse beliefs and practices relating to mental health across the globe. In particular, it is suggested that a greater focus on cultural factors could potentially address the often-cited criticism that the biopsychosocial model lacks specific guidance relating to how support can be operationalized and offered to clients (Ghaemi 2009). Indeed, Ghaemi (2009) suggested that the biopsychosocial approach can lead to “cherry picking” of treatment options, whereby different professionals revert to their specialist training to decide which particular interventions to recommend. This has meant that there has been a tendency to under-recognize the importance of social and cultural factors in the biopsychosocial model. Increased understanding about pertinent cultural factors could help build a shared understanding between professionals and experts by experience about the nature of mental health difficulties and the relevance that forms of support have in particular settings (Babalola et al. 2017).

Scaling-Up and Task-Sharing for Mental Health A pragmatic stance that has been utilized in efforts to “scale-up” services (i.e., build capacity) for mental health in LMIC and in rural settings in particular has been to integrate these with physical primary care health services that may be present. A key policy driver for these initiatives was the Integrating Mental Health Care into Primary Care: A Global Perspective (WHO/WONCA 2008) document. Ventevogel (2014) indicated that a key issue to ensure the success of this integration was engaging community members to be partners in the provision of psychosocial interventions. However, Saraceno and Dua (2009) have noted some complications with the integration of mental health interventions into primary care health services including: primary care workers already being overburdened; a lack of supervision and specialist support after training; and a lack of adequate provision of psychotropic medication in primary care. Difficulties with building human capacity to meet mental health demand include a lack of incentives for professionals to work in rural areas.

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The lack of highly trained individuals has resulted in emphasis being placed on “task-sharing” initiatives. This has been defined as the transfer of tasks, normally performed by a specialist, to a health professional with a different or lower level of education and training, or to a person specifically trained to do a limited task only, without formal health training (Joshi et al. 2014). Citing relevant examples, Kakuma et al. (2011) indicated that mental health care can be integrated in primary care settings, through community-based programs and task-shifting approaches that engage and support skilled nonspecialist health professionals, lay workers, affected individuals, and caregivers. The Programme for Improving Mental health carE (PRIME; Lund et al. 2012; Mendenhall et al. 2014) project that has been conducted in recent years has focused scaling-up and task-sharing initiatives in five LMIC: Ethiopia, India, Nepal, South Africa, and Uganda. A benefit of task-sharing initiatives is that it tends to involve the utilization of local staff who are familiar with local linguistic expressions and presentations of mental distress, and that their involvement can help reduce stigma (Kagee et al. 2013; van Ginneken et al. 2013). Task-sharing is not without its complications. Bruckner et al. (2011) stated that “the success of these (task-sharing) strategies depends on strong, well coordinated management mechanisms and incentives” (p. 192). Padmanathan and De Silva (2013) in a systematic review of 21 studies indicated that although a promising initiative, task-sharing is not an outright solution for human resource scarcity with key issues to be addressed including remuneration, training, and supervision. Van Ginneken et al. (2013) reviewed 38 studies in 15 LMIC that evaluated the use of nonspecialist health care workers for addressing mental disorders in LMIC and noted positive impacts on outcomes in a variety of mental health disorders. They concluded that “this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific non-specialist health workers-led interventions are more effective” (p. 2). Patel (2011) noted that there is a need to address when he termed a “credibility gap” with task-sharing efforts, i.e., the gap that exists between how mental health specialists understand mental disorders and how people in diverse cultural contexts conceptualize emotional/psychological suffering. Differences between the beliefs held between professionals and lay people can often be most pronounced in rural settings. However, Rahman et al. (2012) noted the importance of involving community members in task-shared duties because they have more in common socially, linguistically, and culturally with people experiencing distress than professional workers would. In this way, task-sharing in rural settings can serve to enhance the sociocultural credentials of the interventions and help enhance engagement.

Distinctive Features of Effective Rural and Remote Practice in LMIC As mentioned previously, rural areas of LMIC are particularly underserved and provide important opportunities to reflect on relevant issues. In light of the fact that Africa and Asia have the highest proportion of people living in rural settings

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(UN 2014), this chapter will include case studies from countries situated in each of these continents – Uganda and Bangladesh, respectively – to illustrate key points. In countries such as Uganda and Bangladesh that have endured colonial histories, notions of “euro-superiority” remain deeply entrenched among those who plan, deliver, and receive health interventions (Czyzewski 2011). Said (1979) indicated that a colonial past has its legacy in the inherent presumption of Western superiority in addressing non-Western cultures. These presumptions can continue to exert an influence on the dynamics of power that exist between experts by experience and those who deliver mental health interventions (Stacey 2001). A failure to recognize and negotiate cross-cultural differences in understanding about mental health difficulties risks the perpetration of “epistemic violence” (Watters 2017) whereby, Western models of mental disorders might be erroneously prioritized over local ways of understanding distress by both the local population of health professionals (through internalized assumptions Western superiority) and by Western “experts.” There is a need therefore to name and challenge such assumptions, particularly for those in the “expert”/powerful positions, and it becomes as much about recognizing, valuing, and building confidence in local professionals as it is about applying “expert” knowledge that is culturally harmonious and applicable to the needs of that population.

The Context in Uganda Uganda is a country in East Africa that has a population of over 38 million people (WHO 2014). The population consists of numerous ethnic groups, which can be broadly divided into the Nilotic group (e.g., the Acholi and Langi) in the North and the Bantu (e.g., Buganda and Bunyoro) in the South. Uganda achieved independence from Great Britain in 1962. In 1971, Milton Obote, the first Ugandan prime minister and two-time president, was overthrown by a military coup led by Idi Amin while on a state visit to Singapore. During his rule, Amin oversaw the persecution, imprisonment, torture, and murder of many Ugandan citizens. Amin was finally deposed in 1979, and Obote returned to power in 1980. However, he was overthrown in 1985 and the following year Yoweri Museveni commenced his role as Uganda’s president, which continues to this day. In 1986, Joseph Kony and his band of militia called the Lord’s Resistance Army (LRA) commenced an insurgency in Northern Uganda that inflamed ethnic tensions and armed resistance against the government in Kampala. It is estimated that the LRA have been responsible for the deaths of 100,000 people in Uganda and the displacement of 1.7 million (The Independent 2015). The conflict finally ended in 2006, but Kony continues to be at large. Economic growth in Uganda has slowed in recent years, and this is in part due to conflicts in neighboring South Sudan and the Democratic Republic of Congo (World Bank 2018). In Uganda, the total health expenditure is 59 USD per person per year, and the burden associated with mental health problems is 2578 Disability-Adjusted Life Years (DALYS) per 100,000 of population (WHO 2014). Across Uganda, there are 136 and 266 staff working in mental health inpatient settings and outpatient

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settings, respectively (WHO 2014). Over 40 of the languages indigenous to Uganda fall into 3 main families — Bantu, Nilotic, and Central Sudanic — with another 2 languages in the Kuliak family (see the graphic below for details of how the languages are distributed across the country). According to the 2014 census, Luganda (the mother tongue of the Baganda people) is the most widely spoken indigenous language with 5.6 million people speaking it as a first language with a further one million speaking it as a second language (https://www.ethnologue.com/ country/ug/languages). In light of the elevated levels of trauma experienced by people in Northern Uganda, there is widespread recognition of the need to make psychosocial interventions more widely available in Uganda. Kigozi et al. (2010) has highlighted the limited infrastructure and resources for mental health systems in Uganda. Their article highlighted that approximately 1% of expenditure by the government health department was directed towards mental health in primary care. Of all the mental health expenditures, 55% was directed towards the National Mental Hospital (Kigozi et al. 2010). In Uganda, qualified mental health “experts” tend to be concentrated in urban areas – specifically Kampala or areas surrounding the city (Shah et al. 2017). Approximately, 75% of Ugandan households are in rural areas (Uganda Bureau of Statistics 2016). This means that there is a marked shortage of available professionals to meet the mental health needs of the large number of Ugandans living in rural settings. In African countries such as Uganda, it is estimated that between 60% and 80% of the population goes to traditional healers for health difficulties (WHO 2002). This applies equally to mental health difficulties as much as to physical health difficulties. Indeed, research has indicated that the majority of individuals presenting at mental health units have previously visited a traditional, spiritual, and faith practitioner (Sorsdahl et al. 2009). Traditional healers offer holistic forms of support that can resonate strongly with the explanatory models that the local population hold to account for emotional distress (Klinghardt 2005). In the past, many arguments have been put forward against traditional healing in Africa with some scholars dismissing the practice as unhealthy and dangerous, as belonging to pre-civilization, and many other degrading explanations (Freeman and Motsei 1992). Opportunities exist for integrating Western ideas of mental health difficulties with traditional practices. For example, Okello and Musisi (2001) reflected on the indigenous model of depression among the Baganda in Uganda. The importance of liaising closely with traditional healers in rural Uganda has been highlighted as an important consideration for building capacity for mental health services in Uganda (Abbo 2011; Patel 2011). Nortje et al. (2016) synthesized findings from 32 studies (conducted in 20 different countries) that investigated the efficacy of traditional healers for addressing mental disorders. The review concluded that traditional healers “might help to relieve distress and improve mild symptoms in common mental disorders such as depression and anxiety” (Nortje et al. 2016, p. 154). As with other forms of intervention, it is important that traditional healers and faith healers adhere to a rights-based approach that prioritizes opportunities for enhanced citizenship of people. Reflecting on the role that traditional healers can

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play for people experiencing mental health difficulties in sub-Saharan Africa, a Nigerian psychiatrist stated: “It seems that when they go to the healer, he tries to help them understand what might be happening to them . . . he invests their affliction, their symptoms with significance. Like hearing voices becomes ancestors speaking . . . And in this way, maybe their experiences change from being something problematic, to a more confirming and meaningful experience. And maybe this brings them some kind of relief to the pain and conflict they are experiencing . . .” (Cooper 2016, p. 326). As a linguistically diverse country, mental health-related work in rural Uganda may require the use of interpreters and translators. Schwartz et al. (2014) indicated that there are not always sufficient numbers of highly trained interpreters available to support mental health-related work in LMIC. d’Ardene (2013) noted that communicating in a second language puts experts by experience at a disadvantage and impacts negatively on the therapeutic alliance. It is widely recognized that there is a need for linguistic and cultural mediation in interpretation. However, White et al. (2020) highlighted a need for “epistemic brokering” in interpreted interactions about mental health to reduce the risk of local people’s understanding about emotional distress being subjugated by Western models of mental illness delivered by professionals who may have higher levels of power in the interactions. Raymond (2014, p. 430–1) states that “language brokering occurs when interpreters need to relay some term or piece of information from the source language into a language that lacks the necessary linguistic counterpart . . . (whereas cultural brokering) goes beyond in-depth knowledge of the languages themselves, into the culturally based worldviews inhabited by the speakers of those languages.” Epistemic brokerage in the interpretation of material instead relates to “reshaping the stance or action it (the material) is being mobilized to accomplish” (Raymond 2014, p. 431). The extent to which linguistic, cultural, and epistemic mediation might be feasible in rural settings in countries such as Uganda will vary according to the knowledge, experience, and expertise of people undertaking the interpretation. In general, when engaging in efforts to “scale-up” services for mental health in settings such as Uganda “taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs” (Mendenhall et al. 2014, p. 33). Research conducted by Shah et al. (2017) in the District of Kanungu in south-western Uganda investigated perceptions about mental illness in the rural population. Focus group discussions were conducted with 37 community members, 12 service users and carers, and 5 community health workers. Key themes identified in the qualitative analyses indicated that: (1) peoples’ experience of mental health difficulties are linked to intrinsic (i.e., inherent failures or weaknesses of individuals – such as thinking too much, losing one’s tempers, and making poor choices) and extrinsic causes (e.g., drugs, infectious diseases, seizures, God, satanic forces, poverty, and family disharmony); (2) there is a need to

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determine appropriate treatments for mental health difficulties based on the purported causes (e.g., using medial and/or nonmedical treatment approaches that could involve a spiritual, or pharmacological, or a mix of the two).

The Context in Bangladesh Bangladesh is one of the most densely populated countries in the world, with a population of approximately 160 million people in a geographical area of approximately 150,000 sq. miles. The country is situated on a delta of rivers that empties into the Bay of Bengal. While poverty is chronic and widespread, Bangladesh has, in recent years, reduced population growth and improved health and education, and has moved from “lower income” country status to “middle income” country status. Historically, Bangladesh was known as East Bengal and formed part of India, which was colonized and ruled by the East India Company from 1765, subsequently by the British government from 1858. In 1947, Indian independence brought with it the Partition of India into Muslim and Hindu territories, India and Pakistan. Partition was accompanied by widespread violence and massacres, particularly in Bengal and the Punjab, as the mass migration of millions of Hindus to India, and Muslims to East and West Pakistan. Thus, began a process of East Bengal becoming East Pakistan. There was pronounced social and economic inequity between East Pakistan and West Pakistan. Bangladesh came into being after a war with Pakistan in 1971, which was linked to the systemic inequities between the two regions and prejudicial attitudes towards the Bangla identity of East Pakistan. The experiences of 1971 remain recent enough for many in the current Bangladeshi population to have lived experiences of the war, along with memories of trauma, fear, and loss. Although it has experienced periods of political instability, Bangladesh has experienced a sustained period of stability and economic growth and has remained connected to its historical roots of religious tolerance between the majority Muslim and minority Hindu, Christian, and Buddhist. The geocultural history of the Bengal region is imbibed with a plethora of influences of diverse spiritual beliefs – from rituals of animism, Buddhist, Hinduism, and Islam – and Bangla culture is a reflection of pluralism and the syncretism of these major belief systems. This pluralism continues to exist in the belief systems of rural dwellers, where adherence to religious beliefs and practices are compatible with respecting nature and its processes. Indeed, this pragmatic blending of belief systems arguably helps Bangladeshi people to make sense of the natural disasters that have all too frequently occurred in their country, displaying resilience in adapting to the challenges faced, and continuing to thrive within these adversities. Efforts to provide effective, replicable, and sustainable mental health support in rural Bangladesh need to be cognizant of the rich and nuanced cultural history, beliefs, and practices at play in Bangladeshi communities, and the concomitant

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strengths and opportunities that these provide. This will include an awareness of the values and perspectives that people hold in relation to physical and mental health. Tackling health difficulties in rural and remote areas of Bangladesh presents a unique set of challenges. According to a WHO report (2017), mental health expenditure in Bangladesh from the government health department is minimal and equated to less than 2.8% of the total national health expenditure in 2014. In 2006, a Nation Mental Health Policy was proposed for the surveillance and prevention of noncommunicable diseases (NCD) and community-based activities in mental health (WHO-AIMS, Bangladesh 2007). According to a National Mental Health Survey in 2003–2005, about 16.05% of the adult population in the country are suffering from mental health difficulties; however, such estimates of mental health incidence in the population is likely to be grossly underreported given a lack of resources to evaluate this (Hossain et al. 2014), together with the stigma surrounding mental health issues. There exists no human rights review body in the country to inspect mental health facilities and monitor care delivery, and there is no specific mental health authority in the country. There are 50 outpatient mental health facilities and no facility provides follow-up care in the community. There are no “day treatment” mental health facilities in the country. There are 31 community-based psychiatric inpatient units for a total of 0.58 beds per 100,000 of population. There are 11 community residential facilities in the country, and 55% of the beds in these facilities are for children and adolescents, and 81% of admitted patients are female and 73% of them are children. There is one 500 bedded mental hospital in the country, and on average, patients spend 137 days in the hospital. The density of psychiatric beds in or around the capital city, Dhaka, is five times greater than the density of beds in the rest of the country (WHO-AIMS, Bangladesh 2007). There is currently no specific mental health authority, and mental health service provision is partly through governmental initiatives as related to physical health and to a large extent through NGOs in a donor funding led piecemeal capacity (WHO Regional Office for West Pacific 2015; Government of the People’s Republic of Bangladesh Ministry of Health and Family 2016). The NGO sector is largely unregulated and undocumented leading to further potential issues about the provision of effective and ethical treatment. Quality assurance of sustainable skills training in particular presents a significant challenge for health provision. Regular monitoring and supervision of mental health initiatives may fall prey to issues such as avoidance of contact with supervisors linked to practitioners failing to grasp the importance of engaging in self-evaluation and reflective processes when working in a mental health setting. Possible internalized hierarchical structures in less skilled and experienced mental health workers may mean that supervision and evaluation of mental health work is viewed as a punitive process rather than a supportive and collaborative one that is necessary for any psychological worker to provide effective care, at whatever stage of expertise they may be. Individuals living in rural settings experience particular financial and logistics barriers.

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Practice Implications for Rural and Remote Mental Health Work in LMIC Despite the significant challenges faced in LMIC (such as Uganda and Bangladesh), it is also important to recognize the strengths and adaptive processes that can be evident in communities living in different contexts which may serve to mitigate against the human impact of these challenges. Consideration of the experience of adversity in turn necessitates consideration of resilience processes within the individual as supported by their contexts and systems (Southwick et al. 2014; Ungar 2011). Ungar (2008) discusses the value of exploring resilience processes in the cultural context in which the adversity is experienced. He posits that resilience is “both the individuals’ ability and capacity to navigate their way to health sustaining resources, including opportunities to experience feelings of well-being, and a condition of the individuals’ family, community and culture to provide these health resources and experiences in culturally meaningful ways” (Ungar 2008, p. 225). Essentially, while developing adaptive processes in the individual is important, it is equally important to ensure that there are also social structures available to maintain and support the individual, e.g., social groups, health care systems, legal systems, etc. In societies that operate within a strong social community context, community resources and culturally embedded systems such as nonfamily social organizations can be accessed and utilized with positive effect (Axinn et al. 2015). One of the key domains of resilient processes is the ability to feel valued and to be connected to something of value (Southwick and Charney 2012). As such, resilience can be understood as being located in a relational context as well as being influenced by the individual’s skill set (Ungar 2012). Hagerty et al. (1996) have described a sense of belonging as a personal involvement in a social system that makes one feel essential and integral to that social system. When an individual is able to connect to a group identity and is accepted, they experience a sense of belonging through feeling valued and a necessary group member. The concept of belonging is a nuanced one; it encompasses multiple realms of human perception and experience and is dynamic and contextual. Evidence suggests that strengthening community involvement and capability promotes a sense of affiliation and belonging and is critical to ensuring genuine empowerment for community members (Lamblin et al. 2017; George et al. 2016; Keyes and Kane 2009).

Training People to Deliver Interventions in Rural Settings Acharya et al. (2017) highlighted a number of specific challenges associated with professionals travelling to urban settings from rural settings to attend training opportunities: (1) travel expenses limit the number of clinicians who can attend the training program; (2) when clinicians leave for training, clinical services are often scaled-back or, in some situations, curtailed entirely in rural clinics; and (3) the high turnover of clinicians in rural sites, those with mental health training may suddenly depart. To address these difficulties, a variety of potential solutions have

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been proposed including the use of “training for trainers” approaches (Ray et al. 2012), internet-based training packages (Fairburn and Cooper 2011), and videoassisted training packages (Acharya et al. 2017). To ascertain the appropriateness of these strategies, it is important to pay particular attention to the local context where the services are being scaled-up. In rural settings, in LMIC, internet access tends to be limited, and even when available, it is an expense that few can afford. For clinicians to develop and maintain expertise, they must actively engage in reflective learning to practice within an ethical and culturally competent framework (Kolb 1984: Herschell et al. 2010; Beidas and Kendall 2010; Schoenwald et al. 2009). Studies have shown that the amount of supervision received (vs. training approach) is the most significant predictor of competence and fidelity post-training (Beidas et al. 2012). Given the practical and logistical challenges inherent in rural and remote working, use of technology via the internet and telecommunication would be a possible strategy. However, uptake of these provisions has been noted to be low following training (Kohrt et al. 2018), and are thought to be strongly influenced by cultural beliefs around the possible punitive nature of supervision (and the hierarchical dynamics it may infer), rather than an understanding that it is a collaborative and supportive process, in addition to a key component of effective therapeutic working.

Utilizing Existing Community Resources Research suggests that nonfamily social organizations in the local community present a significant potential to provide social support, a sense of belonging through group affiliation and a sense of purpose and source of growth (Axinn et al. 2015; Chatterjee et al. 2011; Rathod et al. 2017). When taking into consideration the evidence of human responses to social circumstances, and the reciprocal effect on the neurobiology and neuropsychology of the individual (Lambin et al. 2017), nonfamily social groupings (e.g., religious gatherings, attending “market days,” etc.) present a potential resource that is already embedded into the individuals’ social network. Axinn et al. (2015) examined the associations between social organizations of communities and psychiatric disorders in Nepal, finding that schools, markets, health services, and social support groups each substantially reduced the odds of a range of psychiatric “disorders.” This would also be in line with research that psychological resources enabled by social connectedness can act as a “social cure” for psychological ill-health and that larger and more supportive networks are associated with lower stress, increased personal well-being, and greater personal self-efficacy (Chatterjee et al. 2011). Similarly, Drake and Whitley (2015) highlighted how community-based approaches can be used to promote mental wellbeing. Specifically, they suggested that governments should support and enhance “natural supports in local communities before assuming that more hospitals, professionals, and medications are the answer” (p. 51). In rural settings, community members may routinely undertake tasks together and these might create opportunities for informal support that are congruent with the local cultural context (Rathod

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et al. 2017). For example, in rural settings, women may go for water, wash clothes, or meet a health visitor at a scheduled time together. Involving trusted community workers in introducing new interventions requires collaboration and a trusting relationship with the providers, who will also need to recognize the value of any intervention to be able to effectively support and deliver them.

Ethical Considerations Associated with International Collaborations Understanding the ethical implications that the introduction of interventions developed in the West might have in LMIC such as Uganda and Bangladesh requires a reflective, exploratory, and critical understanding of the relationship between ethics, culture, and context (Bhola and Chaturvedi 2017). A specific issue that has created contention is the use of psychiatric diagnostic categories to guide the delivery and evaluation of interventions in LMIC (Mills 2014; Summerfield 2012). These concerns in conjunction with the need for interventions with a breadth of application have led to a focus being allocated to the use of transdiagnostic mental health interventions in low-resource settings (see: Chorpita et al. 2005; Weisz et al. 2011). These approaches tend to share common practice elements that can be delivered in varying combinations to address a range of problems in a range of settings and are therefore of interest in resource-poor LMIC and rural areas. Transdiagnostic interventions specifically include opportunities for flexibility and adaptation, allowing for treatment without specifying a disorder classification, and include guidance for delivering specific elements to clients with comorbidity (Murray et al. 2011). Interventions designed to build and enhance existing community strengths and resources have value for rural and remote settings. In particular, psychosocial interventions that use community members to assist with the facilitation of the intervention have a clear potential for building community well-being from a psychosocial perspective as opposed to a purely biomedical intervention. Psychosocial interventions are aimed at improving psychological well-being and/or social functioning, with a view to improving quality of life (Tol et al. 2011). Where geographical access to the availability of support influences outcomes in mental health (Rathod et al. 2017), such transdiagnostic treatments have been suggested as a practical solution to achieving a greater potential of scalability through task-shifting using nonspecialist or lay-counsellors, who are local to the communities (Atif et al. 2016; Harvey et al. 2004). Evidence suggests that, practically speaking, the majority of mental health interventions in humanitarian settings tend to be in the form of counselling and community-based social supports, structured social activities (including child friendly spaces), and provision of information, psychoeducation, and awareness raising, where the evidence base is inconclusive or nonexistent (Tol et al. 2011). Several further caveats are important to consider in such models. Service delivery models suggest a need for a tiered system of intervention and referral as low intensity working would address the mild to moderate spectrum of mental health difficulties. Identification of core clinical skills, professional practice, and support mechanisms and

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importantly, accountability and regulation of ethical and competent practice are several more of the challenges to be considered.

Case Study from Bangladesh: Shomaj Shongi Psychosocial skills interventions provided through nonfamily organizations and community groups present a potential opportunity for effective preventative interventions in low-resourced settings. There is good evidence of the effectiveness of parenting and preschool programs for children living in poverty – particularly in relation to reducing inequities in children’s health and development and educational outcomes (Barry and Dowling 2015). The Shomaj Shongi (community friends) also known as “barefoot counsellors” program developed by the NGO BRAC’s Institute of Educational Development (BIED) over the last decade drew on such models and developed a model of preventative intervention in schools. Qualified counsellors trained the Shomaj Shongi to work with young children and adolescents in an urban school setting. The intervention consisted of psychosocial skills and support delivered in weekly sessions within the school curriculum; the class learned together about key elements of healthy psychological functioning, i.e., empathy, self-esteem, assertiveness, and mindfulness; distinguishing between healthy and unhealthy relationships; providing education on psychosocial changes during adolescence; and developing skills across a range of topics such as goal-setting. These concepts were enacted through short sketches/role-plays that drew on a variety of sources including art produced by the children and/or discussions undertaken with them. The “barefoot counsellors” are trained and supervised by qualified counselling psychologists, who are in turn supervised by clinical psychologists. The Shomaj Shongi model was then adapted for training medical practitioners in rural settings to raise awareness and skills development in psychological understandings of mental distress. Educators and primary care professionals have also received the training to enable a psychosocial understanding of the pupils and service users. This focus on developing an understanding of psychosocial processes among local community stakeholders enables the development of a supportive relationship and aims to engender a sense of value, acceptance, and belonging. The limitations of this intervention are retention of the trained barefoot counsellors, access for quality assurance and supervision, and sustainability of the model as the project was through an international donor fund. These considerations are not insignificant, and future initiatives would need to address communication with regard to supervision and consider how the concept of reflective practice can be implemented in a collaborative and culturally congruent way. Building on these experiences, BIED is now involved in providing support in the Rohingya refugee camps in Southern Bangladesh, in collaboration with UNICEF, UNHCR, and other donor organizations. BIED adapted the Shomaj Shongi program to develop a customized play-based curriculum in Child Friendly Space (CFS) for the children in the camps. These spaces were designed to serve three purposes:

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1. Provide a safe space for children and adolescents while identifying and addressing psychosocial needs (Metzler et al. 2015) 2. Nurture spontaneity through engagement in a play-based curriculum that encourages language, cognitive, motor, and socio-emotional development (Barry and Dowling 2015) 3. Preserve culture and heritage through activities and spaces tailored to the target community (Weine et al. 2002) Evidence suggest that CFS has the potential to have substantial positive impact on the psychosocial well-being of children and young people in humanitarian contexts, but that the nature and content of the activities are key to this (Metzler et al. 2015). The BIED CFS model was designed therefore to address: • Building resilience in children in fragile settings through a focus on early childhood stimulus and the development of self-regulation. Emerging data from the strengths and difficulties measures administered suggests over 50% of the children screened had emotional problems and this rose to over 80% in guardianless children (Khan in prep). Given the psychological traumas they will have experienced, this would be expected, and it will be important to evaluate the impact of CFS curriculum content as to the efficacy of the interventions. • Fostering a sense of community among displaced peoples by creating a supportive environment for mothers and children while encouraging involvement from others (e.g., in the construction of play materials, monitoring of child friendly spaces, etc.). A comprehensive review of CFS across humanitarian aid settings suggested that there was often poor integration with the immediate and wider camp communities and the host countries and therefore highlights a need to develop strategies to have a broader outreach role into communities regarding child protection and well-being (Metzler et al. 2015). • Empower women leaders to volunteer as play leaders, training them to serve as role models and disseminators of knowledge within the community. Evidence suggests that involving women in these spaces promotes a sense of connection and social value and provides safe community spaces and movement otherwise unavailable through the migration trauma (UNFPA Report on Women and Girl Friendly Space 2015).

Case Study from Uganda: Group Support Psychotherapy for Depression Treatment in People with HIV/AIDS in Northern Uganda Nakimuli-Mpungu et al. (2015, 2017a) highlighted innovative work conducted in rural Northern Uganda to support the mental health needs of people who have been diagnosed as HIV+. Levels of mental health difficulties such as depression have been shown as elevated in people diagnosed as HIV+ (Nakimuli-Mpungu et al. 2012) and are associated with negative outcomes in relation to physical health and socioeconomic outcomes, because it impacts negatively on family, occupational, and

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community functioning (Fried and Nesse 2014; Hamad et al. 2008). In addition, depression in the context of HIV has been shown to negatively impact on adherence with antiretroviral therapy (Uthman et al. 2014; Nakimuli-Mpungu et al. 2012). Indeed, the treatment of depression has been recognized by the World Health Organization (2016) as being integral to HIV treatment programs. The work of Nakimuli-Mpungu and colleagues came in response to a recognition that mental health care had not been integrated into the treatment of HIV in sub-Saharan Africa, and that to a large extent, task-shifted treatments for depression remain scarce. Following an initial single-site randomized controlled trial of group support psychotherapy for depression experienced by people living with HIV (Nakimuli-Mpungu et al. 2015) that indicated positive findings, Nakimuli-Mpungu et al. (2017a) have progressed to conduct a cluster-randomized control trial across 30 primary care health centres situated in three districts in northern Uganda, i.e., Gulu, Kitgum, and Pader. These districts have populations of 450,000, 247,000, and 250,000 respectively, and approximately, 90% of the populations living in these districts engage in small-scale agriculture and animal husbandry activity to generate income (Nakimuli-Mpungu et al. 2017a). Group support psychotherapeutic (GSP) is a culturally sensitive approach, based on group counselling for trauma, that was adapted to meet the mental health needs of people experiencing HIV in Northern Uganda (Nakimuli-Mpungu et al. 2017b). The adaptation process involved focus group discussions being undertaken with community members. Material generated by the focus groups that was integrated into the adaptation of the intervention included information about community perceptions of depression, local strategies utilized to address depression, and community reflections on which components of a group support psychotherapy intervention would be most culturally acceptable for alleviating depression in people diagnosed as HIV+ (Nakimuli-Mpungu et al. 2017b) – further details about the intervention are described by Nakimuli-Mpungu et al. (2014). A process evaluation indicated that the work undertaken to adapt the intervention and maximize the culturally sensitivity of the intervention helped to optimize intervention delivery. GSP is a complex intervention delivered over 8 weekly sessions lasting between 2 and 3 h each to gender-specific groups of 10–12 people. The intervention contains a range of interacting components. The intervention aims to enhance social support, teach coping skills, and build skills for income-generation (Nakimuli-Mpungu et al. 2017a). Nakimuli-Mpungu et al. (2017a) described the development of a GSP training program that was jointly organized by Makerere University, Kampala, and the Ministry of Health. A “training-for-trainers” approach was used in which mental health specialists trained professional health care workers who in turn trained lay health workers. Over a 5-day period training was delivered using eight training modules: (1) an overview of the training program; (2) introduction to the GSP model; (3) introduction to depression and HIV/AIDS; (4) basic counselling skills; (5) effective coping strategies; (6) training in basic livelihood skills (enterprise selection, basic financial skills, and resource mobilization) required to overcome poverty; (7) self-care strategies; and (8) post-training assessments and training workshop evaluation. The facilitators of the workshop utilized active learning

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techniques (e.g., role playing, brainstorming sessions, problem-solving games, and small group discussion) to deliver the training (Nakimuli-Mpungu et al. 2017b). In the delivery of the intervention, the professional health workers supervise the activity of the lay health workers. To be eligible to become a lay health worker, people had to be actively involved in HIV care, able to read and write, and reside within the villages served by the primary health care centres (Nakimuli-Mpungu et al. 2017a). The initial single-site randomized controlled trial (RCT) indicated that at 6 months post-intervention, participants in the GSP group had lower mean depression scores and higher function scores relative to control participants who received group-based HIV education (Nakimuli-Mpungu et al. 2015). No adverse events were reported in either arm of the study. Although the results of the multisite RCT are pending, it is hypothesized that GSP will be efficacious for reducing levels of depression in people with HIV and that this will improve peoples’ ability to work and safe-guard their livelihood assets. The use of a “training for trainers” approach for building capacity for delivering GSP in Northern Uganda provides evidence of the feasibility of utilizing this model to build capacity for other forms of complex interventions in rural settings.

Concluding Comments and Recommendations Over the course of the chapter, we have considered the challenges associated with building capacity for mental health services in LMIC with a particular focus on the rural settings where large proportions of people continue to live, and resources for mental health are particularly scarce. To illustrate the challenges, the contexts of Uganda and Bangladesh were used to indicate how initiatives there have sought to adapt interventions to the local culturally context. The importance of utilizing pragmatic approaches for identifying, training, and supervising nonspecialists to deliver interventions in remote settings in LMIC was highlighted in both Uganda and Bangladesh. Similarly, the importance of working closely with local stakeholders, utilizing existing community networks, and harnessing local forms of knowledge was flagged. Attending to issues of culture, and drawing on locally relevant frames of reference, were presented as being crucial to engaging people and developing forms of support that were deemed credible and appropriate.

Take Home Messages • Nonspecialist workers in remote areas of LMIC can be trained via “task-sharing” initiatives to assume mental health roles historically undertaken by highly skilled practitioners. • Ongoing supervision and support of nonspecialists will be crucially important.

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• Incorporating knowledge about the local social, linguistic, and cultural context into the design and delivery of support will help maximize engagement from the local community. • Attention needs to be allocated to understanding factors that may buffer against the impact of adversity in remote regions of LMIC. • Community-based approaches offer scalable opportunities for harnessing collective strengths to help promote mental health and well-being.

Cross-References ▶ Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas ▶ Depression and Anxiety ▶ Indigenous Mental Health in Remote Communities ▶ Mental Health Research and Evaluation in Rural, Remote, and very Remote Settings ▶ Multidisciplinary Teams in Rural and Remote Mental Health ▶ Peer Work in Rural and Remote Communities and Mental Health Services ▶ Promotion and Prevention of Mental Health Problems in Rural and Remote Context ▶ Providing School-Based Mental Health Services in Rural and Remote Settings ▶ Recovery in Mental Illness Among Rural Communities ▶ Rural and Remote Psychiatry ▶ Rural, Remote, and very Remote Mental Health ▶ Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts ▶ Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand ▶ Supporting Communities

References Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Glob Health Action. 2011:4. https://doi.org/10.3402/gha.v4i0.7117. Acharya B, Tenpa J, Basnet M, Hirachan S, Rimal P, Choudhury N, et al. Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal. Glob Ment Health. 2017;4:e8. Angel R, Thoits P. The impact of culture on the cognitive structure of illness. Cult Med Psychiatry. 1987;11:465–94. Atif N, Lovell K, Husain N, Sikander S, Patel V, Rahman A. Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study. Int J Ment Health Syst. 2016;10:24. https://doi.org/10.1186/s13033-0160055-9. Axinn W, Ghimire DG, Williams NE, Scott KM. Associations between social organisation of communities and psychiatric disorders in rural Asia. Soc Psychiatry Psychiatr Epidemiol. 2015;50:1537–45.

62

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Babalola E, Noel P, White R. The biopsychosocial approach and global mental health: synergies and opportunities. Indian J Soc Psychiatry. 2017;33(4):291. Barry MM, Dowling K. A review of the evidence on enhancing Psychosocial skills development in children and young people. Galway: HPRC, National University of Ireland; 2015. https://doi. org/10.13025/S8001V. Beidas RS, Kendall PC. Training therapists in evidence-based practice: a critical review of studies from a systems-contextual perspective. Clin Psychol (N Y). 2010;17:1–30. Bhola P, Chaturvedi SK. Through a glass, darkly: ethics of mental health practitioner-patient relationships in traditional societies. Int J Cult Ment Health. 2017;10(3):285–97. https://doi. org/10.1080/17542863.2017.1301975. Bruckner TA, Scheffler RM, Shen G. Yoon J, Chisholm D, Morris J, Fulton BD, Dal Poz MR, Saxena S. The mental health workforce gap in low- and middle-income countries: a needs-based approach. B World Health Organ. 2011;89(3):184–194. Carey TA, Mansell W, Tai SJ. A biopsychosocial model based on negative feedback and control. Front Hum Neurosci. 2014;8:article 94. https://doi.org/10.3389/fnhum.2014.00094. Chatterjee S, Leese M, Koschorke M, McCrone P, Naik S, John S, Thornicroft G. Collaborative community based care for people and their families living with schizophrenia in India: protocol for a randomised controlled trial. Trials. 2011;12:12. https://doi.org/10.1186/1745-6215-12-12. Chorpita BF, Daleiden EL, Weisz JR. Identifying and selecting the common elements of evidence based interventions: a distillation and matching model. Ment Health Serv Res. 2005;7(1):5–20. Cooper S. Research on help-seeking for mental illness in Africa: dominant approaches and possible alternatives. Transcult Psychiatry. 2016;53(6):696–718. Czyzewski K. Colonialism as a broader social determinant of health. Int Indigenous Pol J. 2011; 2(1). Retrieved from: http://ir.lib.uwo.ca/iipj/vol2/iss1/5 d’Ardene P. Counselling In transcultural settings. Priorities for a restless world. Los Angeles: Sage Publications Ltd; 2013. Drake RE, Whitley R. Building behavioral health systems from the ground up. World Psychiatry. 2015;14(1):50–1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196 (4286):129–36. Fairburn CG, Cooper Z. Therapist competence, therapy quality, and therapist training. Behav Res Ther. 2011;49:373–8. Freeman M, Motsei M. Planning health care in South Africa–is there a role for traditional healers?. Soc Sci Med. 1992;34(11):1183–90. Fried EI, Nesse RM. The impact of individual depressive symptoms on impairment of psychosocial functioning. PLoS One. 2014;9(2):e90311. George AS, Scott K, Sarriot E, Kanjilal B, Peters DH. Unlocking community capabilities across health systems in LMIC: lessons learned from research and reflective practice. BMC Health Serv Res. 2016;16:1859. Ghaemi SN. The rise and fall of the biopsychosocial model. British J Psychiatry. 2009;195(1):3–4. Government of the People’s Republic of Bangladesh Ministry of Health and Family. Health bulletin 2016. Dhaka: Directorate General of Health Services; 2016. Greco G, Skordis-Worrall J, Mkandawire B, Mills A. What is a good life? Selecting capabilities to assess women’s quality of life in rural Malawi. Soc Sci Med. 2015;130:69–78. Groleau D, Young A, Kirmayer LJ. The McGill Illness Narrative Interview (MINI): an interview schedule to elicit meanings and modes of reasoning related to illness experience. Transcult Psychiatry. 2006;43:671–91. Hacking I. The looping effects of human kinds. In: Sperber D, Premack D, Premack AJ, editors. Causal cognition: a multidisciplinary approach. Oxford: Clarendon Press; 1995. Hagerty B, Williams RA, Coyne JC, Early MR. Sense of belonging and indicators of social and psychological functioning. Arch Psychiatr Nurs. 1996;10(4):235–44. Hamad R, Fernald LCH, Karlan DS, Zinman J. Social and economic correlates of depressive symptoms and perceived stress in South African adults. J Epidemiol Community Health. 2008;62(6):538–44. https://doi.org/10.1136/jech.2007.066191.

3

Global Mental Health Perspectives on Rural and Remote Mental Health. . .

63

Harvey AG, Watkins E, Mansell W, Shafran R. Cognitive behavioural processes across psychological disorders: a transdiagnostic approach to research and treatment. Oxford: Oxford University Press; 2004. Herschell AD, Kolko DJ, Baumann BL, Davis AC. The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations. Clin Psychol Rev. 2010;30:448–66. Hossain MD, Ahmed HU, Chowdhury WA, Niessen LW, Alam DS. Mental disorders in Bangladesh: a systematic review. BMC Psychiatry. 2014;14:216. https://doi.org/10.1186/s12888-014-0216-9. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, Patel AA. Task shifting for non-communicable disease management in low and middle income countries – a systematic review. PLOS One. 2014;9:e103754. Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. Int Health. 2013;5:11–4. Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: current situation and strategies for action. Lancet. 2011;378 (9803):1654–63. Keyes E, Kane C. Belonging and adapting: mental health of Bosnian Refugees living in the United States. Issues Ment Health Nurs. 2009;25(8):809–31. Kigozi F, et al. An overview of Uganda’s mental health care system: results from an assessment using the world health organization’s assessment instrument for mental health systems (WHOAIMS). Int J Ment Health Syst. 2010;4:1. Kirmayer LJ. Beyond the ‘new cross-cultural psychiatry’: cultural biology, discursive psychology and the ironies of globalization. Transcult Psychiatry. 2006;43(1):126–44. Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press; 1980. Klinghardt D. The five levels of healing. Explore. 2005;14:15. Kohrt BA, Jordans MJD, Turner EL, Sikkema KJ, Luitel NP, Rai S, Patel V. Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal. Pilot Feasibility Stud. 2018;4:36. https://doi.org/10.1186/ s40814-018-0234-3. Kolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs: Prentice-Hall; 1984. Lamblin M, Murawski C, Whittle S, Fornito A. Social connectedness, mental health and the adolescent brain. Neurosci Biobehav Rev. 2017;80:57–68. Lloyd KR, Jacob KS, Patel V, et al. The development of the short explanatory model interview (SEMI) and its use among primary-care attenders with common mental disorders. Psychol Med. 1998;28:1231–7. Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, et al. PRIME: a programme to reduce the treatment gap for mental disorders in five low-and middle-income countries. PLoS Med. 2012;9(12):e1001359. Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33–42. Metzler J, Savage K, Yamano M, Ager A. Evaluation of child friendly spaces: an inter-agency series of impact evaluations in humanitarian emergencies. New York/Geneva: Columbia University Mailman School of Public Health and World Vision International; 2015. Mills C. Decolonizing global mental health: the psychiatrization of the majority world. London/New York: Routledge; 2014. Mills C, White RG. ‘Global mental health spreads like Bush fire in the Global South’: efforts to scale up mental health services in low-and middle-income countries. In: The Palgrave handbook of sociocultural perspectives on global mental health. London: Palgrave Macmillan; 2017. p. 187–209.

64

R. G. White et al.

Murray L, Dorsay S, Bolton P, Jordans M, Rahman A, Bass J, Verdeli H. Building capacity in mental health interventions in low resources countries: an apprenticeship model for training local providers. Int J Ment Health Syst. 2011;5:30. Nakimuli-Mpungu E, Bass JK, Alexandre P, Mills EJ, Musisi S, Ram M, Katabira E, Nachega JB. Depression, alcohol use and adherence to antiretroviral therapy in sub-Saharan Africa: a systematic review. AIDS Behav. 2012;16(8):2101–18. https://doi.org/10.1007/s10461-0110087-8. Nakimuli-Mpungu E, Wamala K, Okello J, Alderman S, Odokonyero R, Musisi S, Mojtabai R. Developing a culturally sensitive group support intervention for depression among HIV infected and non-infected Ugandan adults: a qualitative study. J Affect Disord. 2014;163:10–7. Nakimuli-Mpungu E, Wamala K, Okello J, Alderman S, Odokonyero R, Mojtabai R, Mills E, Kanters S, Nachega J, Musisi S. Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-centre randomised controlled trial. Lancet HIV. 2015;2(5):e190–9. https://doi.org/10.1016/S2352-3018(15)00041-7. Nakimuli-Mpungu E, Musisi S, Wamala K, Okello J, Ndyanabangi S, Mojtabai R, et al. The effect of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: protocol of a pragmatic, cluster randomized trial. JMIR Res Protoc. 2017a;6(12):e8. Nakimuli-Mpungu E, Wamala K, Okello J, Ndyanabangi S, Kanters S, Mojtabai R, Nachega J, Mills E, Musisi S. Process evaluation of a randomized controlled trial of group support psychotherapy for depression treatment among people with HIV/AIDS in Northern Uganda. Community Ment Health J. 2017b;53(8):991–1004. Nortje G, Oladeji B, Gureje O, Seedat S. Effectiveness of traditional healers in treating mental disorders: a systematic review. Lancet Psychiatry. 2016;3(2):154–70. Nussbaum M. Capabilities and social justice. Int Stud Rev. 2002;4(2):123–35. Okello E, Musisi S. Depression as a clan illness (eByekika): an indigenous model of psychotic depression among the Baganda of Uganda. J World Cult Psychiatry Res Rev. 2001;1:60–73. Padmanathan P, De Silva MJ. The acceptability and feasibility of task-sharing for mental healthcare in LMIC: a systematic review. Soc Sci Med. 2013;97:82–6. Patel V, Prince M. Global mental health: a new global health field comes of age. JAMA. 2010;303 (19):1976–7. Patel V. Traditional healers for mental health care in Africa. Glob Health Act. 2011;4. https://doi. org/10.3402/gha.v4i0.7956. Rahman A, Sikander S, Malik A, Ahmed I, Tomenson B, Creed F. Effective treatment of perinatal depression for women in debt and lacking financial empowerment in a low-income country. Br J Psychiatry. 2012;201(6):451–7. Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, Naeem F. Mental health service provision in low-and middle-income countries. Health Serv Insights. 2017; 10:1178632917694350. Ray ML, Wilson MM, Wandersman A, Meyers DC, Katz J. Using a training-of-trainers approach and proactive technical assistance to bring evidence based programs to scale: an operationalization of the interactive systems framework’s support system. Am J Community Psychol. 2012;50:415–27. Raymond CW. Epistemic brokering in the interpreter-mediated medical visit: negotiating ‘patient’s side’ and ‘doctor’s side’ knowledge. Res Lang Soc Interact. 2014;47(4):426–46. Rüdell K, Bhui K, Priebe S. Concept, development and application of a new mixed method assessment of cultural variations in illness perceptions: barts explanatory model inventory. J Health Psychol. 2009;14(2):336–47. Said E. Orientalism. New York: Vintage Books; 1979. Saraceno B, Dua T. Global mental health: the role of psychiatry. Eur Arch Psychiatry Clin Neurosci. 2009;259:S109–17. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet. 2007;370(9593):1164–74.

3

Global Mental Health Perspectives on Rural and Remote Mental Health. . .

65

Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. The Lancet. 2007;370(9590):878–89. Schoenwald SK, Sheidow AJ, Chapman JE. Clinical supervision in treatment transport: Effects on adherence and outcomes. J Consult Clin Psychol. 2009;77(3):410–21. Sen A. Commodities and capabilities: Amartya Sen. Delhi: Oxford University Press; 1999. Shah A, Wheeler L, Sessions K, Kuule Y, Agaba E, Merry SP. Community perceptions of mental illness in rural Uganda: an analysis of existing challenges facing the Bwindi Mental Health Programme. Afr J Prim Health Care Fam Med. 2017;9(1):1–9. Shields-Zeeman L, Pathare S, Walters BH, et al. Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach. Int J Ment Health Syst. 2017;11:6. https://doi.org/10.1186/s13033-016-0113-3. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, Williams DR, Myer L. Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis. 2009;197(6):434–41. Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: interdisciplinary perspectives. Eur J Psychotraumatol. 2014;5. https:// doi.org/10.3402/ejpt.v5.25338. Southwick SM, Charney DS. Resilience: the science of mastering life’s greatest challenges. New York: Cambridge University Press; 2012. Stacey RD. Complex responsive processes in organizations: learning and knowledge creation. Routledge; 2001. Summerfield D. How scientifically valid is the knowledge base of global mental health? Br Med J. 2008;336(7651):992. Summerfield D. Afterword: against ‘global mental health’. Transcult Psychiatry. 2012;49 (3–4):519–30. Swartz L, Kilian S, Twesigye J, Attah D, Chiliza B. Language, culture, and task shifting–an emerging challenge for global mental health. Glob Health Action. 2014;7(1):23433. The Independent. 2015. http://www.independent.co.uk/news/world/africa/lra-war-crimes-trialjoseph-kony-general-abducted-into-lords-resistance-army-as-a-child-is-charged-with-crimesagainst-humanity-10004053.html The Lancet Series on Global Mental Health. The Lancet. 2007. http://www.thelancet.com/series/ global-mental-health. Retrieved 29 Mar 2018 The Lancet Series on Global Mental Health. The Lancet. 2011. http://www.thelancet.com/series/ global-mental-health-2011. Retrieved 29 Mar 2018 Tol W, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, Golaz A, Van Ommeren M. Mental health and psychosocial support in humanitarian settings: linking practice and research. The Lancet. 2011;378(9802):1581–91. U.S. Department of Health & Human Services. n.d.. Retrieved from: https://www.cdc.gov/nchhstp/ socialdeterminants/docs/what_is_cultural_competency.pdf Uganda Bureau of Statistics. The national population and housing census 2014 – main report, Kampala. 2016. UNFPA. Report on women and girl friendly spaces. 2015. https://www.unfpa.org/sites/default/files/ resource-pdf/UNFPA%20UNFPA%20Women%20and%20Girls%20Safe%20Spaces%20Guid ance%20%5B1%5D.pdf Ungar M. Resilience across cultures. Br J Soc Work. 2008;38(2):218–35. https://doi.org/10.1093/ bjsw/bcl343. Ungar M. The social ecology of resilience: addressing contextual and cultural ambiguity of a nascent construct. Am J Orthopsychiatry. 2011;81(1):1–17. Ungar M. Social ecologies and their contribution to resilience. In: Ungar M, editor. The social ecology of resilience: a handbook of theory and practice. New York: Springer Science + Business Media; 2012. p. 13–31. United Nations. 2014. https://esa.un.org/unpd/wup/publications/files/wup2014-highlights.pdf Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle-and high-income countries: a systematic review and meta-analysis. Curr HIV/AIDS Rep. 2014;11(3):291–307. https://doi.org/10.1007/s11904-014-0220-1.

66

R. G. White et al.

van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, et al. Non-specialist health worker interventions for the care of mental, neurological and substance- abuse disorders in LMIC. Cochrane Database Syst Rev. 2013;11:CD009149. Ventevogel P. Integration of mental health into primary healthcare in low-income countries: avoiding medicalization. Int Rev Psychiatry. 2014;26(6):669–79. Watters C. Three challenges to a life course approach in global mental health: epistemic violence, temporality and forced migration. In: White RG, Jain S, Orr DMR, Read UM, editors. The Palgrave handbook of sociocultural perspectives on global mental health. London: Palgrave Macmillan; 2017. p. 237–56. Weine S, Danieli Y, Silove D, Ommeren MV, Fairbank JA, Saul J. Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry. 2002;65:156–64. Weiss M. Explanatory model interview catalogue (EMIC): framework for comparative study of illness. Transcult Psychiatry. 1997;34:235–63. Weisz JR, Ugueto AM, Herren J, Afienko SR, Rutt C. Kernels vs. ears, and other questions for a science of treatment dissemination. Clin Psychol: Publ Div Clin Psychol Am Psychol Assoc. 2011;18(1):41–6. https://doi.org/10.1111/j.1468-2850.2010.01233.x. White RG, Imperiale MG, Perera E. The capabilities approach: fostering contexts for enhancing mental health and wellbeing across the globe. Glob Health. 2016;12(1):16. White RG, Orr DM, Read UM, Jain S. Situating global mental health: sociocultural perspectives. In: The Palgrave handbook of sociocultural perspectives on global mental health. London: Palgrave Macmillan; 2017. p. 1–27. White RG, Fay R, Chiumento A, Phipps A. Multi-language communication about wellbeing and distress: epistemic and ethical considerations. Transcult Psychiatry. 2020; in press. WHO. WHO policy perspective on medicines traditional medicine – growing needs and potentials. Geneva: World Health Organization; 2002. WHO. WHO Technical Brief No.3 – DRAFT 3: scaling up health services: challenges and choices. 2008. http://www.who.int/healthsystems/topics/delivery/technical_brief_scale-up_june12.pdf. Retrieved 30 Mar 2018. World Bank. Country Profile – Uganda http://www.worldbank.org/en/country/uganda/overview. Retrieved 8 Jan 2018. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. Geneva: World Health Organization; 2016. World Health Organization, Ministry of Health & Family Welfare Bangladesh. WHO-AIMS Report on Mental Health System in Bangladesh. In A report of the assessment of the mental health system in Bangladesh using the World Health Organization – Assessment Instrument for Mental Health Systems (WHO-AIMS). 2007. http://www.who.int/mental_health/bangladesh_who_ aims_report.pdf World Health Organization, World Organization of National Colleges, Academies, & Academic Associations of General Practitioners/Family Physicians. Integrating mental health into primary care: a global perspective. Geneva: World Health Organization; 2008. World Health Organization. Mental Health Atlas – Uganda Country Profile. 2014. https://www. who.int/mental_health/evidence/atlas/profiles-2014/uga.pdf?ua=1. Retrieved 8 Jan 2018. World Health Organization. Regional Office for the Western Pacific. Bangladesh health system review. Manila: WHO Regional Office for the Western Pacific; 2015.

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Indigenous Mental Health in Remote Communities Lewis Mehl-Madrona and Barbara Mainguy

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strategies for Moving Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Throughout the world, a higher percentage of aboriginal people live in rural and remote locations compared to European-derived populations. The health care in these locations is often less available and less comprehensive than what is found

L. Mehl-Madrona (*) Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Department of Psychiatry, University of Vermont, College of Medicine, Burlington, VT, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA B. Mainguy Center for Family Medicine, Eastern Maine Medical Center, Bangor, ME, USA School of Social Work, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_4

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in urban centres. Mental health care is even more problematic. Conventional biomedical care is often underutilized for it does not match the expectations of the people; nor does it respect and work within their values and belief systems. It can be patronizing and colonizing and often does not address the social determinants of mental health. Respect for local knowledge, practices, and expertise is essential for successful provision of mental health services. Conventional services can be transformed through the involvement and utilization of community members – in planning, as elders providing services, as clinic staff, as advisors, and as peer counselors. Elders are defined as locally recognized and respected holders of traditional knowledge and practices. Other strategies that are showing promise include telemedicine and Internet-based services, consultations, and trainings; group medical visits, especially including elders; inclusion of spirituality in mental health care; bringing the local language into mental health care as widely as possible, including supporting elders to teach the local language to both patients and practitioners; and immersing the mental health services in the local culture through elders and other advisors. Important mental health strategies for rural and remote sites include the liberal use of elders and their ceremonies; providing cultural activities as part of group therapies and community meetings; using peer counselors, peer support, and mentoring; creating opportunities for large group meetings; health-care providers participating in community events; and focusing upon stories of resilience, resistance, and recovery. Communitybased, narrative, and experiential approaches are usually more successful than conventional cognitive behavioral therapy, which is not generally culturally compatible.

Introduction Importance to Rural and Remote Mental Health Care. Throughout the world aboriginal people often live in rural and remote areas with poor housing and limited access to resources more available in populated areas (Silburn et al. 2006). Across the world, they have some of the worst health outcomes within their larger societies (Gracey and King 2009), including Australia and New Zealand (Anderson et al. 2006), Latin America (Pan American Health Organization 2001), Canada (Frohlich et al. 2006), and the United States (U.S. Commission on Civil Rights 2004). An estimated 25% of aboriginal people in Australia live under these conditions (Australian Bureau of Statistics. 2009). Indigenous people display high rates of overall psychological distress (Australian Bureau of Statistics 2013) and suicide (Department of Health and Ageing 2013; Mehl-Madrona 2016), which may result from colonization, dislocation from the country, loss of identity, previous government policies of assimilation and child removal, marginalization from mainstream society, institutionalized racism, poor education and employment outcomes, and intergenerational trauma (Carson et al. 2007; Purdie et al. 2010). Aboriginal and Torres Strait Islander Australians do not access mental health services at rates

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commensurate with their burden of disease (Australian Bureau of Statistics 2013). Often living in rural and remote areas, access to appropriate services for indigenous people may be limited by the lack of availability in addition to other factors such as the cultural inappropriateness of services and stigma associated with seeking treatment (Garvey 2008). Budgets are limited as well. In the United States, the Indian Health Service is the primary provider for indigenous people in rural and remote areas, and its budget has been estimated to be 50 to 75% of what was needed for adequate service delivery in 1996 (Goldsmith 1996) and has only decreased relative to population growth since then. Australian Aboriginal and Torres Strait Islander women give birth to 6% of the babies in Australia, but are 2–3 times more likely to have adverse maternal and perinatal outcomes than non-Indigenous women (Weetra et al. 2016). Weetra et al. (2016) studied 344 such women with a mean age of 25 years (range 15–43). More than half (56.1%) had 3 or more social health issues during pregnancy; 1 in 4 (27%) had 5–12 issues. The most common issues were “being upset by family arguments (55 %), housing problems (43 %), family member/friend passing away (41 %), being scared by other people’s behavior (31 %), being pestered for money (31 %) and having to leave home because of family arguments (27 %).” More than 1/3 of women who had three or more social issues during pregnancy had high or very high postpartum psychological distress (35.6% versus 11.1% for women who had no social issues during pregnancy, adjusted odds ratio ¼ 5.4, 95% confidence interval 1.9–14.9). The authors noted that their findings highlighted unacceptably high rates of social problems among aboriginal women during pregnancy with accompanying high levels of postpartum psychological distress. They say “in order to improve Aboriginal maternal and child health outcomes, there is an urgent need to combine high quality clinical care with a public health approach that gives priority to addressing modifiable social risk factors for poor health outcomes.” Suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to 44 years of age (Canada Health 2010) in Canada and disproportionately affect aboriginal people everywhere (Wexler et al. 2015). Definition of Health. Health to aboriginal people is not just physical well-being but is simultaneously the social, emotional, and cultural well-being of the whole community (Party 1989). This perspective is as true in North America as it is in Australia. Even what constitutes the social determinants of health differs from an aboriginal perspective (Commission 2007). Inadequacies of Conventional Services. Conventional health services, often lacking in cultural sensitivity, are inadequate for indigenous psychological and behavioral problems, with children being particularly vulnerable (Hunter 2007). Typically, conventional services do not consult aboriginal people regarding the services that they actually desire. A recognition is growing that historical trauma plays a role beyond the usual variables of location, poverty, and access to health facilities (Duran et al. 1998; Sotero 2006). Rahnaman et al. (2016) studied health-care provider roles in remote, aboriginal communities in Canada. She found that the aboriginal person’s identity was constructed in relation to the health-care provider’s role in delivering essential health

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services. Health-care providers were not treating the “ill” patient but rather treating the patient for being “ill.” Health-care providers were treating the aboriginal person for being “aboriginal” by separating the patient from his or her identity. The treatment involved reforming the aboriginal patient from the condition of being “aboriginal.” Compounding the lack of services to rural and remote areas is what is being called the treatment gap, referring to the difference between the need for mental health services and what is actually provided. In the United States (and worldwide), most people who could benefit from services do not receive them. Kazdin (2017) believes that the dominant model of one-to-one, in-person treatment, by a trained mental health professional, in a clinical setting (e.g., clinic, private practice office, healthcare facility) is inadequate, and more creative solutions are needed. We will address some of these, including group medical care, e-medicine, and peer counseling. Colonizing Attempts. We have observed that most attempts at cross-cultural dialogue start from the view that the mainstream psychiatric view is correct and that aboriginal people just need to be better educated or indoctrinated into this paradigm. This makes sense to conventional mental health providers who believe that they are completely evidence-based and that what they do is done because it truly works. Mainstream mental health professionals are generally not willing to look at the efficacy of the practices of another culture and especially not at the way that they see themselves. During a 10-year period, LMM applied for funding from the National Institutes of Health (NIH) in the United States to determine the efficacy of traditional aboriginal elders working with people diagnosed as having a mental illness. The feedback he received was that it could only be studied if the elders would agree to work with each person identically. Not surprisingly, they would not. Their position was that spirits guided their work and prescriptions, herbal or behavioral, and that they had to do what the spirits told them. They were not algorithmic in the way that the NIH wanted them to be. Mehl-Madrona (2008) documented the stories of some exceptional survivors (their physicians gave them a 10% chance of living) who visited aboriginal healers in North America. As impressive as these stories were, he could not provide any estimate of the numbers who worked with the healers who did not have dramatic results or even improvement. Nevertheless, colonizing approaches dismiss the activities of the culture’s traditional healers as irrelevant, superstitious, or placebo healing (Linklater 2014). One example of a colonizing study comes from Australia (Loh et al. 2016). The authors set out to study what Aboriginal and Torres Strait Islander people thought of attention-deficit/hyperactivity disorder (ADHD). They didn’t, however, consider that what we call ADHD might be a reaction to the regimentation required by today’s schools, or it might not even exist within Aboriginal and Torres Strait Islander cultures. Biomedical psychiatry assumes that ADHD is a real diagnosis, but it has never studied children within other cultural systems to ask if that diagnosis exists within their own cultural settings. Perhaps there are ways of managing and educating children in which the ADHD diagnosis does not arrive or it is much attenuated. We don’t know because we don’t ask these questions. They are culturally prohibited and not funded by research grants. Parenthetically, a friend of ours is a

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high school principal in Alaska with a large indigenous proportion of students. He began to take as many as possible of his students who were diagnosed with ADHD for a morning run before school. The number of medicated students dropped precipitously, and the children performed better academically. Unfortunately, he is a principal and not a researcher and will probably never publish his data so no one will know. Nevertheless, within an indigenous knowledge framework, we can report the experiences of others that have value. Social Determinants of Mental Health. Conventional services typically do not address these factors, despite their importance for mental health. These include housing, employment, recreation, and social meaning, and purpose. Studies exist in these areas. For example, a meta-analysis of 12 studies determined that installing swimming pools in remote communities had a variety of benefits and surprisingly reduced severity and incidence of skin infections, though the data on the incidence of eye and ear infections was mixed (though certainly not increased) (Hendrickx et al. 2016). Around the world, health services typically ignore the social determinants of health, to the detriment of the populations concerned (Raphael 2012). Respect for Local Knowledge. Crucial for successful development of mental health services for rural and remote indigenous people is respect for local knowledge and the awareness that these knowledge systems are rooted in local or regional culture and ecology, a social context, and an economy (Antweiler 1998). He notes that “the broad use of local knowledge in its entirety seems to be the adequate approach to the needs and requirements of local communities and indigenous peoples (p. 469).” As important as this is for health, contemporary “evidence-based” practices impose externally developed solutions onto people who may not value these solutions or exist in a social-ecological context sufficiently similar to where the studies behind these practices were developed to be applicable. Cernea (1991) writes about the slogan “Putting People First,” which encompasses taking into account the local environment, participation in the development of measures, harnessing existing local technical solutions, local capacity and institution building, and efforts to make visible and articulate for the first-time problems experienced by indigenous communities, women, and other disadvantaged social groups. These ideas are important for all aspects of health-care delivery but especially for mental health, an area in which the very definition of what it means to be mentally healthy may differ greatly from what it means in the dominant culture. For example, within Lakota culture, mental health would emphasize harmonious social and environmental relationships, whereas the dominant culture would have concepts that are more individualistic such as personal happiness or self-esteem. The approaches most closely aligned with making local knowledge available and applicable promote local self-reliance and decision-making. These involve local people setting their own objectives, implementing the measures themselves on the basis of their own view of and approaches to solving problems, and evaluating the results themselves. Rarely does this happen in mental health service delivery in the areas we have studied, including Canada, the United States, and Australia, though more often in New Zealand.

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Mental health services should respectfully define in collaboration with local knowledge experts the extent to which external knowledge (and information) needs to be introduced and integrated into local knowledge systems as a constructive contribution. Local knowledge is the knowledge which the people themselves possess and which is subject to little extraneous influence. It can therefore contribute to measures, which begin where people are, instead of where others want them to be (Marsden 1994, p. 46). Local knowledge is eminently appropriate to the alternative empowerment approach to development. This approach places emphasis on autonomy in the decision-making of self-organized communities, local self-reliance (but not anarchy), direct participatory democracy, and experiential social learning. Its starting point is the locality, because civil society is most readily mobilized around local issues (Friedmann 1992, pp. vii–viii). Local knowledge refers to a dynamic process of acquisition and integration of contemporary information and experience. Deteriorating social structures no longer allow (social and financial) investments into the community but force its members to seek individual survival. Increasing individualism in local communities causes social disruption and prohibits social negotiation on local affairs, the dissemination of knowledge, and local training. To the extent that knowledge gained through oral traditions and experience is no longer systemically used, we encounter a “fragmented” local knowledge system (Mersmann 1993). Knowledge on specific processes includes the knowledge on the precise sequence of steps within processes, e.g., in rituals or ceremonies. In this connection, there exist stereotypical, idealized process models. Normal human beings, like stage performers, follow a sequence of schematically prescribed steps, which have therefore come to be termed “scripts” (Schank and Abelson 1977). Knowledge of these local scripts goes a long way in providing optimal mental health care. Transformation of Conventional Services. The traditions of most indigenous people include an understanding that individual health is achieved as a result of improving the social, emotional, and cultural well-being of the entire community in which that person lives (National Aboriginal Health Strategy Working Party 1989). To produce effective mental health services for aboriginal people, all these areas must be addressed and for the entire community. An example of a community development effort that is promoting health and wellness separately and independently from medicine is the Thunder Valley Development Corporation in Porcupine, South Dakota, on the Pine Ridge Lakota Reservation (Thunder Valley Community Development Corporation 2016). The Thunder Valley effort integrates the creation of housing, with the production of food, with education, with the development of language fluency, with job creation and the promotion of business development, with youth programming, and with community support. They state their intention as “Intentionally disrupting the status quo by creating models of change that will overpower intergenerational poverty and build momentum towards regional equity.” They further state, “Change happens when a group of young people come together and take responsibility for creating the changes they wish to see. It happens when a group of people are committed to creating opportunities and addressing the root causes of systemic injustice. Change is possible when the narrative of poverty and

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hopelessness of a place is changed to opportunity, possibility, and action. To address the systems in place that leave people in poverty, it is essential to create healthy communities as a catalyst for disrupting these systems (http://www.thundervalley. org/change/).” To accomplish this, they are building houses alongside the people who will live in those houses in a habitat-for-humanity format, using only readily available materials. They are teaching kindergarten through grade 4 in the Lakota language to produce fluent children. They are encouraging entrepreneurship by community dwellers that create jobs for other community dwellers. We suspect that this type of internal development is the most viable model for rural and remote communities. Through using local, affordable building materials, and through encouraging entrepreneurship involving community members as employees, one can imagine overcoming some or many of the social determinants of poor mental health more effectively than providing telepsychiatry services or more medications. The kind of grassroots, peer-peer counseling that can happen in an environment like this will probably be more effective than organized, hierarchical, and professional services for mental health.

Strategies for Moving Forward 1. Use of the Internet and Telemedicine for Service Delivery. Research is being conducted on the use of Internet-based services for rural and remote settings. Electronic mental health approaches provide treatment and support to people with mental health concerns through telephone, mobile phone, computer, and online applications and range from the provision of health information, peer support services, virtual applications, and games through to real-time interaction with practitioners. They may be client-driven and practitioner-supported or involve a combination of support and self-driven use. There is growing evidence for their efficacy and cost-effectiveness (Monnier et al. 2003; Hedman et al. 2012). Electronic mental health (e-mental health) interventions could offer effective, accessible, and cost-effective treatment and support for mental illness and wellbeing concerns (Puszka et al. 2016). However, e-mental health approaches have not been well utilized by health services to date, and little is known about their implementation in practice, particularly in diverse contexts and communities. Over a decade ago, Whitfield and Williams determined that the greatest obstacles to the utilization of e-mental health were a deficiency in skills among clinicians, uncertain guidelines for utilization, and negative evaluations of e-mental health including confidentiality issues, lack of confidence in utilization, and the belief that e-mental health was inferior to face-to-face therapy (Whitfield and Williams 2004). A more contemporary review of the use of electronic technology in youth health services found that a deficiency of time, resources, information technology (IT) skills among staff, and technical problems were the largest obstacles, while beliefs about the inferiority e-mental health among staff and patients had vanished (Montague et al. 2014).

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A systematic review of e-mental health use by Australian consumers and practitioners noted increasing therapist support for its use, related to convenience, ease of integration into existing care, and cultural appropriateness (Meurk et al. 2016). Obstacles included the lack of awareness of the existence of e-mental health and a lack of e-mental health training for clinicians. Some variables acted as both facilitators and obstacles across studies, including a belief that e-mental health fostered anonymity, stigmatization of seeking help, gender, rural residence, confidentiality considerations, and preferences for self-help. Qualitative interviews were conducted with 32 managers, directors, chief executive officers (CEOs), and senior practitioners of mental health, well-being, alcohol, and other drug and chronic disease services in rural and remote Australia (Puszka et al. 2016). The researchers noted that the implementation of e-mental health approaches in this context is influenced by practitioner skill and knowledge, client characteristics, communication barriers, and factors related to culturally appropriate design. They concluded that significant potential exists for e-mental health approaches to address mental illness and poor social and emotional well-being among indigenous people and to advance their quality of care. They found that health service stakeholders reported that e-mental health interventions are likely to be most effective “when used to support or extend existing health services, including elements of client-driven and practitioner-supported use.” Potential solutions to obstacles for integration of e-mental health approaches into practice were proposed including practitioner training, appropriate tool design using a consultative approach, and organizational and government investment. 2. Group Medical Care. Stevens et al. (2016) proposed shared medical appointments (SMA) as “a culturally competent and appropriate way of improving access to, and the quality of, primary health-care services for Aboriginal and Torres Strait Islander peoples” (p. 425). They delivered three SMA sessions at an aboriginal men’s health centre in northern New South Wales. Aboriginal men were unanimously positive about SMAs with the numbers in the group increasing over time. “Patients most enjoyed the ‘yarn up’ nature of SMAs with peer support, which reduced the ‘scary’ and culturally ‘unnatural’ nature of one-onone consultations with a general practitioner (GP)” (p. 426). We used SMAs as a culturally syntonic way of addressing opiate use, which is a significant problem for rural and remote areas of the United States and Canada. Opiates are no longer considered the best strategy for the long-term management of chronic pain. Yet, physicians have made many patients dependent on them, and these patients still request treatment (Chou et al. 2015). We (Mehl-Madrona et al. 2016) showed that a significant reduction in opiate use could be achieved through SMAs in a rural setting. These visits were organized around the use of the indigenous format of the talking circle. They were designed to be as nonhierarchical as possible as well as nonjudgmental and accepting. In these visits we provided education about nonpharmacological methods for pain management and taught mindfulness

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techniques, movement, guided imagery, relaxation training, yoga, qigong, and tai chi. Forty-two patients attending SMAs for at least 6 months were matched prospectively with patients receiving conventional care. None of our SMA patients increased their dose of opiates. Seventeen people reduced their dose, and seven people stopped opiates. On a 10-point scale of pain intensity, reductions in pain ratings achieved statistical significance ( p ¼ 0.001). The average reduction was 0.19 (95% confidence interval [CI] 0.12–0.60; p ¼ 0.01). The primary symptom improved on average by 0.42 (95% CI 0.31 to 0.93; p ¼ 0.02) on the My Medical Outcome Profile, second version (Mehl-Madrona et al. 2016). Improvement in the quality-of-life rating was statistically significant ( p ¼ 0.007) with a change of 1.42 (95% CI ¼ 0.59 to 1.62). In conventional care, no patients reduced their opiate use, and 48.5% increased their dose over the 2 years of the project. We concluded that SMAs that incorporated complementary and alternative medicine (CAM) therapies helped patients reduce opiate use. Patients who persisted in attending this group environment of respect and acceptance significantly reduced opiate consumption compared with patients in conventional care. 3. Inclusion of Spirituality in Health Care. Traditional cultural healers, to various degrees, blend traditional healing practices with those of the dominant religion in the region (Huber and Sandstrom 2001). They practice more or less openly and more or less in conjunction with science-based health professionals. Many of these practitioners believe that they work largely through spiritual means. We (Mainguy et al. 2012) explored the narratives produced through interviews and writings of people who worked with traditional aboriginal healers in Canada (Alberta, Saskatchewan, and Manitoba) to assess the degree of spiritual transformation and to determine whether a relationship might exist between that transformation and subsequent changes in medical outcome. We interviewed 150 participants within a narrative inquiry framework to obtain the stories about their lives, their experiences of working with traditional healers, and the changes that the interactions produced. The healers used methods derived from their specific cultural traditions, though all commonly used storytelling. These methods included traditional ceremonies. We used a combination of grounded theory modified from a critical constructivist point of view and narrative analysis to rate the degree of spiritual transformation experienced. Medical outcome was measured by a five-point Likert scale and was confirmed with medical practitioners and other family members. A 5-year follow-up revealed that 44 of the reports were assessed as showing profound levels of persistent spiritual transformation, defined as a sudden and powerful improvement in the spiritual dimension of their lives (Mainguy et al. 2012). The level of spiritual transformation achieved through interaction with healers was associated in a dose-response relationship with subsequent improvement in medical illness in 134 of 155 people ( p < 0.0001).

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We concluded that the degree and intensity of spiritual transformation appeared related to the degree of physical and psychological change among people interacting with traditional North American indigenous healers. Conventional medical services provided for indigenous people sometimes discourage involvement with traditional healers and, more often, operate as if those healers did not exist. This can alienate indigenous patients. Improved services for rural and remote areas can improve care through working collaboratively with traditional cultural healers. 4. The Importance of Indigenous Language for Health. Maintaining and revitalizing indigenous languages results in health benefits for North American aboriginal people and others (Whalen et al. 2016). Forced loss of language has been a fact of life for most indigenous communities since the first European contact. The speed of that loss has increased in the last 50 years. In Canada, a simple variable measuring the knowledge community members have of their own native language had greater predictive power for community suicide rates than six other cultural continuity factors identified in previous research. Youth suicide rates effectively dropped to zero in those communities in which at least half of the tribal members reported a conversational knowledge of their own native language (Hallett et al. 2007). In the rest of Canada, communities where there is a strong sense of culture, community ownership, and other protective factors, have lower rates of suicide and sometimes none at all (Pan American Health Organization 2001). These cultural continuity factors included: selfgovernment; land control; control over education, police, fire services, and health services; and control of cultural activities (Anderson et al. 2006; Frohlich et al. 2006). The usual risk factors for suicide consist of depression and other mental illnesses, alcohol and drug dependency, hopelessness, low self-esteem, sexual abuse and violence, parental loss, and homelessness (U.S. Commission on Civil Rights 2004). High language knowledge bands averaged 13.00 suicides per 100,000 (well below the provincial averages for both aboriginal and non-aboriginal youth), while those with lower language knowledge had more than six times the number of suicides (96.59 per 100,000) (Hallett et al. 2007).“These differential rates reflect the fact that, between 1987 and 1992, only one youth committed suicide from within those 16 bands that had the language factor while, from the remaining 136 bands, 84 youth committed suicide during this same 6-year period” (p. 396). 5. Cultural Continuity and Health. A review of studies on culture and health shows a connection between cultural continuity and health and well-being (Sotero 2006; Auger 2016). In Canada, aboriginal “bands” that lack control over the delivery of health, education, child protection, and policing services, and have not achieved a degree of self-governance, have not secured access to traditional lands, and have not constructed facilities for preserving cultural artifacts and traditions, regularly experience heightened rates of youth suicide and early school leaving (Chandler and Lalonde 1998; Chandler et al. 2003; Hallett 2005). Chandler and Lalonde (1998) write:

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However constitutive self-continuity may be for our ordinary adult conceptions of persons, children, it would appear, are not born into the world with their own especially high-minded understanding of how such arguments in favor of selfcontinuity are meant to work. Rather, they tend instead to proceed only gradually and fitfully toward the first one and then another increasingly mature way of warranting their own continuous identity. En route toward the construction of some acceptably grown-up way of thinking about personal persistence, children and youth regularly abandon the outgrown skins of their own still earlier ways of finding sameness within change and so, until newly refitted with some nextgeneration means of connecting the future to the past, are often temporarily left without a proper sense of care and concern for the person they are otherwise in the process of becoming. Under such transitional circumstances, when self-continuity has temporarily gone missing, suicide newly becomes a “live option” for the reason that the dead person in question would scarcely count as them. Brussoni et al. (2015) studied predictors of injury-related hospitalizations in British Columbian aboriginal communities (thanks to a superior province-wide database). The community standardized relative risks (SRR) of injury hospitalizations varied widely from 0.24 to 9.35. Variables associated with increased SSRs included crowded housing, poor housing conditions, participating in industries with greater risk of a work injury claim, being more remote and being at higher latitude. Higher-income and more high school graduates were protective. In the best-fitting multivariable model, variables independently associated with SRR were the proportion of the population with a high school certificate (relative risk (RR) ¼ 0.89 per unit standard deviation change, 95% confidence interval (CI) of 0.83 to 0.94), and remoteness index (RR ¼ 1.06, 95% CI of 1.01 to 1.11). The authors promote the potential importance of education for reducing injury-related hospitalizations in remote communities.

Practice Implications 1. Inclusion of Traditional Cultural Healers in Health Care. Freeman et al. (2016) reported on the impact of Oglala Lakota Sioux’s traditional healing on family functioning and youth resiliency in situations inclusive of trauma, abuse, and/or violence. They studied 27 families in their quantitative sample and 8 families in their qualitative sample. Involvement with traditional healing and cultural practices, as well as the promotion of cultural identity, had statistically significant positive effects on perceived familial and individual functioning of Lakota youth and their families. Effect sizes indicated that the results had strong practical significance. First Nations and Inuit youth who abuse solvents are one of the most highly stigmatized substance-abusing groups in Canada (Dell et al. 2011). Most come from rural and remote regions. Dell et al. showed that treatment grounded in a culture-based model of resiliency in comparison to psychiatry’s individualized

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approach to treating mental disorders is more effective. They conducted a systematic review of articles published in The Canadian Journal of Psychiatry during the preceding decade, augmented with a review of Canadian and international literature, and revealed gaps in understanding and practice between Western psychiatric disorder-based and aboriginal culture-based approaches to treatment and healing from substance abuse and mental disorders. Aboriginal worldviews focus on connection to self, community, and political context. They highlighted the difficulties of frontline aboriginal health workers even for as simple a technique as storytelling interfacing with conventional psychiatry. They emphasized the importance of culture in the treatment of aboriginal youth who abuse substances. We (Dell et al. 2011) studied the use of culture for aboriginal solvent abusers, one of the most stigmatized groups in Canada today. Culture-based models that build resilience are more effective than psychiatry’s conventional individualized treatment approach. Aboriginal worldviews focus on connection to self and community in a political context. Storytelling is a predominant therapeutic modality. We commented on the great need to educate frontline psychiatrists, doctors, nurses, psychotherapists, and counselors in aboriginal ways of thinking and seeing the world to reduce the friction between aboriginal patients and health workers and non-aboriginal healthcare providers. We (Mehl-Madrona 1999) wrote about a process of developing shared care with rural and remote traditional, aboriginal healers and what happened to 116 people who engaged in that style of care. The shared belief was that any illness, including what conventional medicine sees as uniquely physical, can be addressed through counseling, prayer, and ceremony. People left their usual environment to spend 7 to 10 days in a rural, remote area with the traditional healers. We proposed this as a model for health tourism to bring income into rural and remote areas, though a segment of political activists criticized us for promoting the sharing of aboriginal culture and healing practice with anyone who wanted to come. They believed these practices should remain hidden and only available to full-fledged community members. We were even listed on a website called “plastic shamans” for making such a proposal. 2. Building Self-Continuity. Chandler and Lalonde (1998) explored the sense of self-continuity as a protective factor against suicide. They propose that implicit in the nature of selfhood is the idea that one is continuous in time and can project oneself into the future. When profound personal and cultural change stops one from being able to imagine oneself in the future, one is put at special risk for suicide because it is our future commitments that guarantee appropriate care and concern for our own well-being. They propose that adolescents and young adults are at special risk because they are already living through their own moments of dramatic biological and psychosocial change. They propose that a sense of cultural continuity in communities can mitigate the effects of this dramatic change by providing a kind of scaffolding to support young people to develop a better sense of self-continuity. Across British Columbia’s nearly 200 aboriginal communities, some communities have suicide rates 800 times Canada’s national

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average, while, in others, suicide is virtually unknown. These variable incidence rates are strongly associated with the degree to which British Columbia’s 196 bands are engaged in community practices that indicate a collective effort to preserve cultural continuity. Communities that have taken active steps to preserve and rehabilitate their own cultures are those in which youth suicide rates are dramatically lower. They believe that any threat to the persistence of personal or cultural identity poses a counterpart threat to individual or community well-being (Hallett et al. 2007). In support of this idea, Mehl-Madrona (2016) collected life stories from 54 aboriginal suicide attempters in northern Saskatchewan, using constant comparison techniques and modified grounded theory to identify the common themes expressed. He found three common plots/themes that preceded suicide attempts: (1) relationship breakup, usually sudden, unanticipated, involving a third person; (2) being publicly humiliated by another person(s), accompanied by high levels of shame; and (3) high levels of unremitting, chronic life stress (including poverty) with relative isolation. He found five common purposes for suicide attempts: (1) to “show” someone how badly they had hurt the attempter; (2) to stop the pain; (3) to save face in a difficult social situation; (4) to get revenge; and (5) don’t know/don’t remember/made sense at the time, all stated by people who were under the influence of alcohol and/or drugs at the time of their suicide attempt. He found five common beliefs about death: (1) you just cease to exist, and everything just disappears; (2) you go into the spirit world and can see and hear everything that is happening in this world; (3) you go to heaven or hell; (4) you go to a better place; and (5) you don’t know/didn’t think about it. He concluded that the idea of personal and cultural continuity is essential to understanding suicide among First Nations youth. Interventions targeted to the individual’s beliefs about death and purpose for suicide and consistent with the life story (plot) in which they find themselves are more successful than one-size-fits-all programs developed outside of aboriginal communities. In as yet unpublished work, we present our work with aboriginal suicide attempters in Canada that reduced or eliminated future attempts by creating a sense of personal continuity – that the person’s consciousness extended irreducibly into the future. How do humanity help people build a sense that they, as an entity, will persist in time, when their culture is on the verge of extinction? Habermas (1991) writes that the sense of personal continuity is not just an elective feature of the self but actually brings it into being, implying that human beings need personal continuity to feel like a person. We would suggest humans can feel like a person without the sense of personal continuity only if they are embedded in a larger community with a strong sense of continuity and they feel like a component of that larger entity. Humans need to either feel that they will persist or that the larger entity of which they are a part will persist, perhaps related to their efforts within it. Lifton (1974) points out that selfcontinuity may not always be an ordinary part of one’s moment-by-moment conscious awareness, but such convictions do appear to underlie and support the tone and quality of one’s self-awareness. We would suggest that humans maintain a story about themselves that has continuity and a plausible trajectory from past to present to

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the anticipated future. Communities support that continuity narrative by helping their members fill the gaps. Without human embeddedness in the community, the gaps become too great to ignore, and people begin to feel fragmented. Continuity breaks down. Chandler and Lalonde (1998) studied how young people reacted to the presentation of apparent disjunctures in their self-presentations. They quickly came forward with what they understood to be good reasons for why evident changes could be discounted in ways that left untouched what they saw to be the underlying continuity of their lives. Middle school children, for example, believed themselves to be selfsame because of the simple existence of one or more personal attributes (e.g., same name, same fingerprints, etc.) that were thought to stand apart from time. Older adolescents, by contrast, more often found commonalties either (a) by hypothesizing underpinning genotypic personality characteristics thought to be capable of bridging the merely phenotypic changes they judged to have taken place in their more outward appearances or (b) by seeing functional relations thought to make their own pasts the “causes” of which their present identities were the “effect.” 3. Use of Peer Counselors, Peer Support, and Mentoring. Mohajer et al. (2009) interviewed 99 aboriginal adolescents who were between 12 and 18 years of age at three rural Australian sites between 2006 and 2008: two were aboriginalcontrolled communities and one was a rural town. Alcohol, drugs, and violence were their greatest problems along with boredom. Racism and bullying interfered with their attending school. Their most important supports were members of their families. They strongly liked sports and were proud to be aboriginal though most had no future plans or ambitions. They wanted a “safe and fun” place to go to in the evenings. The authors noted: “Mentorship and peer-support programs are more effective than health professionals and agencies in working with youth. The expertise of those traditionally working with youth could be channelled into coordinating a mentorship program. Personal wellbeing and safety is an important issue and multipurpose youth centres may provide a secure place for adolescents to learn, interact and develop a vision for their futures.” This was also our observation in rural and remote communities in Saskatchewan – most lacked a community centre. Life occurred in people’s homes that were overcrowded and not conducive to age-specific interaction. Mentoring programs were largely nonexistent. In separate research, we (Behler et al. 2015) showed that peer support groups and peer counseling provided something of importance to people with affective disorders that was not available from their families or from their health professionals. In one study we showed how the implementation of healing and talking circles in the community clinic’s waiting room after hours using local elders was more effective than conventional psychotherapy in relieving emotional distress (MehlMadrona and Mainguy 2014). The talking circle is an indigenous, North American practice for communication and dispute resolution. It is now also being used for restorative justice. In this procedure, a group convenes for a purpose or meets

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regularly for that purpose, in this case, to reduce the distress and resolve problems for its members. The convener of the meeting poses a question or presents a problem to the group. A ceremonial object, usually a decorated staff or talking stick, is passed around the circle. Each person speaks in turn, and no one speaks when they do not hold the staff. Additionally, each person who is not speaking sits silently and respectfully without making sounds and without facial micro-expressions. The stick continues around the circle until all have spoken as much as they wish or, in modern times, until time has ended that has been allotted to the circle. The experience of being in a circle is profoundly being heard and acknowledged that rarely happens elsewhere. 4. Cultivating Resilience. Our work has supported the importance of cultivating resilience, as has others. Resilience is a positive adaptation despite adversity. Much of what seems to promote resilience originates outside of the individual. Resilience is a feature of entire communities and cultural groups. Resilience is a process. Three main types are hypothesized: “compensatory;” “protective;” and “challenge” models (Fleming and Ledogar 2008). Two additional concepts are resilient reintegration, in which a confrontation with adversity leads individuals to a new level of growth, and the notion endorsed by some aboriginal educators that resilience is an innate quality that needs only to be properly awakened. If they are to thrive, both individual young persons and whole cultural communities must succeed in warranting a sense of continuity, or persistent identity, in a rapidly changing world (Chandler et al. 2003). 5. Large Group Interventions. Mehl-Madrona (2007, Chap. 5) presents two stories of large group healings in rural and remote reservation settings in Saskatchewan, Canada. He notes that these types of larger group/community interventions are actually easier to accomplish in rural and remote settings than they would be in larger, urban settings, because of the close-knit nature of rural and remote communities and the existence of large, extended families. Large group interventions, however, are difficult to render evidence-based, for how would one do a randomized, double-blind controlled trial when everyone in the community is aware of the intervention. And, what would the control condition be? To ignore the identified patient? Or treatment as usual without community involvement? These types of considerations form part of the critique of what is currently being called evidence-based medicine related to the privileging the double-blinded, randomized controlled trial (DBRCT) as superior to all other types of evidence. The politics of evidence-based medicine assigns greater weight to drug studies, for they are most amenable to the DBRCT methodology. That, however, is another topic beyond the scope of this paper: [Alfred was] a lonely man who had been arrested for threatening a social worker with an axe. . .. No charges were pressed and we were called to evaluate him. We saw him in his home. . .. Alfred recounted amazing [spiritual] visions in between paroxysms of a raspy and repetitive smoker’s cough. He primarily trapped and fished out in the bush and described beavers standing up on top of their houses in the middle of ponds to tell

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L. Mehl-Madrona and B. Mainguy him about the second coming of Christ. He pointed out stains on the walls of his cabin that he interpreted as signs of the Virgin Mary’s visitations. . ... An immediate intervention was to call everyone together who knew Alfred. . .. [H]e had a large family and many contacts in the community. Twenty-five people came to that first meeting. Everyone liked him on some level, but not everyone trusted him. He was known to use drugs on occasion and to manipulate people into buying him plane tickets to where he wanted to go, ostensibly for mental health treatment. When he got there, he would check out after one day, and do what he wanted. . .. We developed a story with which everyone could agree. Alfred’s brain had been frozen from sleeping out on the snow for too long. He needed help thawing his brain. Medication could help. . .. On the other hand, his experience in the bush had caused a spiritual awakening that could be inspirational for everyone. We found some young men who would volunteer to spend time with Alfred, to write down his visions, and to return to read them back to him so that he could confirm the accuracy or make changes. . ..The young people were enthusiastic about this, especially since we had negotiated with the tribe to pay them for this effort. Alfred was lonely and isolated. His psychotic symptoms brought him attention and notoriety in the community, which was preferable to being alone. It cost less to provide him with attention than to ship him to the psychiatric hospital. His relatives helped care for him. . .. Alfred settled down and stopped causing trouble for social workers. He usually had a smile on his face. He still disappeared at times into the bush, but always came back with new visions and fish and meat for everyone. We reduced Alfred’s psychotic symptoms by helping his community make his actual life more interesting than his psychotic life. Also, the community created a narrative for him as a visionary hunter. He liked this story. It gave him meaning and purpose. . ..

Juha Holma and Jukka Aaltonen advocated interventions such as this in what was called the Finnish Integrated Approach to the Treatment of Acute Psychosis (Holma and Aaltonen 1997, 1998). Interestingly, this Finnish approach started in a rural area in northern Finland, a 7-hour drive from the nearest psychiatric inpatient facility. It was an area of a large indigenous population. This approach has become renamed as “Open Dialogue” and is being taught around the globe by its original Finnish inventors and those they have trained. However, it is simply what we have described. One gathers the community (all who will come) around the identified patient to gather all the available and circulating stories about what is happening and eventually helps to shift those stories toward one in which the patient has more agency and behaves in a manner that moves toward recovery. Indigenous people have been engaged in similar processes for years.

Distinctive Features 1. Engaging in circle processes seems helpful throughout the indigenous world. We described the North American talking circle and Holma’s and Aaltonen’s open dialogue process. Communication around circles removes the hierarchical elements of communication, equalizes power imbalances, and overcomes cultural restrictions on direct communication by directing all communication to the centre of the circle.

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2. Community-based, participatory action methods are preferred to top-down expert opinion, hierarchical approaches.

Concluding Comments and Recommendations The world’s indigenous peoples are disadvantaged in terms of mental health, largely in relation to factors related to the social determinants of health – poverty, lack of adequate housing, lack of educational opportunities, and unemployment. Being more rural and remote exacerbates these effects. Conventional health services are often organized in ways that discount or ignore local knowledge and practices, local culture, and asking communities what matters most to them. In fact, optimal mental health services are developed by communities themselves with external “experts” as participatory and respectful consultants who do not dictate terms and impose on communities what will be but assist communities to move in directions deemed important by the community. Culture matters and is medicine. Communities who speak their language have much lower rates of suicide than the national average for all people. Communities who have lost their language have much higher suicide rates than the national average. Successful interventions include those that involve elders, use talking circles, provide group medical care that acknowledges spirituality, and respect local knowledge. This can be hard for conventional medical practitioners and organizers of services who believe that they know best and attempt to place evidence-based medicine upon people who may not have the same definitions of mental health and values for a good life and may not agree on the same definitions of what constitutes evidence.

Take-Home Messages • Explanatory pluralism is essential for effective collaborative practice with indigenous people in rural and remote regions. • Traditional healers and culture-carrying elders should be integrated into mental health services as equal partners. • Psychotherapeutic techniques utilized should be more bottom-up and egalitarian than top-down and hierarchical. Indigenous friendly approaches include narrative therapy, solution-focused therapy, and family and system therapy. More top-down approaches, such as cognitive behavioral therapy, must be modified to be acceptable. • Peer counseling, talking circles, and indigenous listening practices and storytelling should be integrated into mental health services. • Respect for local knowledge, elders, and practitioners, in an inclusive, collaborative way, is crucial for improving health services and outcomes. • Understanding that the community is the unit of study instead of the individual and involving the community and family in helping the identified patient can be quite effective.

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Case Studies

1. Healing Circle. Mehl-Madrona and Mainguy (2014) wrote about introducing talking circles into rural and remote health centres in Saskatchewan. The Talking Circle is a North American aboriginal process in which a group convenes in a circle. The convener announces the purpose of the circle and says a prayer. A decorated stick (the talking stick) is passed around the circle. The person holding the stick talks as long as desired without any interruption or acknowledgment or response from the other members of the circle. The circle passes clockwise, and each person can only respond to what has been said when he or she holds the stick. MehlMadrona and Mainguy found that the effect size for reducing primary problems was large and that talking circles were more effective than seeing the doctor for mental health problems. Here is a story about one woman’s involvement in a talking circle. These circles were conducted by community elders in the clinic waiting room after hours and were free of charge. Mary was part of a healing circle. She suffered from debilitating back pain and was unable to work due to her many absences. She also experienced severe depression, which she believed to be due to her chronic pain and its complete control of her life. Mary joined the talking circle that was happening in the clinic’s waiting room after closing. During her first circle, she talked about her pain incessantly each time the stick came to her. During her second circle, she talked about her sadness, misery, and unhappiness. By the third circle, she talked about her boyfriend and how he didn’t want to have children and she did. During her fourth circle, she talked about having been raped 7 years earlier. When the stick came to him, another member of the circle wondered about possible connections between rape and back pain. Others echoed similar wonder. When the stick returned to Mary, she expressed confusion. How could being raped cause chronic back pain? She said she had even asked her gynecologist who had dismissed the idea as nonsense. The next speaker suggested that doctors didn’t know everything about the causes of health and disease. During the fifth circle, the group reached a consensus to help Mary heal from her pain and trauma. During the sixth circle, Mary talked about her father beating her and sexually molesting her. She talked about how frightened she had been when her parents drank and she had to hide. During her seventh circle, Mary talked more about her father beating her mother so badly she went to the hospital. Eventually he crossed the line and hurt her mother so badly that he went to jail. Then Mary and her siblings went to other relatives who drank heavily, and things were just as bad. During the ninth circle, the elder offered to conduct a formal prayer ceremony for Mary. This was organized outside the circle. After the singing, drumming, sage, prayer, and pipe (continued)

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ceremony, Mary felt transformed. She continued to come to the talking circle but no longer needed to be the focus of the group’s attention. Over the course of the next year, she left her boyfriend and stopped having pain. Her depression lifted. She eventually began dating a man who wanted children and reported that she was having her first non-abusive relationship, to which everyone cheered. 2. Working with Story. Mehl-Madrona (2010) has written about the use of story in healing by aboriginal elders. Here is an example of the use of a story for healing. The context was one in which LMM provided distance “supervision” for peer counselors on a reserve. He visited there once per month. Rowen was deeply tortured by his voices. He invented ritual after ritual to make them go away, but they never did. They told him terrible things – that he had killed his younger sister, that he was going to burn in hell, and the like. They commanded him to mutilate his body, to rob a bank, and to randomly kill someone. We used our approach of involving all appropriate members of his community in dialogue about his predicament and how to change things. As more family members appeared, we learned from Rowen’s sister that he was quite upset by her having been molested, though she wondered how he could have ever known, since even her mother didn’t know. Rowen was terrified that he would mutilate himself and asked us to handcuff him to the bed. We complied with toy handcuffs, which he found greatly comforting. We were teaching voice dialogue approaches which were highly compatible with local approaches already used by the elders and taught drama therapy techniques to help Rowen interact with his voices, identify them, and resist them. Rowen slowly improved and recovered. Using peer counselors, we had implemented what seemed to us to be a rather sophisticated individual, family, and community psychotherapy in a rural and remote location. The key to this was that nothing we did was out of context with an indigenous way of thinking. Involving the community, communicating with the voices in a way that gave them full ontological validity, and dramatic enactment were all in keeping with the traditional practices of the community. We visited the community monthly to continue training and supervision, which mostly consisted of validating how well the peer counselors were doing and encouraging them to continue to apply their local understanding and intuitive knowledge for how to help Rowen. 3. Rural and Remote Working with Story. We were providing a training and ongoing supervision for reservation-based rural and remote peer counselors. We were asked how to use a story with Rhonda, a 17-year-old woman who was half Cree and half Hawai’i and who had been diagnosed with early anorexia nervosa. Recently she had threatened suicide. That had to be addressed first. We participated in a session with her mother the day (continued)

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after the training. Rhonda’s mother began by wondering if Rhonda needed to be flown out of the community for hospitalization but wished for the opposite. In talking with Rhonda and her mother, we learned that Rhonda had been more severely anorexic in the past and had actually gained some weight taking herbs offered by one of the local elders. Rhonda thought this was mostly “bull” and was taking the herbs to please her mother. She believed that life was hopeless and just wanted to be dead. Strangely, she couldn’t kill herself until exams were over, because it would adversely affect her grades. We learned that she was a driven achiever. Doing less than perfect was unacceptable. As part of our ongoing supervision, we participated in some further sessions via telemedicine. LMM told her he was required to commit her to the psychiatric hospital if she couldn’t agree to postpone suicide for a specific period of time. At first, she refused, saying that going to the hospital was fine for her. He then told her stories about his experiences of working on psychiatric units and what they’re actually like. He gave her some consumer resources to read about people’s experiences of hospitalization, especially when it is involuntary. Her mother and the peer counselor had several stories to add. LMM continued to say that he respected her right to choose as she wished but worried about that choice based upon experience. As we neared the end of the meeting, Rhonda suddenly announced that she was willing to make a deal for 1 month. We negotiated a 1-month moratorium on suicide to see if Rhonda could find a reason to live. In the next session with Rhonda, LMM had suggested that the peer counselor tell her the story of Moki, the laughing gecko, and Bufo, the toad. Once upon a time, in the Hawaiian Islands, we find a young gecko named Moki. Moki was an ordinary gecko in every respect except for one thing – he had the loudest, most obnoxious laugh anyone had ever heard. Moki and his friend, owl, were constantly getting in trouble for their pranks, mostly because of the aftereffects of Moki’s laughter. “This story, like all these kinds of stories, takes place a long time ago, ‘cause that’s the way it is. The story occurs in the days of the great choosing when every noble family was to select an animal to be its totem of power, or amakua. A most serious and powerful ceremony would be taking place that evening, and Moki’s parents warned him to behave. They stressed upon him the importance of being serious and not laughing, not even once, lest he bring shame upon the gecko family. Moki solemnly agreed not to laugh, tell jokes, or pull any pranks. He would be the model of decorum, as would his partner in crime, owl. They resolved to be more serious than the serious, more perfect than the perfect, quieter than the quiet, the best [which is what we suspect Rhonda was trying to achieve – best student, best anorexic, most depressed of the depressed]. (continued)

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Night came and the conch shells blew to call the people and the animals to gather. All of the ali’i, or noble families were present, including the Greatest King of all the Islands. The most powerful kahuna of anywhere presided over this majestic event in which families came forward in accordance with their rank and stature and picked their power animal for all time. One by one the animals were chosen. Pomp and circumstance were preserved until Moki noticed the fattest man he had ever seen waddling forward to choose his family’s power animal. Oh, not us, he thought. You would crush us without noticing. That image made Moki think of a joke about a great big fat bufo toad. The more he tried not to think about it, the more it occupied his mind, until he told owl, and suddenly the two of them could contain themselves no more and they burst out laughing. The ceremony came to a screeching halt. Silence reigned except for their laughter. Soon they noticed that the drum had stopped, chanting was suspended, and all eyes glared at them. Moki’s laugh was the loudest and it was upon Moki that the kahuna focused his rage. The gecko family has dishonoured this solemn ceremony. They are to leave immediately. They will not be chosen by anyone.’ The kahuna folded his massive arms across his chest and towered above the geckos. Moki turned and ran into the jungle lest he be scorched by his father’s and mother’s rage. He wanted to die that night right there in the jungle, he was so embarrassed. [This captures the theme of wanting to die, perhaps offering her alternate solutions, perhaps showing her how silly that response is when done by someone else, especially an animal, like a laughing gecko.]. Moki ran and ran and ran. He ran so hard, and so far, that he had no idea where he was. He just wanted any creature to jump out of the jungle and eat him. He was so mortified he knew he could never go back. He could never face his parents or the other animals. He could never face the kahuna again or any of the ali’i. He might as well be dead. When he was so breathless and exhausted that he thought he would die right there on the trail, he suddenly heard a noise that did not belong to the jungle. ‘What’s that?’ he wondered. He listened closer and discovered a young human girl, crying. He followed the sound of her sobs into a clearing, finding her sitting alone, tears pouring down her cheeks. ‘Young girl,’ Moki said. ‘What’s wrong and why are you out here alone? It’s dangerous in the jungle at night.’ The little girl stood as tall as she could, acting as proud as a tearful young one can. ‘I’m the daughter of the Great Chief,’ she said. ‘Daddy wouldn’t let me come to the ceremony. He said I was too young and made me stay home. I was going to show him and come all by myself. But I’m lost and I can’t find it and now I don’t know where I am.’ Neither do I, thought Moki, who decided not to say that, since he had to be brave for the Princess. ‘Don’t worry, princess,’ he said. ‘I just came from the ceremony and I’ll figure out a way to get you back there.’ (continued)

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Just as Moki took her hand to lead her back the way he had come, a dark shadow fell upon them. He looked up to see a massive bufo toad, at least 200 kilos. Sores and warts covered its skin which oozed a slimy-looking substance. Worse, the toad stank. Its eyes were glowing coals inside a malevolent face. ‘Uh, hello, Mr. Toad,’ Moki said. ‘This is the Great Chief’s daughter, and I’m taking her back to the ceremony. You could come, too,’ he stammered. ‘No,’ said the Toad. I think I’ll stay here and take you both to dinner. You’ll be the appetizer and she can be the main course.’ ‘But what would the Great Chief say about that?’ Moki pleaded. “You don’t want to anger the Great Chief!’ ‘I’ll anger anyone I please,’ shouted the Great Toad, who was staring into Moki’s eyes, making Moki feel drowsy. Moki’s will was draining away. He found himself slowly walking toward the toad’s gaping mouth. ‘Moki, no,’ cried the Princess. ‘Don’t look in his eyes. He’s got you under his spell. Fight it, Moki. Fight it for my sake.’ [In parallel fashion, we wanted Rhonda to fight the seductive fascination of suicide or anorexia, both of which are like the toad’s eye in that they can just pull you into their spell.] Hard as he tried, Moki couldn’t break free. The toad’s eyes bore down upon his, forcing its will upon him. He was dangerously close to that gaping hole of a mouth, one bite away from annihilation, when suddenly he remembered the joke that had gotten him cast out of the choosing ceremony, and he started to laugh uncontrollably. This terribly ruffled the toad, since the first course wasn’t supposed to break out laughing. ‘What’s this about?’ demanded the toad. ‘Heh,’ said Moki. “Do you know where a 400 pound bufo toad sleeps at night?’ ‘Where,’ said the toad, puzzled. ‘Anywhere it wants,’ answered Moki, still giggling. The toad paused for a moment to consider this. Then slowly it began to laugh, its huge body shaking and quivering with each guffaw. Before long, the toad was laughing uncontrollably also. You’re ok, Moki,’ said the toad. ‘And I wasn’t really going to eat you.’ ‘Like heck you weren’t,’ thought Moki, but he wisely kept that to himself. ‘I’m really a nice guy,’ said the toad, ‘with a skin problem.’ ‘Help me take her back to the ceremony,’ said Moki, ‘and they’ll be lots to eat there.’ The toad agreed and together they sat off across the jungle, taking short cuts that the toad knew. When they reached the ceremonial grounds, they were the strangest sight of all – a little girl, a huge bufo, and a laughing gecko, for Moki had kept telling jokes to keep the toad in the best of moods. ‘Stop,’ cried the guards with their spears ready. ‘No,’ called the Princess. ‘Let them pass. The bufo is my friend and the gecko saved my life.’ The guards recognized the princess and bowed before (continued)

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her. When her father saw her, he demanded to know how she had gotten there. Upon hearing the story, he welcomed the bufo to chow down, and he had more to say to Moki. ‘Little gecko,’ he said. ‘You have restored the honor of the gecko family. Unfortunately, all the power animals have been chosen, but one honor remains – to be the power animal for all the Islands. That I give to the gecko family. From now on, you are the amakua for these islands upon which we live. Moki was proud, so proud he could look his parents in the eye without wanting to die anymore. And they happily went home.’ The story got Rhonda’s attention. It had a lot of the necessary elements – wanting to die, wanting to be perfect, being embarrassed, encountering massive fat, eating and being eaten, etc. Also, it provided some levity to her situation. It’s not a terribly serious story in its own gecko/coyote way. Later we would joke about snacks to befit a 200-kilo toad and what to do with the hallucinogens found upon its skin. The work continued through the peer counselor and the local elder using stories, humor, talking circles, and ceremony. Though Rhonda rolled her eyes at the ceremony, she did participate. The work also had the effect of embedding her more into the community. She had felt estranged, being partHawai’ian, and having a father from “away.” The work was done almost entirely by people who would be considered non-professionals in the European-derived sense of that term, following a training program and with some internet-based supervision. The approach was collaborative, community-based and community-focused, narrative, and syntonic with the local culture.

References Anderson I, Crengle S, Kamaka ML. Indigenous health in Australia, New Zealand, and the Pacific. Lancet. 2006;367(9524):1775–85. Antweiler C. Local knowledge and local knowing. An anthropological analysis of contested “cultural products” in the context of development. Anthropos. 1998;93(4/6):469–94. Auger MD. Cultural continuity as a determinant of indigenous peoples’ health: a Metasynthesis of qualitative research in Canada and the United States. Int Indigenous Policy J. 2016;7(4):3. Australian Bureau of Statistics. National aboriginal and Torres Strait islander social survey, 2008. Canberra: Australian Bureau of Statistics; 2009. Behler J, Scott J, Mehl-Madrona L. Qualitative exploration of peer-group and peer-counseling for people with affective disorders. The Qualitative Report in press. 2015. Brussoni M, Jin A, George MA, Lalonde CE. Aboriginal community-level predictors of injuryrelated hospitalizations in British Columbia, Canada. Prev Sci. 2015;16(4):560–7. Canada Health. Acting on what we know: preventing youth suicide in First Nations. 2010. Retrieved 30 May, 2016, from http://www.hc-sc.gc.ca/fniah-spnia/pubs/promotion/_suicide/ prev_youth-jeunes/index-eng.php-tphp Carson B, Dunbar T, Chenhall R, Bailie R. Social determinants of indigenous health. Crows Nest: Allen and Unwin; 2007.

90

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Cernea MM. Putting people first: sociological variables in rural development. No. 9831. The World Bank. 1991. Chandler MJ, Lalonde C. Cultural continuity as a hedge against suicide in Canada’s first nations. J Transpers Psychol. 1998;35(2):191–219. Chandler MJ, Lalonde CE, Sokol BW, Hallett D. Personal persistence, identity development, and suicide: a study of native and non-native north American adolescents. Monogr Soc Res Child Dev. 2003;68(2):273–8. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health pathways to prevention workshop. Ann Intern Med. 2015;162(4):276–96. Commission, A. H. R. Social determinants and the health of Indigenous peoples in Australia— Ahuman rights based approach. 2007. Retrieved 7 November, 2016, from www.humanrights. gov.au/news/speeches/social-determinants-and-health-indigenous-peoples-australiahumanrights-based Dell CA, Seguin M, Hopkins C, Tempier R, Mehl-Madrona L, Dell D, Duncan R, Mosier K. From Benzos to Berries: treatment offered at an aboriginal youth solvent abuse treatment centre relays the importance of culture. Can J Psychiatr. 2011;56(2):75–83. Department of Health and Ageing. National aboriginal and Torres Strait Islander suicide prevention strategy. Canberra, 2013. 2013, Sept 6. Retrieved 24 December, 2016, from http://www.health. gov.au/internet/main/publishing.nsf/Content/mental-pub-atsi-suicide-prevention-strategy Duran B, Duran E, Brave Heart MYH. In: Thornton R, editor. The trauma of history. Studying native America: problems and perspectives. Madison: University of Wisconsin Press; 1998. p. 60–78. Fleming J, Ledogar RJ. Resilience, an evolving concept: a review of literature relevant to aboriginal research. Pimatisiwin. 2008;6(2):7. Freeman BJ, Coll KM, Two Dogs R, Iron Cloud Two Dogs E, Iron Cloud E, Robertson P. The value of Lakota traditional healing for youth resiliency and family functioning. J Aggress Maltreat Trauma. 2016;25(5):455–69. Frohlich KL, Ross N, Richmond C. Health disparities in Canada today: some evidence and a theoretical framework. Health Policy. 2006;79(2–3):132–43. Garvey D. Review of the social and emotional wellbeing of Indigenous Australian peoples: considerations, challenges and opportunities. 2008. [2016-02-09]. Retrieved 24 December, 2016, from http://www.healthinfonet.ecu.edu.au/other-health-conditions/mental-health/ reviews/our-review Goldsmith MF. First Americans face their latest challenge: Indian healthcare meets state medicaid reform. JAMA. 1996;275:1786. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374 (9683):65–75. Habermas J. The paradigm shift in Mead philosophy, social theory, and the thought of George Herbert Mead. M. Aboulafia. Albany: State University of New York Press; 1991. p. 138–68. Hallett D. Aboriginal identity development, language knowledge, and school attrition: an examination of cultural continuity. Unpublished doctoral dissertation. Vancouver: University of British Columbia; 2005. Hallett D, Chandler MJ, Lalonde CE. Aboriginal language knowledge and youth suicide. Cogn Dev. 2007;22(3):392–9. Hedman E, Ljótsson B, Lindefors N. Cognitive behavior therapy via the internet: a systematic review of applications, clinical efficacy and cost-effectiveness. Expert Rev Pharmacoecon Outcomes Res. 2012;12(6):745–64. Hendrickx D, Stephen A, Lehmann D, Silva D, Boelaert M, Carapetis J, Walker R. A systematic review of the evidence that swimming pools improve health and wellbeing in remote aboriginal communities in Australia. Aust N Z J Public Health. 2016;40(1):30–6. Holma J, Aaltonen J. The sense of agency and the search for a narrative in acute psychosis. Contemp Fam Ther. 1997;19(4):463–377.

4

Indigenous Mental Health in Remote Communities

91

Holma J, Aaltonen J. Narrative understandng in acute psychosis. Contemp Fam Ther. 1998;20 (3):253–63. Huber BR, Sandstrom AR. Mesoamerican healers. Austin: University of Texas Press; 2001. Hunter E. Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote indigenous Australians. Aust J Rural Health. 2007;15:88–93. Kazdin AE. Addressing the treatment gap: a key challenge for extending evidence-based psychosocial interventions. Behav Res Ther. 2017;88:7–18. Lifton R. Living and dying. New York City: Praeger; 1974. Linklater, R.. Decolonising Trauma Work: indigenous practitioners share stories and strategies. Winnipeg, Manitoba, Fernwood; 2014. Loh PR, Hayden G, Vicary D, Mancini V, Martin N, Piek JP. Australian aboriginal perspectives of attention deficit hyperactivity disorder. Aust N Z J Psychiatry. 2016;50(4):309–10. Mainguy B, Valenti PM, Mehl-Madrona L. Relationships between level of spiritual transformation and medical outcome. Adv Mind Body Med. 2012;27(1):4–11. Marsden T. Opening the boundaries of the rural experience: progressing critical tensions. Prog Hum Geog. 1994;18(4):523–531. Mehl-Madrona L. Native American medicine in the treatment of chronic illness. Altern Ther Health Med. 1999;5(1):36–44. Mehl-Madrona L. Narrative medicine: the use of history and story in the healing process. Rochester: Vermont, Bear & Company; 2007. Mehl-Madrona L. Narratives of exceptional survivors who work with aboriginal healers. J Altern Complement Med. 2008;14(5):1–12. Mehl-Madrona L. Healing the mind through the power of story: the promise of narrative psychiatry. Toronto: Bear & Company; 2010. Mehl-Madrona L. Indigenous knowledge approach to successful psychotherapies with aboriginal suicide attempters. Can J Psychiatr. 2016;61(11):696–9. Mehl-Madrona L, Mainguy B. Introducing healing circles and talking circles into primary care. Perm J. 2014;18(2):4. Mehl-Madrona L, Mainguy B, Plummer J. Integration of complementary and alternative medicine therapies into primary-care pain management for opiate reduction in a rural setting. J Altern Complement Med. 2016;22(8):621–6. Mersmann C. Environmental knowledge and land use in an African village: farmer commitment to the management of land in the Usambara Mountains of Tanzania. Environmental knowledge and land use in an African village: farmer commitment to the management of land in the Usambara Mountains of Tanzania. (1993). Meurk C, Leung J, Hall W, Head BW, Whiteford H. Establishing and governing e-mental health care in Australia: a systematic review of challenges and a call for policy-focused research. J Med Internet Res. 2016;18(1):e10. Mohajer N, Bessarab D, Earnest J. There should be more help out here! A qualitative study of the needs of aboriginal adolescents in rural Australia. Rural Remote Health. 2009;9(2):1–11. Monnier J, Knapp RG, Frueh BC. Recent advances in telepsychiatry: an updated review. Psychiatr Serv. 2003;54(12):1604–9. Montague AE, Varcin KJ, Parker AG. Putting technology into practice: evidence and opinions on integrating technology with youth health services. Melbourne: Young and Well Cooperative Research Centre; 2014. National Aboriginal Health Strategy Working Party. A national aboriginal health strategy. NAHSWP. Canberra: Government of Australia; 1989. Pan American Health Organization. Equity and health: views from the Pan American sanitary bureau. Washington, DC: Pan American Health Organization; 2001. Party, N. A. H. S. W. National aboriginal health strategy. Canberra: National Aboriginal Health Strategy Working Party; 1989. Purdie N, Dudgeon P, Walker R. Working together: aboriginal and Torres Strait islander mental health and wellbeing principles and practice. Canberra: Commonwealth of Australia; 2010.

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Puszka S, Dingwall KM, Sweet M, Nagel T. E-mental health innovations for aboriginal and Torres Strait islander Australians: a qualitative study of implementation needs in health services. JMIR Mental Health. 2016;3(3):e43. Rahaman Z, Holmes D, Chartrand L. An opportunity for healing and holistic care exploring the roles of health care providers working within northern Canadian aboriginal communities. J Holist Nurs. 2016; https://doi.org/10.1177/0898010116650773. Raphael D. Educating the Canadian public about the social determinants of health: the time for local public health action is now!. Glob Health Promo. 2012;19(3):54–59. Schank R, Abelson R. Scripts Plans Goals and Understanding: An Inquiry into Human Knowledge Structures. Hillside, NJ: Laurence Erlbaum Associates; 1977. Silburn S, Wubrick S, De Maio J, Shepherd C, Griffin J. The Western Australian Aboriginal Child Health Survey: Strengthening the Capacity of Aboriginal Children, Families and Communities. Perth, Western Australia, Curtin University of Technology and Telethon Institute for Child Health Research; 2006. Sotero MM. A conceptual model of historical trauma: implications for public health practice and research. J Health Dispar Res Pract. 2006;1(1):93–108. Stevens JA, Dixon J, Binns A, Morgan B, Richardson J, Egger G. Shared medical appointments for aboriginal and Torres Strait islander men. Aust Fam Physician. 2016;45(6):425–9. Thunder Valley Community Development Corporation. Thunder Valley Community Development Corporation. 2016. Retrieved 21 April, 2017, from http://www.thundervalley.org/ U.S. Commission on Civil Rights. Broken promises: evaluating the native American health care system. Washington, DC: U.S. Commission on Civil Rights; 2004. p. 1–155. Weetra D, Glover K, Buckskin M, Kit JA, Leane C, Mitchell A, Stuart-Butler D, Turner M, Yelland J, Gartland D. Stressful events, social health issues and psychological distress in aboriginal women having a baby in South Australia: implications for antenatal care. BMC Pregnancy Childbirth. 2016;16(1):1. Wexler L, Chandler M, Gone JP, Cwik M, Kirmayer LJ, LaFromboise T, Brockie T, O’Keefe V, Walkup J, Allen J. Advancing suicide prevention research with rural American Indian and Alaska native populations. Am J Public Health. 2015;105(5):891–9. Whalen D, Moss M, Baldwin D. Healing through language: positive physical health effects of indigenous language use. F1000Res. 2016;5:852. Whitfield G, Williams C. If the evidence is so good – why doesn't anyone use them? A national survey of the use of computerized cognitive behaviour therapy. Behav Cogn Psychother. 2004;32(1):57–65.

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Mental Health Research and Evaluation in Rural, Remote, and very Remote Settings Timothy A. Carey

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using and Also Creating Evidence Is Fundamental to Effective Mental Health Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Form and Function of RRvR Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Purpose of RRvR Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Principles of RRvR Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultivating a Learning Orientation Supports the Generation and Use of Evidence . . . . . . . Partnering with Practices and Academics Can Amplify the Learning Opportunities . . . . . . Engaging Patients – The Heart and Soul of Practice – In Collecting and Using Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Demonstrating Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

While the inequities in health outcomes between metropolitan and nonurban centres are well established and widely recognized, the absence of high-quality research and evaluation from these centres has received less attention. It could be argued, however, that the extent to which programs and services in rural, remote, and very remote locations are routinely not evaluated is a major contributor to the inequities that exist. In order to both establish the effectiveness and efficiency of an intervention as well as improve that effectiveness and efficiency when required, ongoing monitoring and evaluation is essential. This chapter outlines the differences between conventional research and the research activity that is likely to be more meaningful and useful in T. A. Carey (*) Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_5

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rural, remote, and very remote jurisdictions. Five important principles rigor; reliability; replicability; reporting; and routine are explained and illustrated with a case study. Incorporating these principles into health-care services is likely to make service provision more effective and efficient for ultimately better health outcomes for residents of rural, remote, and very remote places.

Introduction There is an urgent need, generally, to improve both the quantity and quality of research and evaluation conducted in rural, remote, very remote (RRvR) settings. Mental health research is no exception to this. In order to bring about lasting improvements in mental health for people who live rurally, remotely, or very remotely, it is imperative that programs and services are systematically evaluated in an ongoing way. To a very great extent, however, routine research and evaluation does not seem to occur on any widespread scale outside metropolitan centres. Throughout this chapter, rather than continuing to refer to “research and evaluation,” I will use “research” to encompass activities involving the systematic collection of data to discover something that was not previously known including how effective a program or service is for a selected group of people in a particular context. In Australia, a recent review reported that approximately $5.9 billion is spent annually on programs and services for Aboriginal and Torres Strait Islander peoples (Hudson 2016). Not all of these programs and services will be in RRvR locations, but many of them will be. Alarmingly, of the 1082 programs identified, only 88 of these had been evaluated at all (less than 10%). Furthermore, with regard to the programs that had been evaluated, conclusions of effectiveness could not be confidently made because of the inappropriateness of the methods used (Hudson 2016). There are large and enduring disparities in health outcomes in Australia between Aboriginal and Torres Strait Islander Australians and other Australians, so it is especially concerning that so much money is being allocated to programs and services without any requirement for the demonstration of effectiveness of these interventions. Even when data are collected, it appears that these data are used primarily for reporting to government agencies and not for demonstrating the effectiveness of the programs to community members (Hudson 2016). Hudson made the recommendation that “All programs receiving taxpayer funding should be subject to independent evaluations. At the same time, governments and organisations should cease collecting data that does not make a valuable contribution towards improving the level of knowledge about the effectiveness of programs” (p. 23). Other reviews support Hudson’s (2016) conclusions and recommendations. In a systematic review of community development programs in Aboriginal and Torres Strait Islander communities, Snijder et al. (2015) identified the methodological quality of studies as a major weakness. Due to these weaknesses, the cost-effectiveness of the programs in improving the health and wellbeing of community residents

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could not be determined. Snijder et al. called for higher-quality studies to improve the evidence base. The poor quality of evaluations regarding mental health programs for Aboriginal and Torres Strait Islander is long-standing. Clelland et al. (2007) identified more than 10 years ago that the evidence base for mental health promotion programs for Aboriginal and Torres Strait Islander Australians was weak, largely because there were few evaluations conducted that were of high quality. Importantly, Clelland et al. highlighted that many mental health promotion initiatives for Aboriginal and Torres Strait Islander Australians emphasize individual behavior change rather than balancing this focus with a concurrent consideration of the broader social, ecological, and policy determinants. Finally, the cultural relevance of programs as well as the importance of community involvement was identified as essential aspects of effective interventions. As a result of the lack of any kind of policy imperative to provide ongoing, meaningful, practice-based evidence of the effectiveness of programs and services, there is substantial duplication and waste of government funding (Hudson 2016). For example, Roebourne in Western Australia has a population of 1150 people with 67 local service providers and more than 400 different programs being delivered (Commonwealth of Australia 2014). Toomelah in New South Wales has a population of 300 people and 70 service providers (Commonwealth of Australia). It is critical, therefore, in order to ensure both that government funds are being allocated prudently and also that mental health services and programs in RRvR localities are provided effectively and efficiently, that research becomes a routine, systematic, and ongoing feature of the delivery of these interventions. It is likely that this will require policy changes so that the imperative to provide meaningful and relevant data about the effectiveness of interventions will be a necessary requirement of accessing government funds. Equally important, however, will be the requirement of governments to understand that research in RRvR settings will not necessarily be the same as research conducted in metropolitan locations. While the appearance of this activity will differ, however, there is no reason to expect a reduction in the quality of the activity. Appreciating the distinctive features of research in RRvR settings will assist policy makers, health service managers, and service providers to both demand and conduct research that is of sufficient quality for confident conclusions to be drawn and significant progress in improving the mental health of RRvR residents to be realized. Prior to examining the distinctive features of RRvR mental health research, it is important to appreciate the critical role of evidence for effective practice. Mental health practitioners and other service providers often work in isolated contexts, so being able to manage evidence in a sophisticated manner is essential for effective and sustainable practices. The evidence that needs to be understood and applied appropriately has two general sources. The first source is evidence provided by other researchers and organizations, and the second source is evidence that the practitioner, service provider, or organization collects. It is also critical to understand that evidence should be broader than evidence of effectiveness. As will be explained

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below, feasibility, appropriateness, and meaningfulness research should be prioritized just as strongly as effectiveness research.

Using and Also Creating Evidence Is Fundamental to Effective Mental Health Practice In order to improve the efficiency and effectiveness of mental health practice in RRvR locations, it is important that mental health professionals can not only use the existing evidence judiciously but also create their own evidence. Generally, there will be three main ways in which evidence will be important to mental health practices. Firstly, mental health professionals need skills in using existing evidence in terms of translating research findings into procedures and practices that are relevant for their own particular context. Secondly, mental health professionals in RRvR settings should be able to test the effectiveness of new interventions that arise from innovative clinical practices. Finally, the practice of ongoing monitoring needs to become commonplace so that evaluation and program modification can occur as part of a continual process of improving effectiveness as well as ensuring that interventions remain feasible, appropriate, and meaningful. Extant research has limited relevance to RRvR practice. In mental health research, the randomized controlled trial (RCT) has become the method du jour for developing and evaluating treatments. Although the RCT is a rigorous and robust methodology, it has come to be seen as superior, in a general sense, to other methodologies, and this has had unfortunate consequences (Carey and Stiles 2016). One of the strengths of the RCT design is the very strong internal validity that is created (Carey et al. 2017). Unfortunately, internal validity has been emphasized to such an extent that the implications of the findings from RCTs for clinical practice can be extremely difficulty to decipher. For the most part, the participants who present with difficulties to be addressed in RCT research are very unlike the people who access treatment in routine clinical practice (Carey et al. 2017). Moreover, the regularly scheduled appointments and the fixed treatment protocols are also atypical of what occurs in clinical practice settings. Since the research setting of the RCT can differ markedly from the clinical settings of regular practice, it is not surprising that clinicians find translating research evidence less than straightforward. The emergence of implementation science and the emphasis on translational research have essentially arisen as remedies of the iatrogenic problem of creating research settings that are far removed from practice settings. The importance of the difference in context between research and practice settings is compounded in RRvR settings where very few RCTs are conducted. A simple search conducted on 29 October 2018 of the PsycINFO database, for example, combined the keywords “randomized controlled trial” with “cognitive behavior therapy” and “rural.” These terms were selected to gain some sense of the extent to which a commonly used psychological treatment might have been evaluated in rural settings using a widely regarded rigorous methodology. Combining “randomized controlled trial” and “cognitive behavior therapy” with the Boolean

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operator “and” produced 1440 articles. When “rural” was added, however, this number reduced to ten. This finding may highlight the difficulty of conducting RCTs in RRvR locations as well as the caution that needs to be exercised in applying the knowledge gained from RCTs to RRvR settings. Given the difficulties in translating research findings into service delivery approaches, it is important that RRvR mental health clinicians are skilled at understanding the principles of effective service delivery and the way in which any particular study informs these principles. Clinicians working in RRvR settings will often need to adapt research findings to suit the characteristics of their particular locality in order to accommodate issues of comorbidity, for example, and irregular appointment attendance. For effective mental health practice in RRvR settings, therefore, it is important that clinicians can read research reports critically and apply their conclusions and recommendations in a sophisticated and nuanced manner. Even the concept of evidence-based practice underscores the necessity for clinicians to use sound judgment when integrating the best available information with knowledge of the local context. Pearson et al. (2012) describe the Joanna Briggs Institute’s (JBI) model of evidence-based health care as incorporating four components: research evidence; the context of care; the values and preferences of the patient; and the experience, expertise, and clinical judgment of the health professional. In this model, being able to critically appraise the research evidence is a necessary but not sufficient condition for providing evidence-based health care. Not only do evidence-based health professionals need to be able to assess the plausibility of the research findings, they must be able to synthesize these findings with their understanding of the local context as well as the preferences, priorities, and values of their patients. By considering each of these components, the health professional will be able to determine the most appropriate treatment decision in any given situation. The JBI approach to evidence-based health care highlights the importance of conducting local research in RRvR settings. If one component of evidence-based health care involves the local context, then it makes sense to undertake research in the settings in which health care is being provided. Given the way in which RRvR contexts can differ, the significance of local context is especially important. The strong influence of context as well as personal preferences in the manifestation and impact of mental health problems makes the JBI model of evidence-based health care particularly relevant for mental health research and practice. Generating new evidence in RRvR contexts is challenging. The difficulties of conducting rigorous, dependable, mental health research in RRvR settings should not be underestimated. Characteristics of RRvR mental health settings can make the routine collection of accurate and precise data particularly problematic. By their very nature, these settings are less densely populated than metropolitan settings, and this feature can increase concerns about privacy, confidentiality, and the storage of data. It is common, for example, in RRvR communities for many people to know each other and, in some cases, to be related. The problems created by stigma for people in RRvR communities accessing mental health services are well documented and long-standing (Crawford and

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Brown 2002). A recent study of fly-in fly-out (FIFO) remote mining and construction workers, for example, reported that the strongest predictor of high psychological distress in this sample of 1124 construction, open-cut, and underground mining site employees was the stress related to the stigma associated with mental health problems (Bowers et al. 2018). The same issues with stigma that affect the extent to which people access mental health services may also affect their willingness to participate in mental health research making recruitment of research participants problematic. Furthermore, research in RRvR settings is drawing from a much smaller population base than research in metropolitan settings. Recruitment of appropriate numbers of research participants is, therefore, likely to be difficult. Even when people do consent to engage in the research project, they may be reluctant to provide sensitive information in case other people in the community inadvertently gain access to this information. The nature of mental health research and the stigma associated with mental health problems may influence the way in which people participate. Bowers et al. (2018), for example, reported that, given the workplace setting of remote construction and mining sites, socially desirable responses would not be unexpected. Alternatively, people might provide information that is different to the information they would otherwise provide in a situation in which they felt anonymous. Genuinely de-identifying data can be a challenge for researchers in RRvR locations. Even with mundane, demographic data, depending on the data being collected, potential research participants might be concerned that their responses will be identifiable. A workforce survey about workplace stress, bullying, and burnout, for example, might ask about the gender, age, and qualifications of participants. In some RRvR mental health workplaces, there may be only one female in the 25–29 age group who has a PhD. This participant, then, would be immediately identifiable. The quality of the data that are obtained, therefore, might be compromised because of the features of the RRvR research environment. This is a particularly insidious problem because the researcher is unlikely to be able to accurately judge data quality in all situations. Of course, metropolitan researchers also have to contend with issues such as recruitment and biased responding; however, because research is already so limited in RRvR contexts, these issues have a much greater impact in nonurban locations. Finally, a lack of access to researchers with the necessary skills and expertise to conduct the research, such as university academics, limits the amount of research activity in RRvR settings. A problem related to the lack of appropriate personnel is the difficulty in accessing the necessary technology and other infrastructure required to conduct research appropriately and efficiently. Additionally, mental health professionals in RRvR communities are likely to have limited capacity to assist with the research process. A number of factors, therefore, make it very difficult to conduct mental health research in RRvR locations such as testing the effectiveness of new interventions or answering other important clinical questions. So, to ensure effective mental health practice, it is important that mental health professionals in RRvR locations become skilled at using different methodologies to

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organize and understand the data they are collecting during the course of their routine clinical practice. Methodologies such as case study research, realist evaluation, and benchmarking may be useful ways of answering important questions in RRvR contexts. Sophisticated skills in statistical analysis will not always be required, but a nuanced understanding of the most appropriate way to generate defensible answers to important research questions will be necessary. Evidence is a multi-faceted construct. When evidence in health-care contexts, and particularly mental health-care settings, is referred to, it is perhaps the case that most people understand evidence to mean evidence of effectiveness. While effectiveness evidence is undoubtedly essential, it is not the only type of evidence that is important. In order to develop a comprehensive understanding of a program and the way in which it can be helpful for people, researchers should consider collecting evidence related to the feasibility, appropriateness, and meaningfulness of the program in addition to evidence regarding its effectiveness. The FAME (feasibility, appropriateness, meaningfulness, and effectiveness) approach to conceptualizing evidence (Pearson et al. 2012) further compounds the difficulties of conducting RRvR mental health research. Despite the complications that the FAME model introduces, these other dimensions to evidence are likely to be crucial with regard to decision-making about the implementation of programs and services that are genuinely helpful to the recipients of these interventions. Some evidence, for example, indicates that Internet interventions can be effective in helping people to reduce psychological distress although these interventions are typically characterized by low rates of adherence in routine clinical practice (Powell et al. 2013). This suggests that, in addition to effectiveness research, research regarding Internet and online approaches to mental health treatments should prioritize feasibility, appropriateness, and meaningfulness research now that effectiveness research has been conducted. This is particularly important in RRvR contexts where Internet treatments are often offered as a solution to problems of timely access to effective mental health treatment. In a comparison of Internet-based exposure and behavioral activation for complicated grief and rumination, while both treatments were effective, feasibility appeared to be higher for exposure than for behavioral activation (Eisma et al. 2015). Thus, important information was obtained by examining the feasibility of the treatments that would otherwise have been obscured if only effectiveness had been evaluated. Two broad categories of research related to programs and services. In the process of accumulating evidence, the answers to two different categories of research question can be sought. The first category of question is largely descriptive and concerns what changed during the period of service provision. The second category is primarily explanatory and should, ideally, incorporate links to a theory or an organized system of accepted knowledge (Piantadosi 2005). Questions in this category are how or why questions. Piantadosi makes the point that experimentation alone is insufficient for scientific progress. Rather, research results need to be reconciled with theory or existing knowledge in order to make progress in any field. Answering “what” questions. To understand the benefits of an intervention collecting information on the changes that have occurred is essential. The data to

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be collected should be negotiated ahead of time with the people who will be receiving, and, ideally, benefitting from, the service so that the results of the research will be meaningful for them. The more that data can be either counts or rates of particular important indicators, the more robust the results will be. Data such as the cigarettes smoked per day, the number of standard drinks consumed per day, the number of social contacts each week, the number of school office referrals, the number of presentations to the hospital emergency department, and so on are all data that can be independently verified and provide evidence of change. Typically, in mental health research, the term “measure” is used for reporting devices that ask people to provide information on various aspects of their functioning. While these tools can be extremely useful, they do not “measure” attributes or characteristics in the way that measuring height or weight or blood pressure might be understood. The more that interventions can demonstrate changes that can actually be measured, the stronger the effect of the intervention is likely to be. In one GP practice, for example, in a regional centre in Scotland, a change was made to the way in which appointments for psychological treatment were scheduled. After the change had been introduced, data were collected over a 6-month period and then compared with data from the same 6-month period for the two previous years. To evaluate the change, the number of referrals to the service was counted. In the previous 2 years, 52 referrals each year were received by the service, and, after the change had been introduced, 93 referrals were received (Carey and Spratt 2009). Moreover, a 7-month waiting list that had existed prior to the introduction of the change had been eliminated at the end of the 6-month evaluation period. These simple count data, therefore, provide strong evidence for an important change in service capacity and patient access to the service. Answering “how” or “why” questions. While understanding what the changes of an intervention were, it is also necessary to understand why the changes occurred. It is important, for example, to be able to rule out competing explanations. It is just as essential to be able to explain the result in terms of some plausible mechanism or principle of change (Piantadosi 2005). Service providers need to know whether it was the resources of the program and the interaction between service provider and service recipient that produced the change or whether the change occurred for some other reason. RCTs are perhaps the most commonly regarded methodological procedure for establishing causality (Carey and Stiles 2016). Fundamentally, the RCT is used to assert that it was the treatment, rather than some other explanation, that was responsible for the observed effects. With RCTs, therefore, an a priori assumption regarding the locus of causality is that causation resides in the treatment or intervention. While this might be a defensible assumption for a surgical or other medical procedure, it is much harder to maintain with psychological and social programs. With psychological and social treatments, program effectiveness is not a property of the treatment protocol (Carey et al. 2019). Rather, effective outcomes are created by the service provider and the service recipient (Carey and Stiles 2016). This difference in understanding with regard to causality further calls into question the appropriateness of RCTs for psychological and social interventions.

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Despite the limitations of RCT methodology, there are different ways in which competing explanations can be eliminated to make robust conclusions about the value of an intervention (Carey and Stiles 2016). Kazdin (2011) outlines different types of data and the ways in which they might be collected in order to draw conclusions about the impact of an intervention and to systematically eliminate competing explanations for the change. A researcher needs to be able to demonstrate, for example, that the change was not due to other factors such as the passage of time, maturation, or the normal and expected course of the problem (Kazdin 2011). Carey et al. (2017) illustrate one way in which a program of research might be constructed to understand the why positive change occurred for clients who experienced an a-diagnostic cognitive therapy developed and delivered in rural contexts. Ongoing monitoring takes time. Mental health clinicians frequently have multiple and competing demands on their time. This can be especially the case in RRvR mental health settings where there may not be the support of a multi-skilled team to assist with program planning and service delivery. Ongoing monitoring, however, is a well-established component of effective mental health practice (Lambert and Shimokawa 2011). Collecting progress data on a regular and ongoing basis from clients has been demonstrated to assist with enhancing the effectiveness of mental health care generally and particularly for people who might not be progressing as expected (De Jong et al. 2014). Although the ongoing collection of data need not be a particularly onerous habit, it does require extra organization and additional time along with resources that could be allocated elsewhere if ongoing monitoring was not being implemented. Undertaking this way of working, therefore, requires a commitment to the concept and an understanding of the benefits of this way of working. A recent research project sought to understand the principles that might be important in initiating and sustaining ongoing monitoring and evaluation in service organizations in rural and underserved communities (Carey et al. 2019). People in different positions within a variety of organizations were recruited and interviewed regarding their experiences with this form of evaluation. From the synthesis of the data provided by their transcripts, a small set of common principles were extracted. The principles that are likely to be important across different contexts are engagement; commitment; responsiveness (to context); and accessibility (of resources) (Carey et al. 2019).

Distinctive Features Research and evaluation in RRvR mental health settings has a number of distinctive features. Some of these have already been alluded to; however, they will be expanded upon and explained further in this section. Understanding the distinctive features of mental health research in RRvR contexts is important in order to be able to maintain the high quality of research that would be regarded as standard in metropolitan centres.

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The Form and Function of RRvR Research Both the form and the function of mental health research in RRvR settings are likely to be different from the same kind of research conducted in metropolitan contexts. With smaller, more dispersed populations, it is unlikely that research regarding treatment efficacy or program effectiveness for specific disorders would be viable. Instead, research should focus on comorbid presentations and transdiagnostic treatment approaches. Also, in RRvR contexts, access to services is not always straightforward or orderly. Rather than evaluating discreet packages of treatment delivered according to regularly scheduled treatment protocols, it may be more meaningful to assess flexible methods of program delivery. Individual sessions of ongoing face-toface therapy will still occur in RRvR contexts; however, other programs will co-exist and sometimes be more desirable than standard therapeutic approaches. Community development programs, for example, may need to be allocated more research attention than might be the case in urban centres.

The Purpose of RRvR Research Importantly, the purpose of research in RRvR areas is, in many ways, fundamentally different from the aims of research in highly populated centres. In RRvR settings, research should be driven much more by community needs and priorities than by a general interest in advancing scientific knowledge and progressing specific fields of enquiry. Large, random samples from defined populations, therefore, are not so important, because the generalizability of the results is not necessarily a priority. RRvR communities are generally regarded as being unique, with each one having considerations and features that are specific to that particular context. Generalizing specific programs, therefore, will not usually be appropriate or successful, so, for RRvR research, there needs to be a much greater focus on principles of effective practice. Important principles are likely to be far more transportable than specific programs. Australia’s first Rural Health Commissioner, Emeritus Professor Paul Worley, maintains that while the statement “if you’ve seen one rural community, you’ve seen one rural community” is a truism, if we maintain a focus on differences between communities, our research findings will have very little impact on policy (Carey et al. 2019). Policy change will only be realized by identifying the important features that are common across apparently different contexts. Testing hypotheses that might be important for advancing or elucidating particular theoretical positions is also likely to be less of a focus than answering urgent and relevant research questions that have been shaped through community involvement. Community consultation, therefore, in a variety of forms is an essential component of each stage of the research process in RRvR settings. In order for communities to support both the conduct of the research and the dissemination and uptake of the findings, it is important that they make genuine and substantial contributions to the focus of the research as well as the design of the study.

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Principles of RRvR Research Even though the form and function of research in RRvR settings will be different from what might be expected in metropolitan contexts, the principles of highquality research will be very similar. The four Rs rigor, reliability, replication, and reporting will be important to incorporate into the planning of any research activity. It is important, for example, that all research is carried out rigorously in a systematic and organized way. It is also essential that, as much as possible, researchers strive to produce reliable results in which systematic forms of bias have been identified and removed from their data collection and analysis procedures so that consumers of the research can have confidence in the results. Ideally, depending on the research question being answered, the results of the research should be replicated in other RRvR settings as a way of demonstrating that a particular intervention was effective over and above the impact of a charismatic and dynamic service provider. The distinction between principles and practices that was mentioned above will be important to consider when replication work is being undertaken. The form of any specific intervention should be expected to differ from one RRvR location to another; however, the purported key principles of effective practice will remain constant. Replication work, therefore, in the RRvR context, will be the replication of principles rather than programs and practices. Finally, reporting the results of research is an important, but often neglected, feature of the research process. It will be important at all stages of the research process to maintain an awareness of the necessity of reporting the research results to different audiences. Researchers may need to report the results to funding bodies such as government agencies; the communities who participated in, and are seeking to benefit from, the research; and the wider scientific community through peer-reviewed publications and other dissemination mechanisms. Reporting research results to different audiences contributes to the rigor of the research activity by inviting scrutiny and questioning from outside sources. For RRvR mental health research, a fifth R can be added to the other four Rs which could be considered generic principles of high-quality research. The fifth R that is particularly important in RRvR contexts is routine. Whereas research in urban centres might be conducted as specific projects or discreet programs of activity, mental health research in RRvR settings needs to be an ongoing feature of effective and efficient service delivery. Research in RRvR settings should be characterized by an enduring interplay between the collection and analysis of data and program improvement. Dudgeon et al. (2017) provide an excellent example of localized participatory action research that was used throughout 11 Aboriginal and Torres Strait Islander communities in Australia as part of the National Empowerment Project (NEP) to improve the cultural, social, and emotional wellbeing of local residents. Service providers must be compelled to develop systems so that the data that are available to them on a regular basis as they deliver their interventions are collected, organized, and synthesized to inform the monitoring and improvement of the intervention. The embodiment of the five Rs rigor, reliability, replication,

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reporting, and routine in RRvR research has important practice implications for the way in which programs and services are designed and delivered.

Practice Implications The five principles rigor, reliability, replication, reporting, and routine can be used to shape the design and conduct of high-quality research in RRvR settings. A researcher may not have access to a large research centre or an abundance of resources. Furthermore, the researcher might be a researcher-clinician who is conducting this research as part of a small team or as a quality improvement exercise. It is not always easy or straightforward to make time in a busy clinic schedule for analyzing data and compiling reports in various formats. Many obstacles, therefore, will need to be negotiated if programs and services are to be improved systematically through ongoing research. Establishing and sustaining the necessary systems for ongoing monitoring and evaluation that is critical for improving services and programs in nonurban areas has important implications for practice. Three main implications that apply generically across RRvR centres are discussed below. The implications to research practices are cultivating a learning orientation; recruiting external experts; and engaging participants.

Cultivating a Learning Orientation Supports the Generation and Use of Evidence Ongoing monitoring and evaluation invites a conceptual shift from considering research as a judgment about the effectiveness of an intervention to using research activity to encourage a learning process (Carey et al. 2019). When approached from a learning perspective, service providers can be encouraged to adapt scholarly knowledge in local contexts. It is this synthesis of evidence from the literature with an understanding of local contexts that is at the heart of evidence-based practice (Pearson et al. 2012). Stakeholder engagement is likely to be enhanced when research processes are understood to be part of the feedback loops that are the essential mechanisms for improving services and achieving better outcomes, and service providers will feel empowered and more confident in the interventions they offer. Service providers will see themselves as essential contributors to the iterative cycles of hypothesis generation and testing, and, therefore, the data will be more meaningful to them.

Partnering with Practices and Academics Can Amplify the Learning Opportunities In one study, participants who had successfully established and sustained systems of ongoing monitoring and evaluation in rural and underserved communities felt it was

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ideal if external partners could be recruited (Carey et al. 2019). The external partners would be expert researchers themselves such as university academics. The role of the external experts could change over time, but their involvement in the research process was seen as invaluable. Through their involvement the learning opportunities were amplified through the introduction of novel perspectives, increased awareness of areas requiring attention, and benchmarking comparisons where appropriate. It is essential, however, that care is taken when partnering with experts such as university academics. Sometimes, due to the demands facing these experts, they may prioritize their own research and publishing needs ahead of the learning and service needs of the clinicians and the community. University academics must understand the nuances of RRvR contexts in order to contribute helpfully in these locations.

Engaging Patients – The Heart and Soul of Practice – In Collecting and Using Evidence As has been previously mentioned, engaging the local community is important at all stages of the research process in RRvR localities. In particular, the service recipients’ perspective is critical yet often underrepresented. Careful consideration and planning should be directed to ways to engage patient expertise in the design and conduct of the research as well as the way in which the results are disseminated. By genuinely engaging patients and not only listening to but acting on the information they provide, the services they receive are likely to become more effective and efficient.

Demonstrating Impact Demonstrating impact is essential for both research and practice. In RRvR settings, it is vital to attend to the impact of interventions to ensure that the intended results are being achieved. While the importance of impact is widely acknowledged, the way in which impact can be understood and demonstrated has been slow to progress. To assist in this endeavor, it may be useful to think of impact as an acronym (Carey 2019). In order to persuasively demonstrate the impact of programs of research, it is necessary to ensure that the research is: • • • • •

Important to the community Monitored and measured so that genuine improvement can be demonstrated Planned so that initiatives develop through systematic, cohesive collaboration Adequately and appropriately resourced Courageously challenging the status quo, prevailing attitudes, and accepted wisdom • Telling a story that affects people’s hearts as well as their heads Paying attention to each of these components is likely to make research more targeted, precise, and effective. For example, who is the “community” that the

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research is intended to benefit (Carey 2019). Is it the community and entire collection of people living in a geographically distinct location, or is it people who are grouped together in a different way such as youth who self-harm? By ensuring that each of these components is genuinely addressed in the research, the results are far more likely to be of interest to the intended beneficiaries as well as policy-makers and other decision-makers.

Concluding Comments and Recommendations In order to reduce the long-standing health inequities that exist between metropolitan and RRvR locations, it is crucial that ongoing monitoring and evaluation of programs and services becomes a routine, even mundane, aspect of the service provision landscape. While there are similarities between research conduction in metropolitan and nonurban settings, there are also important differences. The differences described in this chapter should be attended to if research is to be successfully conducted and be of benefit to RRvR residents. In particular, the five principles of RRvR research that have been articulated should be reflected in all research activity. Moreover, research should be considered to be part of a learning process in improving the services provided rather than as an activity to arrive at judgments about an intervention’s effectiveness. Partnering with expert researchers and engaging participants in all aspects of the research process are important aspects of RRvR research. Ideally, policy changes would ensure that evaluation was a non-negotiable component of all government-funded services and programs. Ultimately, it is likely to be a policy change such as this that will drive change to practice. Once ongoing monitoring and evaluation becomes a standard feature of service delivery in RRvR locations, nonurban residents will begin to enjoy the same health outcomes that their metropolitan counterparts take for granted.

Take-Home Messages • To improve health equity and the disparity in health outcomes between metropolitan and nonurban centres, the routine conduct of ongoing, high-quality research is essential. • Changes to both policy and practice are required for research to be conducted as frequently as it needs to occur and in the ways it needs to occur. • The five important principles for research in RRvR settings are: – Rigor – Reliability – Replication – Reporting – Routine

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Case Study

An innovative approach to the scheduling of patient appointments for psychological treatment was developed in the National Health Service (NHS) in rural Scotland and later transferred to remote Australia (Carey 2005, 2010, 2011; Carey and Mullan 2007; Carey and Spratt 2009; Carey et al. 2013). The new model is called patient-led appointment scheduling and was created to address the long waiting times that existed. The motivation for undertaking this work was based on a practical problem to be solved as well as policy directives. The practical problem was a 15-month waiting list to receive treatment in the adult primary care service in one district in Scotland. Current NHS policy at the time contained explicit statements about empowering patients and putting patients more in charge of their own health care. The innovation was startling in both its simplicity and its effectiveness. The basic concept entailed a shift from clinicians scheduling appointments to patients scheduling appointments as and when they required them. This simple strategy brought about a dramatic reduction in cancelled and missed appointments to the extent that, over a 5year period, the waiting list decreased from 15 months to less than 1 month. The work that was undertaken provides a clear demonstration of the five important principles. Rigor From the beginning of this research, a methodical and systematic approach was undertaken. Time was taken to ensure the context was understood, a thorough review of the literature was conducted, and a preliminary investigation was completed with just one researcher (Carey 2005). As more clinicianresearchers became involved in the research, the same data collection procedures were used, and additional data were collected periodically to complement the standard data being collected (Carey and Mullan 2007). Moreover, the approach that was developed was based on sound theoretical principles which further enhanced the rigor of the scientific process. Reliability The researchers used standardized outcomes measures to promote the reliability of their work. Furthermore they used the same measures across multiple studies. They also used the same data recording spreadsheet to ensure that the same data were being collected across different research sites. On some occasions the researchers employed assistant researchers to collect qualitative data to assist in the removal of possible bias (Carey and Mullan 2007). Replication From the outset, the researchers prioritized the replication of their results. This work was replicated across different primary care sites and with different clinicians. Furthermore, the results have also been replicated across different health systems (Carey et al. 2013). Although the initial work was conducted in (continued)

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primary care settings in rural Scotland, it was then replicated in secondary care in remote Australia (Carey et al. 2013). Reporting As already indicated, the results have been routinely reported in peerreviewed publications. Furthermore, the results have been presented at national and international conferences (Carey 2013; Carey and Mullan 2006) to ensure the dissemination of this work via different forums. Subjecting this work to public scrutiny and peer review processes through different reporting avenues not only increased awareness of this innovation on a wider scale but also further enhanced the rigor of the research. Routine The routine aspect of this work was demonstrated in two ways. Firstly, all of this work has been conducted, from the outset, in routine clinical practice by researcher-clinicians. The participants in the research were the standard patients who present for treatment in primary and secondary care. Secondly, systems were embedded in the practice of the clinicians, so data collection itself became a routine aspect of their work. The way in which this research was conducted overcame the translational difficulties that often plague conventional research and makes it an ideal model for the conduct of mental health research in RRvR locations. By changing the way in which appointments for psychological treatment were offered and rigorously evaluating this change, psychological services demonstrated increased efficiency in the care they were able to offer to patients.

References Bowers J, Lo J, Miller P, Mawren D, Jones B. Psychological distress in remote mining and construction workers in Australia. Med J Aust. 2018;208(9):391–7. Carey TA. Can patients specify treatment parameters? Clin Psychol Psychother. 2005;12(4):326–35. Carey TA. Will you follow while they lead? Introducing a patient-led approach to low intensity CBT interventions. In: Bennett-Levy J, et al., editors. Oxford guide to low intensity CBT interventions. Oxford: Oxford University Press; 2010. p. 331–8. Carey T. Patient-led primary care mental health treatment: efficient and effective. Paper presented at the 48th Annual Conference of the Australian Psychological Society, 8–12 October, 2013. Carey, T. A. As you like it: Adopting a patient-led approach to the issue of treatment length. Journal of Public Mental Health. 2011; 10(1), 6–16. Carey, T. A. Prioritizing impact to improve health services and reduce inequities in rural, remote and very remote locations. JBI Database of Systematic Reviews and Implementation Reports. 2019; 17(9), 1729–1730. Carey TA, Mullan RJ. Patients in charge: a naturalistic investigation of a patient led approach to treatment in primary care. In: Annual conference of the British Association for behavioural and cognitive psychotherapies. England: Warwick; 2006. Carey TA, Mullan RJ. Patients taking the lead: a naturalistic investigation of a patient led approach to treatment in primary care. Couns Psychol Q. 2007;20(1):27–40.

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Carey TA, Spratt MB. When is enough enough? Structuring the organisation of treatment to maximise patient choice and control. Cogn Behav Ther. 2009;2:211–26. Carey TA, Stiles WB. Some problems with randomized controlled trials and some viable alternatives. Clin Psychol Psychother. 2016;23(1):87–95. https://doi.org/10.1002/cpp.1942. Carey TA, Tai SJ, Stiles WB. Effective and efficient: using patient-led appointment scheduling in routine mental health practice in remote Australia. Prof Psychol Res Pract. 2013;44:405–14. Carey TA, Tai SJ, Mansell W, Huddy V, Griffiths R, Marken RS. Improving professional psychological practice through an increased repertoire of research methodologies: illustrated by the development of MOL. Prof Psychol Res Pract. Advance online publication. 2017; https://doi. org/10.1037/pro0000132. Carey TA, Fauth JM, Tremblay GC. Rethinking evaluation for improved health outcomes: implications for remote Australia. Am J Eval. 2019;41:234–54. Clelland N, Gould T, Parker E. Searching for evidence: what works in indigenous mental health promotion? Health Promot J Austr. 2007;18(3):208–16. Commonwealth of Australia. Towards responsible government. The report of the National Commission of Audit. Phase one. Canberra: Commonwealth of Australia; 2014. Retrieved from http://www.ncoa.gov.au/report/docs/phase_one_report.pdf Crawford P, Brown B. ‘Like a friend going round’: reducing the stigma attached to mental healthcare in rural communities. Health Soc Care Community. 2002;10(4):229–38. De Jong K, Timman R, Hakkaart-Van Roijen L, Vermeulen P, Kooiman K, Passchier J, Van Busschbach J. The effect of outcome monitoring feedback to clinicians and patients in short and long-term psychotherapy: a randomized controlled trial. Psychother Res. 2014;24(6):629– 36. https://doi.org/10.1080/10503307.2013.871079. Dudgeon P, Scrine C, Cox A, Walker R. Facilitating empowerment and self-determination through participatory action research: findings from the National Empowerment Project. Int J Qual Methods. 2017;16:1–11. Eisma MC, Boelen PA, van den Bout J, Stroebe W, Schut HAW, Lancee J, Stroebe MS. Internetbased exposure and behavioral activation for complicated grief and rumination: a randomized controlled trial. Behav Ther. 2015;46:729–48. Hudson S. Mapping the indigenous program and funding maze. Research report 18. Sydney: Centre for Independent Studies; 2016. Kazdin AE. Single-case research designs. 2nd ed. New York: Oxford University Press; 2011. Lambert MJ, Shimokawa K. Collecting client feedback. Psychotherapy. 2011;48(1):72–9. Pearson A, Jordan Z, Munn Z. Translational science and evidence-based healthcare: a clarification and reconceptualization of how knowledge is generated and used in healthcare. Nurs Res Pract. 2012;2012:792519. https://doi.org/10.1155/2012/792519. Piantadosi S. Clinical trials: a methodologic perspective. 2nd ed. Hoboken: Wiley; 2005. Powell J, Hamborg T, Stallard N, Burls A, McSorley J, Bennett K, . . . Christensen H. Effectiveness of a web-based cognitive-behavioral tool to improve mental well-being in the general population: randomized controlled trial. J Med Internet Res. 2013;15(1):e2. Snijder M, Shakeshaft A, Wagemakers A, Stephens A, Calabria B. A systematic review of studies evaluating Australian indigenous community development projects: the extent of community participation, their methodological quality and their outcomes health behavior, health promotion and society. BMC Public Health. 2015;15(1):1154.

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Recovery in Mental Illness Among Rural Communities Keith Sutton and Anton Isaacs

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meanings of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elements of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical (Reduction in Symptoms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tasks of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing a Positive Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Framing the Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-managing the Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing Valued Social Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal Recovery in a Rural Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to Clinical Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dual/Overlapping Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural Community Understanding of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Limited Employment Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enabling Recovery in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Support and Service Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antistigma/Antidiscrimination Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co-design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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K. Sutton (*) Monash Rural Health (Warragul), Monash University, Warragul, VIC, Australia e-mail: [email protected] A. Isaacs Monash Rural Health (Tralagon and Warragul), Monash University, Traralgon, VIC, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_6

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Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Abstract

Sutton and Isaacs challenge those involved in the rural mental health sector to adopt a new approach to developing rural models of recovery practice. Rural mental health services have been criticized as urban centric. Additionally, although the notion of recovery emerged in the mental health field over thirty years ago, there is little evidence that rural models of recovery practice have been developed. Mental health recovery research to date has focused upon defining, describing, and developing models of recovery practice. However, recovery is context specific and is influenced by local cultural mores, social and economic context, and availability of treatment and support services. The authors therefore advocate for the adoption of a social inclusion approach to developing locally tailored rural models of recovery practice that are designed to address social enablers and barriers to recovery found in rural communities. Specifically, recovery practice should include interventions that address access to community services and supports and strategies to lessen the impact of stigma and discrimination on rural people experiencing mental health problems. Co-design is proposed as a participatory approach to engaging stakeholders, including those from the broader community, into the process of designing, implementing, and evaluating rurally appropriate models of recovery practice. A new approach is required because re-engineering the current rural mental health service system to operate in a recovery focused manner will not adequately address the uniquely rural social challenges to personal recovery.

Introduction In the three decades since the concept of recovery gained credence in the field of mental health, there is little to no evidence of effective rural models of recovery practice (McCord et al. 2012). In the 30 plus years since the notion of recovery emerged, mental health recovery research has primarily focused on defining personal recovery, identifying the social characteristics of recovery and developing generic models of recovery practice. Meanwhile, the rural mental health literature continues to be dominated by a deficit based discourse that focuses on the shortcomings of the rural mental health service system (Schmidt 2000) and challenges faced by service users and their carers (Judd et al. 2006; McCord et al. 2012; Hyde et al. 2015). A fundamental problem is that rural mental health services tend to operate using urban models of service delivery (Schmidt 2000; Bourke 2012).

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It is our contention that recovery is a context specific experience (Pilgrim and McCranie 2013) and that current models of recovery practice do not address the specific social enablers and barriers to personal recovery for those living in rural areas. We also believe that simply re-orientating, or re-engineering, current rural mental health services to operate in a recovery focused manner fails to systematically address the challenges to personal recovery that is unique to rural environments. We therefore advocate for the development and evaluation of rural models of recovery practice. We envisage that multiple, locally tailored models of rural recovery practice will emerge from this endeavor. Bespoke local models provide a way to address the social enablers and barriers of personal recovery specific to the rural environments in which they are developed. We recommend that a social inclusion approach inform the development of rural recovery practice as this provides a theory informed approach to lessening the impact of discrimination and inequality experienced by rural individuals with mental health problems. We also suggest that codesign provides a participatory process to expediting whole of community approaches to designing, implementing, and evaluating rural models of recovery practice. Initiating this type of change requires leadership from rural people in recovery, rural mental health practitioners, and rural mental health researchers. We therefore encourage these stakeholders to form alliances that aim to foster the development of locally tailored models of recovery focused practice.

Distinctive Features The aim of recovery focused practice is to enable people experiencing mental illness to have purposeful and meaningful lives within the communities in which they live. Current models of recovery practice fail to address the unique, yet diverse, characteristics of rural communities that enable or stymie personal recovery. Adopting a social inclusion framework to designing rural models of recovery practice will enable the development of locally tailored interventions that address local rural social contexts that hinder or foster recovery. This goal is best achieved through participatory alliances of rural people in recovery, rural mental health practitioners, and rural mental health researchers.

Practice Implications Recovery focused practice requires a fundamental change to the way in which mental health services have historically operated. Enabling personal recovery requires a whole of community approach to lessening the impact of social factors that serve to marginalize people experiencing mental health problems. Rural recovery orientated practice necessitates consideration of the unique social, economic, and geographical contexts in which programs are delivered.

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Recovery The concept of recovery rose to prominence in mental health during the 1990s in the aftermath of deinstitutionalization when it was deemed that individuals with severe and persistent mental illness (SPMI) could be rehabilitated outside of hospitals and other institutions (Anthony 1993). During this time, it became increasingly clear that individuals with severe mental illness needed much more than just symptom relief to lead productive and fulfilling lives. This led to the understanding that a person could recover even when their mental illness was not “cured” (Anthony 1993). Recovery was described as, “a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness” (Anthony 1993, p. 257). In other words, personal recovery which was characterized more as a sense of independence, a better ability to undertake activities of normal life and considering oneself an integral part of society, was distinguished from recovery from symptoms of a mental illness or clinical recovery (Drake and Whitley 2014). To better understand the meaning of recovery, one needs to first understand the circumstances which individuals find themselves in because of experiencing an SPMI. Persons with SPMIs have “severe symptoms or severe difficulty in social, occupational or school functioning” (Ruggeri et al. 2000, p. 149). They are also likely to have received treatment for two years or more (Ruggeri et al. 2000). Owing to the debilitating nature of their illness, such individuals usually endure social stigma and discrimination. They are unable to stay employed or have regular housing (Wright and Kloos 2007). They have difficulties with transport, with having a social circle, and are unable to readily access services (Berren et al. 1999). As a result, such individuals often fall through service gaps and end up on the fringes of society. Several authors have explored the concepts of recovery (Jacobson and Greenley 2001; Onken et al. 2007; Leamy et al. 2011). In the following paragraphs of this section, we describe the current concepts in recovery that relate to SPMI.

Meanings of Recovery Recovery can have different meanings for individuals with a mental illness or a substance addiction. For instance, for a person who has experienced a single episode of psychosis or major depression and has returned to health, recovery might mean a return to their full state of functioning (Davidson et al. 2005, 2009). On the other hand, in a person who has been addicted to drugs, recovery will invariably involve a degree of abstinence from the drugs while the person who continues to actively use drugs might not be considered to be in recovery. Furthermore, recovery might comprise a more complex mix of symptom relief and other socio-economic determinants for a person whose illness is severe and persistent. For such individuals, their illness has become integral to their day to day lives. Living with multiple disabilities could cause them to redefine their understanding of self and identity (Davidson et al. 2005, 2009). Recovery in such individuals has been referred to as a

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“journey” (Leamy et al. 2011) where individuals have to explore what they can and cannot do, and under what circumstances, while continuously striving to overcome their symptoms. Davidson and Roe (2007) refer to this as recovery “in” rather than recovery “from” mental illness owing to the need to find meaning and purpose within the boundaries and limitations imposed by their illness. It is this meaning of personal recovery that is the focus of this chapter.

Elements of Recovery Clinical (Reduction in Symptoms) Orientation towards recovery has been found to be better with lower severity of depressive symptoms (Resnick et al. 2004). Individuals with severe mental illness also recognize the need for a clinical/medical process in their recovery (Piat et al. 2009). In addition, an individual’s recovery process is augmented when the distress caused by symptoms is alleviated (Slade 2009). However, reduction in symptoms is most often possible only with adherence to treatment (McIntyre et al. 2015). Nonetheless, a case has been made that even when individuals are acutely unwell, they can be capable of making a reasoned decision to discontinue treatment (Bellack 2006). This decision must be treated with respect because rehabilitation and recovery can occur in the absence of symptom reduction (Slade and Longden 2015).

Social Following a systematic review and narrative synthesis of recovery literature, Leamy et al. (2011) developed the CHIME Framework which stands for Connectedness, Hope and optimism, Identity, Meaning in life, and Empowerment. This framework sums up the key social elements of recovery.

Connectedness The need to be connected to others in a social context is a key element of the recovery process. Three categories of connectedness have been described. They are peer support, support from others (social inclusion), and forming of relationships. Peer support could be described as the support provided to an individual currently experiencing an SPMI and considered to be in an early stage of recovery by one or more persons who have experienced significant improvement from their mental illness and are considered to be much further along their own recovery journey (Davidson et al. 2006a). Peers are known to better understand both the subtle and not so subtle difficulties experienced by persons with SPMI and provide support by selfdisclosure and role-modeling (Davidson et al. 2006a). Involving peers as members of mental health service staff can improve consumer engagement with services, reduce visits to hospitals, as well as reduce substance use in persons with comorbidity (Davidson et al. 2012). Peer support has also been found to improve a

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consumer’s hope and their ability to care for themselves as well as reduce the severity of their symptoms (Davidson et al. 2012). To be accepted by others is a basic human social need. However, people with SPMI commonly feel excluded and left out from the routine functioning of society. Individuals feel socially included when they have friends, are involved in some work, and feel that they are productive members of society (Lloyd et al. 2006). Networks of family and friends are important sources of support for persons with SPMI, with the quality of contacts more favored than the quantity (Pernice-Duca 2010). Being part of social networks, be it family or otherwise, has been shown to improve recovery outcomes (Corrigan and Phelan 2004; Hendryx et al. 2009). Mental health practitioners can follow four strategies to improve social inclusion of their clients (Lloyd et al. 2006): 1. Address attitudes and beliefs (e.g., believe in the consumer’s potential to recover; examine one’s own attitude towards and discrimination against those with mental illness). 2. Promote employment opportunities (e.g., liaise with employment and other government and nongovernment agencies to provide employment opportunities for clients (Evans and Repper 2000) and facilitate education opportunities. 3. Support families and enable community participation (e.g., form partnerships with community organizations to develop joint social/recreational programs). 4. Address issues related to housing, finance, transport, and access (e.g., liaise with housing agencies, provide training in finance, and facilitate transport arrangements). Persons with SPMI commonly feel a sense of social isolation immediately before and during their time in psychiatric care and yearn for social relationships (Schön 2010). It is not uncommon for persons to feel hopeless and humiliated by their clinicians and the services they access. The long standing legacy of chronic mental illness being associated with poor outcomes is often transmitted by clinicians to those who seek help from them (Davidson et al. 2006b). It is therefore important and necessary to have a good relationship with the treating clinician. Recovery oriented clinicians have the ability to support the person when they experience difficulties such as anxiety as well as deal with the challenging behaviors demonstrated by them (Borg and Kristiansen 2004; Hughes et al. 2009). It is also important to have caring relationships with friends and family. When relationships with friends continue despite the illness, individuals feel that recovery is possible (Schon et al. 2009). Family members such as partners, parents, and children play a significant role in the recovery of persons with SPMI. Family members are usually present from the start of the illness. They act as advocates for the person, understand the person’s difficulties more than others, and usually are by their side during treatment (Schon et al. 2009). However, this is not always possible particularly when disruptive parenting or broken homes are considered the reason for the illness.

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Hope and Optimism Hope and optimism are related concepts. While hope relates to the personal achievement of specific goals, optimism refers to a general expectation that future outcomes will be positive (Bryant and Cvengros 2004). Both hope and optimism are important indicators of, and potential pathways to, positive mental health (Gallagher and Lopez 2009). Mental illness, particularly when it is severe and chronic, tends to be very discouraging and is often considered a harbinger of a hopeless future (Shiers et al. 2009). Mental health professionals are also known to be pessimistic about recovery from severe mental illness and when this is conveyed to the client, it hinders recovery (Onken et al. 2002). However, if services take an optimistic approach and promote practices that are hope inspiring, positive outcomes are possible (Fowler et al. 2009). Mental health professionals can promote hope and optimism in their clients in various ways such as: listening with a nonjudgmental attitude; valuing the person and trusting the authenticity of what they say; acknowledging the importance of, and supporting access to, housing, education, and employment; accepting set-backs as part of the recovery process; encouraging the person to explore spirituality; and adopting a strengths based approach (Slade 2009). Identity Identity, or perhaps more specifically, the change in identity, is a crucial part of recovery. Soon after the initial onset of a severe mental illness, the person begins to recognize two different versions of themselves. They are able to differentiate between who they were before they became ill and who they have become following the illness (Pettie and Triolo 1999). Value judgments are also invariably attached to the different selves wherein the preillness version of themselves is considered to be the standard with attached positive values such as confidence, success, and being useful. The postillness version is often considered to be weak, burdensome, dependent, etc. There is often a need to reconcile who a person wants to be, with who they really are (Pettie and Triolo 1999). This conflict can lead to an identity crisis. Making sense of this new self and responding to it in a positive way enables recovery, whereas accepting a negative sense of self such as being inadequate and incompetent can worsen symptoms and reduce functioning, which in turn can adversely affect hope, self-esteem, and social interaction leading to suicidal ideation (Yanos et al. 2010). Recovery oriented agencies need to provide identity reclaiming activities as part of their suite of services. Meaning in Life Meaning in life can be defined as a sense of satisfaction that one draws from the “pursuit and/or attainment of life goals” while purpose can be defined as a reason for one’s existence (Lyons et al. 2010, p. 537). Meaning and purpose are therefore constructs that are inextricably dovetailed. Human beings need to feel that life is meaningful in order to experience a sense of wellbeing. Those who feel that their life is meaningful feel less depressed, have better self-esteem, and overall greater appreciation of life (Steger et al. 2006). Individuals with severe and persistent mental illness are known to struggle with a loss of meaning and purpose when their identity

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is confined to a diagnosis or label (Weinberg 2013). Self-stigma, a personal sense of hopelessness, and a pessimistic attitude can impede recovery. Often times, consumers themselves become their own greatest obstacle to recovery. This occurs when they refuse to accept responsibility for their recovery. They tend to get affected by some people’s negative messages and become overcome with shame, self-doubt, and unworthiness (Onken et al. 2002). Meaning and purpose and can be found through learning, relationships, paid or volunteer work, spirituality and religion, pets, music, art, sports, etc. (Weinberg 2013). Meaning can be different for each person. Individuals can seek to find meaning by “rediscovering what is important to them” by exploring their life goals (Weinberg 2013, p. 125). It includes learning how to extract what is best from what appears to be a bitter and painful experience. When clients are surrounded by people with a positive attitude who enable them to realize that they can be survivors rather than victims, who bring a sense of humor into their lives and help them set goals for the future and find something worth living for, then they could well be on the recovery road (Onken et al. 2002).

Empowerment Individuals are said to be empowered when they have what is necessary (such as resources and opportunity) to achieve what they want to. Nelson et al. (2001) define empowerment as “opportunities for and conditions that promote choice and control, community integration, and valued resources” (p. 127). This involves increased confidence, self-esteem, control over daily life, and independence (Nelson et al. 2001). Empowerment also includes factors such as getting access to education, employment, and housing (Nelson et al. 2001). This is possible by improving personal motivation with the help of supportive relationships, peer support, organizations and communities that are responsive, and advocacy for social justice and equity. Modified versions of the Patient Empowerment Program for Schizophrenia (PEPS) have been successfully used to improve empowerment in different settings (Park and Sung 2013; Hasan and Musleh 2017).

Tasks of Recovery According to Slade (2009), in order to achieve personal recovery, there are four tasks that need to be accomplished. They are: developing a positive identity; framing the mental illness; self-managing the mental illness; and developing valued social roles.

Developing a Positive Identity The first task to achieving recovery is to develop a positive identity apart from the illness. In other words, it involves asking oneself, “Who am I apart from my illness?” This will be different for each individual and hence needs to be decided by the individual

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rather than by others, although others might help the individual decide. It is necessary for a person with a severe mental illness to form a positive identity to separate themselves from the illness. This gives one hope for the future because the positive identity has a brighter future than the illness per se. The purpose of this task is not to ignore the mental illness altogether but rather to not be defined by it. Developing a positive identity can be a painstaking process because it could mean working towards a paradigm shift in one’s original understandings of one’s identity. Hence, this process takes time and is often referred to as a journey (Slade 2009). So where does one start? It might be useful to get help from people one trusts and understands to start the process and the discussion might revolve around negotiating between the questions “What do I want my identity to be?” and “How much of that identity can I achieve?” It might take much toing and froing before one is able to be content and satisfied with the positive identity one has developed for oneself.

Framing the Mental Illness The next recovery task is to describe one’s experience that the mental health system calls a disorder and box it so as to ascertain that “This experience is part of who I am but not all of who I am.” It is important to separate one’s identity from the illness experience. If mental illness is not framed or boxed as an entity that is different from one’s positive identity, it tends to take over and dictate all aspects of one’s life. This situation precludes self-determination and freedom (Slade 2009). Moreover, framing one’s illness experience enables one to understand what one can and cannot do and the extent to which the illness gets in the way of the activities that one chooses to be involved in. This understanding helps the person to learn ways of working around one’s illness.

Self-managing the Mental Illness Self-managing one’s mental illness is to take control of one’s life. What this means is that the person drives their life and makes decisions on what to do while at the same time managing the illness experience as if it is a child that one has responsibility for. Just because one has an active little child does not mean one’s life is determined entirely by the child and his or her needs. It is true that some activities might be challenging to perform while also having to look after the child but that does not mean that the child takes over the parent’s life. Nonetheless, similar to the analogy of the child, self-managing one’s mental illness is sometimes a difficult process which can be overcome with help and support from family, friends, and other support networks.

Developing Valued Social Roles The fourth recovery task suggested by Slade (2009) is the acquisition of social roles. Some of these roles might have been performed previously, some might be new

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while others might be a modification of previous roles. These social roles provide the structure on which the recovering person will develop their identity to the world around them or to their environment. Hence, as described earlier, one has to first develop a positive identity of oneself – then develop social roles to reveal that identity to one’s external environment. The focus needs to be on developing social roles that are valued both by the individual and by society so that they will be doubly reinforced and easier to sustain.

Personal Recovery in a Rural Environment Personal recovery journeys proceed within the context and environment in which people live and experience their day-to-day life. Recovery is context dependent (Pilgrim and McCranie 2013), influenced by local cultural mores, social and economic context, and the availability of treatment and support. Although the process of recovery has common features and elements, the experience of recovery will vary based upon an individual’s unique circumstance. The urban–rural dichotomy is an example of contexts and environments that will influence and impact on an individual’s recovery journey in different ways. This section of the chapter considers the impact that living in a rural area may have upon personal recovery by briefly defining the rural context and exploring factors that impinge upon aspects of personal recovery in rural settings.

Defining Rural Kilpatrick (2009) posits that improving health outcomes of rural communities and rural people requires an understanding of the rural context. However, rural communities are commonly portrayed in a somewhat rustic, idealized, and stereotypical fashion (Parr et al. 2004; Nicholson 2008; Wainer and Chesters 2000). These notions are perhaps best characterized by the concept “Gemeinschaft,” inclusive communities bound by tradition, common beliefs, family ties, trust, and familiarity (Bradshaw 2008). This common conceptualization of rural communities as simply communities of place (Nicholson 2008) is increasingly being challenged as too simplistic and not representative of the heterogeneity of rural settings and rural communities (Parr et al. 2004; Nicholson 2008; Wainer and Chesters 2000). Wainer and Chesters (2000) advocated for a more nuanced conceptualization that reflects the complex interplay of geographical location, population density, socio-economic conditions, diversity of population, states of health and wellbeing, and changing social norms. Nicholson (2008) highlights that a diverse range of rural communities exists, reflecting the overlapping and competing influences of the shared experience of place, interest, and attachment. Recognizing and respecting the diverse nature and range of individual rural community values, norms, traditions, and expectations enables mental health services to garner the local community assets to promote improved mental health outcomes for individuals and communities (Kilpatrick 2009). It is important,

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therefore, to not only recognize that recovery is a unique process for each person but also acknowledge the potentially positive and negative impacts that specific local rural contexts and characteristics may have upon an individual’s recovery journey. While it is important to consider the unique interplay of the individual and their place of residence, five general rural characteristics that commonly are cited in the rural mental health literature that impact upon recovery include: access to clinical support (Gamm et al. 2003; Judd et al. 2006; Aisbett et al. 2007; Nicholson 2008; Bourke 2012; McCord et al. 2012; Ward et al. 2017); dual/overlapping relationships (Gamm et al. 2003; Bourke et al. 2004; Scopelliti et al. 2004; Boyd et al. 2006; Nicholson 2008; Larson et al. 2012; Young et al. 2015); rural community’s understanding of mental illness (Fuller et al. 2000; Gamm et al. 2003; Scopelliti et al. 2004; Judd et al. 2006; Boyd and Parr 2008; Nicholson 2008; Larson et al. 2012); stigma (Gamm et al. 2003; Judd et al. 2006; Boyd and Parr 2008; Nicholson 2008; Larson et al. 2012; Robeiro Gruhl et al. 2012); and limited employment opportunities (Fuller et al. 2000; Schmidt 2000; Boyd and Parr 2008; Nicholson 2008; Robeiro Gruhl et al. 2012).

Access to Clinical Support Even though rural communities experience the same prevalence of mental health problems as urban communities, rural people have less access to services compared to their urban counterparts (Judd et al. 2006; McCord et al. 2012). Nicholson (2008) suggests that access to mental health services in rural settings is a complex interplay of geographical distance from or proximity to services, together with the social, economic, and perceived consequences of travel and displacement when seeking support. Boyd et al. (2006) highlight that proximity to continuing care services influences the likelihood of clients continuing to access care. Specialist service hubs and other health and support services are either not physically located in rural areas or only available in larger rural townships (Schmidt 2000). Many rural people must travel significant distances to access the nearest treatment service (Young et al. 2015), particularly if they live in more remote areas. The tyranny of distance is further compounded by a lack of access to adequate and reliable transport (Bjorklund and Pippard 1999; Schmidt 2000; Knight 2004; Boyd et al. 2006; Aisbett et al. 2007; Young et al. 2015), cost of fuel and travel (Young et al. 2015), and the lack of a vehicle or lack of valid driver’s license (Young et al. 2015; Schmidt 2000). Travel time and loss of earnings are additional burdens rural people face when accessing services (McKinstry and Cusick 2015; Young et al. 2015). These obstacles also serve to diminish the capacity of parents to actively engage in the care and treatment of a child (Young et al. 2015). There is an absence of rural and remote mental health service delivery models (McCord et al. 2012). Consequently services are overwhelmingly implemented using inappropriate urban-centric models of mental health care (Schmidt 2000; Bourke 2012). Often these predominately medical models of care are further

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compromised by shortages of suitably qualified staff, high demand, waiting lists, limited afterhours services (Ward et al. 2017; Bourke 2012; Gamm et al. 2003; Aisbett et al. 2007), and a failure to recognize the importance of family support (Hyde et al. 2015). Additionally, fragmentation of the rural mental health system compromises discharge planning (Schmidt 2000). Generally these shortcomings are more pronounced in remote areas (Schmidt 2000). Consequently rural mental health services have been characterized as being focused on managing risk through containment and medication compliance (Tew 2013).

Dual/Overlapping Relationships Mental health professionals face boundary issues with their clients. These challenges are particularly obvious in smaller rural and remote communities (Scopelliti et al. 2004). A consequence of the limited population size of these communities is that individuals “occupy several roles or role levels and encounter each other in a number of different situations” (Scopelliti et al. 2004, p. 953). Dual and overlapping relationships in rural communities are not limited to interactions with health professionals, but include contacts with administrative and ancillary staff as well as those who facilitate mutual support programs. Such overlapping, or dual, relationships are almost unavoidable and are a characteristic of the social norms intrinsic to rural and remote communities (Scopelliti et al. 2004). Nevertheless, dual and overlapping relationships are a particular concern for rural people with mental health problems (Bourke et al. 2004). Apprehensions are frequently expressed as concerns regarding loss of confidentiality and anonymity (Young et al. 2015; Boyd et al. 2006; Nicholson 2008; Gamm et al. 2003). These trepidations make disclosure in rural settings more challenging (Young et al. 2015), particularly in smaller and more remote communities (Larson et al. 2012). They also serve to restrict choice of other supports such as self-help and mutual support programs. Consequently, it is not uncommon for people to seek assistance outside their community (Young et al. 2015). A particular challenge experienced by young people is parental involvement when help seeking (Boyd et al. 2006). However, if help seeking becomes known, people of all ages can encounter strained social and community relationships (Young et al. 2015).

Rural Community Understanding of Mental Illness Generally people in rural communities are reported to have stereotypical views of mental illness, commonly understanding mental illness in terms of psychosis (Boyd and Parr 2008; Nicholson 2008), incompetence, and dangerousness (Larson et al. 2012). The low level of mental health literacy (Judd et al. 2006; Boyd and Parr 2008) manifests in nonrecognition of mental health problems (Boyd and Parr 2008; Nicholson 2008), hesitancy to acknowledge mental health problems (Gamm et al. 2003; Fuller et al. 2000), reluctance to seek help (Boyd and Parr 2008), lack of

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confidence in dealing with mental health issues (Barry et al. 2000), and poor knowledge of local services (Schmidt 2000). The low levels of awareness are compounded by rural stoicism (Boyd and Parr 2008; Judd et al. 2006; Nicholson 2008; Larson et al. 2012; Fuller et al. 2000), self-reliance (Fuller et al. 2000; Judd et al. 2006; Scopelliti et al. 2004), and self-efficacy (Judd et al. 2006).

Stigma Stigma towards mental illness is pervasive in rural areas (Boyd and Parr 2008; Larson et al. 2012; Judd et al. 2006; Nicholson 2008; Gamm et al. 2003). Larson et al. (2012) suggest that the degree of stigma varies across rural communities. Smaller communities are reported to hold more stigmatizing attitudes (Larson et al. 2012; Robeiro Gruhl et al. 2012), particularly in remote First Nations communities where mental illness can be associated with the stigma and shame of bad medicine or curse (Schmidt 2000). However, rural communities are also reported as tolerating eccentricity (Fuller et al. 2000; Nicholson 2008). Barry et al. (2000) found that stigma towards mental illness varied by gender with men, principally those under 40 years of age, being more concerned about the social implications of disclosing a mental health problem compared to women. The fear and social stigma associated with mental illness in rural communities influences familial attitudes to addressing mental health problems (Larson et al. 2012), inhibits help seeking (Larson et al. 2012; Boyd and Parr 2008), and can result in people with obvious mental health problems being ostracized and excluded (Parr et al. 2004; Aisbett et al. 2007). Stigma influences the general rural mores towards mental illness and increases the risk of self-stigmatization for rural people experiencing mental health problems. This risk is compounded by social visibility (Aisbett et al. 2007), unemployment, level of education, and economic status (Larson et al. 2012).

Limited Employment Opportunities Employment in rural and remote communities is related to the economic circumstances of the local and regional area in which a particular community is located (Fuller et al. 2000). Often there is a reliance, particularly in more remote areas, on a small number of industries and employers (Nicholson 2008), and some rural industries only offer seasonal work or are not particularly viable (Boyd and Parr 2008). Securing meaningful and gainful employment in rural areas is challenging enough for rural people without the added burden of having a mental health problem, particularly in more remote areas that lack prevocational training opportunities, have high rates of unemployment and people may have limited educational attainment (Schmidt 2000). Robeiro Gruhl et al. (2012) found that people with serious mental illness in rural Canada experienced employment discrimination; that employers focused on the illness not the individual and their capabilities.

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Furthermore, those with serious mental illness were only offered menial work or work that others were unwilling to accept (Robeiro Gruhl et al. 2012). Personal recovery for individuals from rural areas with a mental health problem is significantly influenced by the prevailing community attitudes towards, and understanding of, mental illness. Even when someone is willing to seek help, concerns regarding anonymity and confidentiality may further restrict the limited available treatment options. Furthermore, restricted educational and employment opportunities may limit the horizons to which a person with a mental illness in a rural community can aspire. These challenges to recovery in rural settings may be further compounded by other characteristics of the rural environment including isolation and loneliness (Rainer and Martion 2012), local rural economy (Boyd and Parr 2008), limited access to other support services, limited access to social infrastructure (Schmidt 2000; Nicholson 2008), and poor and unreliable communication infrastructure (Nicholson 2008). Although these obstacles to recovery are common to all those with mental health problems in rural areas, the issues may be magnified for First Nation communities (Schmidt 2000) and those from minority groups including those who identify as gay, lesbian, bisexual, transsexual and/or intersex, those from ethnic minorities, and those from nondominant language backgrounds.

Enabling Recovery in Rural Areas Considering the challenges outlined in the preceding section of this chapter, it is reasonable to understand that the challenges faced by rural people with a mental health problem, rurally based practitioners, and rurally focused policy makers to realize opportunities for personal recovery appear bleak. Unfortunately, this overwhelming gloom is reinforced by the dominant deficit focused discourse presented in the rural mental health literature. The extant mental health recovery literature has a dearth of papers addressing personal recovery in a rural setting and there is little evidence of research that explores recovery in the rural context. The scant literature to date primarily consists of case histories and evaluations of localized service initiatives (Taylor et al. 2010; Hyde et al. 2015; Knight 2004; Prabhu and OakleyBrowne 2007; Dunstan et al. 2014; Veysey et al. 2004), case histories of initiatives designed to support an individual (Wilson 2014), meet a local community’s need (Leenders et al. 2011), or explore the recovery experiences of rural men (Gorman et al. 2007). It is unsurprising that the deficit focused rural mental health discourse has resulted in a paucity of evidence of rural recovery informed service innovation and an absence of a cogent rural recovery research agenda. Just as personal recovery requires hope, re-orientating the rural mental health service system to operate from a personal recovery orientated fashion requires hope and inspiration. Inspiration may be found in Patricia Deegan’s (1988) simple, yet profound, statement that the aspiration of recovery is “to live, work and love in a community in which one makes a significant contribution” (p. 15). Deegan’s statement highlights that the central aim of recovery orientated practice is to facilitate pathways to active community participation for those experiencing mental illness. Therefore,

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recovery focused practice should promote and enable social inclusion. Implementing a social inclusion model to recovery practice requires consideration of the enablers and barriers to community participation in the environment within which individuals experiencing mental illness live. This section of the chapter considers how adopting a social inclusion approach may provide a conceptual framework to inform the development, implementation, and research of rural models of recovery practice.

Social Inclusion Social inclusion emerged as an element of social policy during the 1990s (Schneider and Bramley 2008). It was an approach designed to prevent and alleviate the multiple social disadvantages suffered by individuals, families, groups, and communities due to varying degrees of social exclusion (Schneider and Bramley 2008; Sayce 2001; Wright and Stickley 2013). Socially inclusive interventions are therefore designed to ameliorate the comparative discrimination and/or inequality that individuals, families, groups, and communities face relative to others from the society within which they live (Schneider and Bramley 2008; Sayce 2001; Wright and Stickley 2013). Social exclusion is an inherently dynamic construct that is fashioned by the ever changing impact of environmental, social, political, and economic forces that shape people’s lives (Schneider and Bramley 2008). Cobigo and Stuart (2010) suggest that approaches to promote social inclusion can be categorized into four broad domains: legislation, community based supports and services, antistigma/antidiscrimination initiatives, and system monitoring and evaluation. Both legislation and system monitoring/evaluation are whole of population approaches to lessening the impacts of social exclusion (Cobigo and Stuart 2010). In contrast, the two other action domains can be operationalized at either whole of population or local community levels (Cobigo and Stuart 2010). Both community based supports and services interventions and antistigma/antidiscrimination initiatives should address the factors that prevent individuals, families, groups, and communities from exercising their full citizenship rights (Cobigo and Stuart 2010). Promoting social inclusion is therefore integral to personal recovery. Cobigo and Stuart (2010) suggest that “disability and social exclusion are integrally intertwined” (p. 454). Similarly, the link between social exclusion and mental illness is multifaceted and interactional, where aspects of social exclusion can be either the cause or the consequence of experiencing mental illness (Sayce 2001). Regardless of the etiology, Wright and Stickley (2013) propose that mental health practitioners should foster social inclusion by concentrating on promoting client’s rights, supporting clients into gainful employment, and working to resolve the health inequalities experienced by people with mental illness. In the context of people from rural areas with a mental illness, social inclusion interventions should specifically address improving access to clinical support, the negative impact of dual/overlapping relationships, improving understanding of mental illness across rural communities, the discriminatory impact of stigma, and improving access to education and gainful employment.

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Targeted interventions to address these unique rural issues fall within two of social inclusion action domains identified by Cobigo and Stuart (2010), namely, access to community based support and services and antistigma/antidiscrimination initiatives. The identification of these two action areas is further justified through the work of Tew et al.’s (2012) review of social interventions that address three areas of the CHIME Framework, namely, empowerment, identity, and connectedness. The authors identified promising evidence that community-based support and services interventions enhance recovery. Interventions that have demonstrated some degree of effectiveness include: enabling self-directed support; peer-organized services; utilizing a family or systems approach; and supporting access to education and employment (Tew et al. 2012). Tew et al. (2012) also identified evidence that interventions designed to address the impact of stigma facilitate personal recovery. Antistigma/antidiscrimination interventions supported by evidence include programs designed to address the stigma of mental illness, reduce discrimination, promote self-efficacy, and enable individuals impacted by mental illness to rebuild positive personal and social identities (Tew et al. 2012).

Community Support and Service Interventions The goal of this domain of social inclusion interventions is to enable people with mental illness to fully participate in the civic life of the communities in which they live (Cobigo and Stuart 2010). Interventions therefore need to focus on creating opportunities for rural people with mental health problems to live fulfilling and satisfying lives and assume purposeful and valued social roles. Central to this approach is working to ensure that services and supports are implemented within a person-centred recovery framework (Cobigo and Stuart 2010). Interventions therefore need to include strategies that overcome individual barriers to recovery together with actions designed to alleviate the impact of social and environmental factors that stymie personal recovery (Tew et al. 2012). Community supports and services interventions that have been reported to facilitate personal recovery include: • Adopting a strengths based approach; • Implementing self-directed support through individualized funding packages that offer choice and control; • Initiating user led services and supports (e.g., self-help groups, mutual support initiatives, and peer led services); • Providing opportunities for people with lived experience to take on meaningful and valued roles within services; • Instituting treatment and support services that minimize dislocation from one’s community; • Delivering systems interventions (e.g., family therapy); • Establishing friendship or buddying programs; and • Creating pathways to paid and voluntary employment (Tew et al. 2012).

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Unfortunately, more is currently known about how social factors contribute to the incidence of mental health problems than how social factors may enable recovery (Tew et al. 2012). The limited rural recovery literature addressing this social inclusion domain principally provides case studies of individual service initiatives from the USA and Australia. Veysey et al. (2004) describe how a community development approach was used to inform a recovery informed service for rural women with dual diagnosis in New England. Key features of the approach included utilizing an addiction recovery model (Addiction and Trauma Recovery Model), incorporating peer advocacy processes and roles, providing opportunities for service users to take on valued roles, and developing strong linkages with other services. Knight (2004) outlines how a rural community mental health service in Colorado transitioned to a recovery focused approach through a collaborative participatory approach to redesigning the service. The re-engineered service included a housing program, dual diagnosis program, enabled access to other health care services, and created roles for peer workers. Both service initiatives report providing transport to address access issues (Knight 2004; Veysey et al. 2004). Prabhu and Oakley-Browne (2007) outline the implementation of an outreach collaborative recovery model in a rural region of Victoria, Australia. The program aimed to engage with service users and their carers in their home environments, provide access to psychosocial rehabilitation, and minimize hospitalization. Taylor et al. (2010) describe the establishment of a consumer led community mental health support service in rural South Australia. Aims of the service included creating a nurturing environment in which people felt accepted, providing service recipients with the opportunity to take on roles, and enabling service access by providing transport. However, the authors reported that the longer-term sustainability of the initiative was dependent upon acceptance and support from the wider community. Dunstan et al. (2014) report on the implementation of the Personal Helpers and Mentors program in rural New South Wales, Australia. This program operates principally using peer workers. The program engaged well with Aboriginal people, in part due to the high proportion of Aboriginal workers employed in the service. Although an evaluation indicated that service recipients were achieving their recovery goals, service users raised concerns regarding confidentiality related to dual/overlapping roles of staff. Wilson (2014) recounts a local community initiative designed to assist someone who recently had an inpatient admission re-integrate into her local church community. The initiative involved providing information to members of a quilting group about mental illness and its impacts prior to the individual joining the group. Perhaps the most well-known recovery oriented program in Australia is the Partners in Recovery (PIR) initiative (Australian Government Department of Health 2014). However, there are few studies of this initiative that were conducted in a rural setting. Evaluation of this project in rural Victoria showed that clients with severe mental illness were able to overcome stigma, easily navigate through the maze of services, enroll for an employment-oriented course, and obtain stable

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accommodation. The PIR initiative also brought hope to the lives of individuals living with SPMI and improved their ongoing quality of life (Isaacs et al. 2017; Sutton et al. 2017).

Antistigma/Antidiscrimination Interventions The most pervasive barriers to social inclusion for people with mental health problems are the enduring stereotypical perceptions that exist in the general population (Cobigo and Stuart 2010). The belief that people with mental illness do not have the capacity to make decisions and suffer life-long conditions that are not amenable to community based treatment and support fosters the common misconception that mental health services exist to protect society (Cobigo and Stuart 2010). However, people with mental health problems frequently identify health professionals as the principal source of stigma and discrimination they encounter (Cobigo and Stuart 2010). Furthermore, stigmatization by association has been found to affect the families of those with mental illness (Tew et al. 2012). The goal of the antistigma/antidiscrimination domain of social inclusion interventions is to change attitudes and misconceptions and mitigate the impact of prejudice and discrimination on individuals with mental health problems. The emerging evidence identified by Tew et al. (2012) for social inclusion interventions that addresses this domain includes: • Therapies and programs that enable individuals to re-build positive personal and social identities; • Therapies that assist individuals to develop stigma resistance strategies; • Community level strategies that address the prevailing attitudes about mental illness and behaviors towards those experiencing mental health problems; and • Processes that identify and challenge inadvertent stigmatizing professional practice. The most effective interventions that have emerged are approaches which involve active learning combined with direct social contact with people with mental illness who are in recovery (Stuart 2016). The evidence for other interventions such as awareness raising, mass media, and mental health literacy programs (including Mental Health First Aid) is poor at best (Stuart 2016). Sartorius and Stuart (2009) suggest that to be effective anti-stigma programs must: 1. Be sustained over long periods of time; 2. Have dedicated support and resources to deliver locally relevant and feasible initiatives; 3. Aim to make a difference in the lives of those with mental illness and their families; 4. Be multisectoral and have a whole of community approach;

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5. Actively involve people with mental illness and their families in the planning, delivery, and evaluation of the intervention; 6. Use a theory informed approach to designing, implementing, and evaluating interventions; 7. Institute strategies to prevent burn-out in those responsible for delivering programs; 8. Establish extensive links across the community in which programs operate; 9. Create strategies to recruit and orientate new members to the implementation team; and 10. Evaluate the impact of interventions and programs. Stuart (2016) also emphasized that antistigma programs must be tailored to the local context in which they are delivered. Furthermore, interventions should be informed by theory and evidence, target the behavioral outcomes of stigmatization at both individual and communal levels, and be objectively evaluated, ideally through a community-university alliance (Stuart 2016). Social inclusion provides a framework for re-orientating rural mental health service systems to promote and support personal recovery in rural areas. Models of rural recovery practice need to be tailored to the local context and operationalized at a local community level. Rural recovery practice should include targeted local strategies designed to enable access to community based support and services together with specific localized interventions that aim to lessen the impact of stigma and discrimination. A social inclusion approach to designing, implementing, and evaluating models of rural recovery focused practice goes beyond the remit and capacity of traditional rural mental health services. Socially inclusive recovery practice requires a whole of community approach that engages rural people with mental health problems and their carers, community members, rural industry, social support services, rural mental health practitioners, rural bureaucrats, and rural researchers. Co-design offers a mechanism to engage the various stakeholders to drive the process of designing, implementing, and evaluating recovery focused services that are tailored to suit local rural environments.

Co-design The principles of co-design provide a framework for the involvement of multiple stakeholders in the design, implementation, and evaluation of local interventions designed to address social inclusion in both the community service and support domain and the antistigma/antidiscrimination domain. Co-design of mental health services refers to the process where consumers, carers, and service providers jointly design models of care. This concept is similar to the model of “Experience Based Design” proposed by Bate and Robert (2007). The need to involve consumers in the planning of mental health services has been stated in national mental health policies for several years (Simpson and House 2003).

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However, implementation has been slow to eventuate. There are several challenges to implementing co-designed services because consumers, carers, and service providers approach issues from very different perspectives (Reeve et al. 2016) and these approaches need to be reconciled in order for co-design to succeed. Despite these challenges, co-design is possible (Vaeggemose et al. 2018) and has been found to be useful in the provision of support and service access (Lakeman 2008) as well as discharge planning and consumer education (Paton et al. 2013). Co-design is an emerging science in mental health care and is currently being utilized in Recovery Colleges as an educational tool (Surrey and Borders Partnership NHS Foundation Trust 2017; Mind 2017).

Conclusion The concept of recovery emerged in the mental health field emerged in the 1990s. Through the late 1990s and 2000s, personal recovery was adopted by western nations as the policy framework for mental health service systems. The paradigm shift from an emphasis on treatment and cure to personalized approaches that enable people experiencing mental illness to live purposeful and meaningful lives is far from over. The relatively recent field of mental health recovery research has helped inform a better understanding of factors important to enabling personal recovery, although much is still unknown. The tasks of recovery and the CHIME Framework provide useful schemas for exploring and understanding the impact of recovery focused interventions. However, these conceptual frameworks do not provide the necessary theoretical context to help better understand the social factors that enable personal recovery. Furthermore, personal recovery is context specific which suggests the need for rural models of recovery practice. However, the extant rural mental health literature suggests that current rural models of service delivery are urban centric in design and unsuited to the diverse nuances of local rural environments. Additionally, there is little evidence of any systematic endeavor to design, implement, and evaluate rural recovery focused mental health services. Social inclusion provides a theoretical framework to guide the design, implementation, and evaluation of rural models of recovery practice. Socially inclusive recovery interventions should be designed to lessen the impact of discrimination and inequality that individuals with mental health problems face relative to others from their local community. The design of rural models of recovery practice should therefore include strategies to improve access to community services and supports, as well as antistigma/antidiscrimination programs. Emerging evidence demonstrates that theory informed recovery interventions designed to address these two social inclusion action areas facilitate personal recovery. However, re-orientating rural mental health services to operate within a social inclusion paradigm requires the involvement of stakeholders from across the local community and not just service users and mental health practitioners. Co-design offers a promising participatory approach to engaging stakeholders in the design, implementation, and evaluation of locally tailored models of rural recovery focused practice. It is incumbent upon rural

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people in recovery, rural mental health practitioners, and rural mental health researchers to form alliances which aim to foster the development of locally tailored models of recovery focused practice.

Take Home Messages • The experience of recovery is context specific. • Models of rural recovery focused practice should be tailored to address the unique characteristics of the communities in which programs operate. • Models of recovery practice must include interventions that address access to community services and supports and strategies to lessen the impact of stigma and discrimination on rural people experiencing mental health problems. • Designing, implementing, and evaluating models of rural orientated practice requires a whole of community approach. • Co-design provides a participatory approach to developing rural models of recovery practice.

Cross-References ▶ Environmental Impacts on Mental Health ▶ Future of Rural, Remote, and very Remote Mental Health ▶ Global Mental Health Perspectives on Rural and Remote Mental Health Provision ▶ Indigenous Mental Health in Remote Communities ▶ Mental Health Research and Evaluation in Rural, Remote, and very Remote Settings ▶ Models of Service Delivery and Funding of Mental Health Services ▶ Promotion and Prevention of Mental Health Problems in Rural and Remote Context ▶ Providing School-Based Mental Health Services in Rural and Remote Settings ▶ Rural, Remote, and very Remote Mental Health ▶ Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts ▶ Supporting Communities

References Aisbett DL, Boyd CP, Francis KJ, Newnham K, Newnham K. Understanding barriers to mental health service utilization for adolescents in rural Australia. Rural Remote Health. 2007;7:624. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabil J. 1993;16:11–23. Australian Government Department of Health. Partners in Recovery: coordinated support and flexible funding for people with severe and persistent mental illness with complex needs

132

K. Sutton and A. Isaacs

(PIR) [Online]. Canberra: Commonwealth of Australia 2014; 2014. Available: http://www. health.gov.au/internet/main/publishing.nsf/Content/mental-pir. Accessed 26 May 2015. Barry MM, Doherty A, Hope A, Sixsmith J, Kelleher CC. A community needs assessment for rural mental health promotion. Health Educ Res. 2000;15:293–304. Bate P, Robert G. Bringing user experience to healthcare improvement: the concepts, methods and practices of experience-based design. Abingdon: Radcliffe Publishing Ltd; 2007. Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull. 2006;32:432–42. Berren MR, Santiago JM, Zent MR, Carbone CP. Health care utilization by persons with severe and persistent mental illness. Psychiatr Serv. 1999;50:559–61. Bjorklund R, Pippard J. The mental health consumer movement: implications for rural practice. Community Ment Health J. 1999;35:347–59. Borg M, Kristiansen K. Recovery-oriented professionals: helping relationships in mental health services. J Ment Health. 2004;13:493–505. Bourke L. Forgotten rural health? J Community Med Health Educ. 2012;2:e106. Bourke L, Sheridan C, Russell U, Jones G, Dewitt D, Liaw ST. Developing a conceptual understanding of rural health practice. Aust J Rural Health. 2004;12:181–6. Boyd CP, Parr H. Social geography and rural mental health research. Rural Remote Health. 2008;8:804. Boyd CP, Aisbett DL, Francis K, Kelly M, Newnham K, Newnham K. Issues in rural adolescent mental health in Australia. Rural Remote Health. 2006;6:501. Bradshaw TK. The post-place community: contributions to the debate about the definition of community. Community Dev. 2008;39:5–16. Bryant FB, Cvengros JA. Distinguishing hope and optimism: two sides of a coin, or two separate coins? J Soc Clin Psychol. 2004;23:273–302. Cobigo V, Stuart H. Social inclusion and mental health. Curr Opin Psychiatry. 2010;23:453–7. Corrigan PW, Phelan SM. Social support and recovery in people with serious mental illnesses. Community Ment Health J. 2004;40:513–23. Davidson L, Roe D. Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery. J Ment Health. 2007;16:459–70. Davidson L, O’connell MJ, Tondora J, Lawless M, Evans AC. Recovery in serious mental illness: a new wine or just a new bottle? Prof Psychol Res Pract. 2005;36:480–7. Davidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the field. Schizophr Bull. 2006a;32:443–50. Davidson L, O’Connell M, Tondora J, Styron T, Kangas K. The top ten concerns about recovery encountered in mental health system transformation. Psychiatr Serv. 2006b;57:640–5. Davidson L, Tondora J, Lawless MS, O’Connell M, Rowe M. A practical guide to recovery-oriented practice tools for transforming mental health care. Oxford: Oxford University Press; 2009. Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012;11:123–8. Deegan P. Recovery: the lived experience of rehabilitation. Psychosocial Rehabil J. 1988;11:11–9. Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatr. 2014;59:236–42. Dunstan DA, Todd AK, Kennedy LM, Anderson DL. Impact and outcomes of a rural Personal Helpers and Mentors service. Aust J Rural Health. 2014;22:50–5. Evans J, Repper J. Employment, social inclusion and mental health. J Psychiatr Ment Health Nurs. 2000;7:15–24. Fowler D, Hodgekins J, Painter M, Reilly T, Crane C, Macmillan I, Mugford M, Croudace T, Jones PB. Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis). Psychol Med. 2009;39:1627–36. Fuller J, Edwards J, Procter N, Moss J. How definition of mental health problems can influence help seeking in rural and remote communities. Aust J Rural Health. 2000;8:148–53.

6

Recovery in Mental Illness Among Rural Communities

133

Gallagher MW, Lopez SJ. Positive expectancies and mental health: identifying the unique contributions of hope and optimism. J Posit Psychol. 2009;4:548–56. Gamm L, Stone S, Pittman S. Mental health and mental disorders – a rural challenge: a literatiure review. Rural Healthy People 2010: a companion document to Healthy People 2010. In: Rural Healthy People 2010: a companion document to Healthy People 2010. College Station: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Rural Research Center; 2003. Gorman D, Buikstra E, Hegney D, Pearce S, Rogers-Clark C, Weir J, Mccullagh B. Rural men and mental health: their experiences and how they managed: feature article. Int J Ment Health Nurs. 2007;16:298–306. Hasan A, Musleh M. The impact of an empowerment intervention on people with schizophrenia: results of a randomized controlled trial. Int J Soc Psychiatry. 2017;63:212–23. Hendryx M, Green CA, Perrin NA. Social support, activities, and recovery from serious mental illness: STARS study findings. J Behav Health Serv Res. 2009;36:320–9. Hughes R, Hayward M, Finlay WML. Patients’ perceptions of the impact of involuntary inpatient care on self, relationships and recovery. J Ment Health. 2009;18:152–60. Hyde B, Bowles W, Pawar M. ‘We’re still in there’ – consumer voices on mental health inpatient care: social work research highlighting lessons for recovery practice. Br J Soc Work. 2015;45: i62–78. Isaacs AN, Sutton K, Dalziel K, Maybery D. Outcomes of a care coordinated service model for persons with severe and persistent mental illness: a qualitative study. Int J Soc Psychiatry. 2017;63(1):40–47. Jacobson N, Greenley D. What is recovery? A conceptual model and explication. Psychiatr Serv. 2001;52:482–5. Judd F, Jackson H, Komiti A, Murray G, Fraser C, Grieve A, Gomez R. Help-seeking by rural residents for mental health problems: the importance of agrarian values. Aust N Z J Psychiatry. 2006;40(9):769–76. Kilpatrick S. Multi-level rural community engagement in health. Aust J Rural Health. 2009;17:39–44. Knight EL. Exemplary rural mental health services delivery. Behav Healthc Tomorrow. 2004;13:20–4. Lakeman R. Family and carer participation in mental health care: perspectives of consumers and carers in hospital and home care settings. J Psychiatr Ment Health Nurs. 2008;15:203–11. Larson J, Corrigan P, Cothran T. The impact of mental health stigma on clients from rural settings. In: Smalley KB, Warren JC, Rainer JP, editors. Rural mental health: issues, policies, and best practices. New York: Springer; 2012. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–452. Leenders M, Dyer GM, Saunders V. Work in progress: creative recovery to creative livelihoods. Australas Psychiatry. 2011;19(Suppl 1):S45–8. Lloyd C, Tse S, Deane FP. Community participation and social inclusion: how practitioners can make a difference. Aust e-J Adv Mental Health. 2006;5. [Online]. Available: www.auseinet. com/journal/vol5iss3/lloyd.pdf Lyons GCB, Deane FP, Kelly PJ. Forgiveness and purpose in life as spiritual mechanisms of recovery from substance use disorders. Addict Res Theory. 2010;18:528–43. McCord C, Elliott T, Brossart D, Castillo L. Mental health issues in rural areas. In: Crosby R, Vanderpool R, Wendel M, Casey B, editors. Rural populations and health: determinants, disparities, and solutions. San Francisco: Jossey-Bass; 2012. McIntyre RS, Lee Y, Mansur RB. Treating to target in major depressive disorder: response to remission to functional recovery. CNS Spectr. 2015;20(Suppl 1):20–30; quiz 31 Mckinstry C, Cusick A. Australia needs more occupational therapists in rural mental health services. Aust Occup Ther J. 2015;62:275–6.

134

K. Sutton and A. Isaacs

MIND. Mind recovery college [Online]. Cheltenham: MIND; 2017. Available: http://www. recoverycollege.org.au/. Accessed 29 Nov 2017. Nelson G, Lord J, Ochocka J. Empowerment and mental health in community: narratives of psychiatric consumer/survivors. J Community Appl Soc Psychol. 2001;11:125–42. Nicholson LA. Rural mental health. Adv Psychiatr Treat. 2008;14:302. Onken SJ, Dumont JM, Ridgway P, Dornan DH, Ralph RO. Mental health recovery: what helps and what hinders? A national research project for the development of recovery facilitating system performance indicators. Phase one research report: a national study of consumer perspectives on what helps and hinders mental health recovery. Alexandria: National Association of State Mental Health Program Directors (NASMHPD), National Technical Assistance Center (NTAC); 2002. Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. An analysis of the definitions and elements of recovery: a review of the literature. Psychiatr Rehabil J. 2007;31:9–22. Park SA, Sung KM. The effects on helplessness and recovery of an empowerment program for hospitalized persons with schizophrenia. Perspect Psychiatr Care. 2013;49:110–7. Parr H, Philo C, Burns N. Social geographies of rural mental health: experiencing inclusions and exclusions. Trans Inst Br Geogr. 2004;29:401–19. Paton N, Callander R, Cavill M, Ning L, Weavell W. Collaborative quality improvement: consumers, carers and mental health service providers working together in service co-design. Australas Psychiatry. 2013;21:78–9. Pernice-Duca F. Family network support and mental health recovery. J Marital Fam Ther. 2010;36:13–27. Pettie D, Triolo AM. Illness as evolution: the search for identity and meaning in the recovery process. Psychiatr Rehabil J. 1999;22:255–62. Piat M, Sabetti J, Couture A, Sylvestre J, Provencher H, Botschner J, Stayner D. What does recovery mean for me? Perspectives of Canadian mental health consumers. Psychiatr Rehabil J. 2009;32:199–207. Pilgrim D, Mccranie A. Recovery and mental health: a critical sociological account. Houndmills: Basingstoke Palgrave Macmillan; 2013. Prabhu R, Oakley-Browne M. A recovery-based outreach program in rural Victoria. Australas Psychiatry. 2007;15:120–4. Rainer J, Martion J. Loneliness and isolation in rural areas. In: Smalley KB, Rainer J, Warren J, editors. Rural mental health: issues, policies, and best practices. New York: Springer; 2012. Reeve J, Cooper L, Harrington S, Rosbottom P, Watkins J. Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention. BMC Health Serv Res. 2016;16:470. Resnick SG, Rosenheck RA, Lehman AF. An exploratory analysis of correlates of recovery. Psychiatr Serv. 2004;55:540–7. Robeiro Gruhl K, Kauppi C, Montgomery P, James S. “Stuck in the mud”: limited employment success of persons with serious mental illness in northeastern Ontario. Can J Commun Ment Health. 2012;31:67–81. Ruggeri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. Definition and prevalence of severe and persistent mental illness. Br J Psychiatry. 2000;177:149–55. Sartorius N, Stuart H. Stigma of mental disorders and consequent discrimination. Korean J Schizophr Res. 2009;12:5–9. Sayce L. Editorial: social inclusion and mental health. Psychiatr Bull. 2001;25:121–3. Schmidt G. Barriers to recovery in a first nations community. Can J Commun Mental Health. 2000;19:75–87. Schneider J, Bramley CJ. Towards social inclusion in mental health? Adv Psychiatr Treat. 2008;14:131–8. Schön U-K. Recovery from severe mental illness, a gender prespective. Scand J Caring Sci. 2010;24:557–64. Schon UK, Denhov A, Topor A. Social relationships as a decisive factor in recovering from severe mental illness. Int J Soc Psychiatry. 2009;55:336–47.

6

Recovery in Mental Illness Among Rural Communities

135

Scopelliti J, Judd F, Grigg M, Hodgins G, Fraser C, Hulbert C, Endacott R, Wood A. Dual relationships in mental health practice: issues for clinicians in rural settings. Aust N Z J Psychiatry. 2004;38:953–9. Shiers D, Rosen A, Shiers A. Beyond early intervention: can we adopt alternative narratives like ‘Woodshedding’ as pathways to recovery in schizophrenia? Early Interv Psychiatry. 2009;3:163–71. Simpson EL, House AO. User and carer involvement in mental health services: from rhetoric to science. Br J Psychiatry. 2003;183:89–91. Slade M. Personal recovery and mental illness: a guide for mental health professionals. New York: Cambridge University Press; 2009. Slade M, Longden E. Empirical evidence about recovery and mental health. BMC Psychiatry. 2015;15:285. Steger MF, Frazier P, Kaler M, Oishi S. The meaning in life questionnaire: assessing the presence of and search for meaning in life. J Couns Psychol. 2006;53:80–93. Stuart H. Reducing the stigma of mental illness. Global Mental Health. 2016; 3. Surrey and Borders Partnership NHS Foundation Trust. Recovery college [Online]. Surrey: Surrey and Borders Partnership NHS Foundation Trust; 2017. Available: http://www.sabp.nhs.uk/ recovery/recovery-college. Accessed 29 Nov 2017. Sutton K, Isaacs AN, Dalziel K, Maybery D. Roles and competencies of the Support Facilitator in Australia. Aust Health Rev. 2017;41(1):91–97. Taylor J, Jones RM, O’Reilly P, Oldfield W, Blackburn A. The Station Community Mental Health Centre Inc: nurturing and empowering. Rural Remote Health. 2010;10:1411. Tew J. Recovery capital: what enables a sustainable recovery from mental health difficulties? Eur J Soc Work. 2013;16:360–74. Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and recovery from mental health difficulties: a review of the evidence. Br J Soc Work. 2012;42:443–60. Vaeggemose U, Ankersen PV, Aagaard J, Burau V. Co-production of community mental health services: organising the interplay between public services and civil society in Denmark. Health Soc Care Community. 2018;26(1):122–130. Veysey BM, Andersen R, Lewis L, Mueller M, Stenius VMK. Integration of alcohol and other drug, trauma and mental health services: an experiment in rural services integration in Franklin County, MA. Alcohol Treat Q. 2004;22:19–39. Wainer J, Chesters J. Rural mental health: neither romanticism nor despair. Aust J Rural Health. 2000;8:141–7. Ward B, Reupert A, Mccormick F, Waller S, Kidd S. Family-focused practice within a recovery framework: practitioners’ qualitative perspectives. BMC Health Serv Res. 2017;17(1):234. Weinberg CM. Hope, meaning, and purpose: making recovery possible. Psychiatr Rehabil J. 2013;36:124–5. Wilson RL. Mental health recovery and quilting: evaluation of a grass-roots project in a small, rural, Australian christian church. Issues Ment Health Nurs. 2014;35:292–8. Wright PA, Kloos B. Housing environment and mental health outcomes: a levels of analysis perspective. J Environ Psychol. 2007;27:79–89. Wright N, Stickley T. Concepts of social inclusion, exclusion and mental health: a review of the international literature. J Psychiatr Ment Health Nurs. 2013;20:71–81. Yanos PT, Roe D, Lysaker PH. The impact of illness identity on recovery from severe mental illness. Am J Psychiatr Rehabil. 2010;13:73–93. Young LB, Grant KM, Tyler KA. Community-level barriers to recovery for substance-dependent rural residents. J Soc Work Pract Addict. 2015;15:307–26.

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Professional Ethics in Rural Practice: Relational Territory Judi L. Malone

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overlapping Relationships and Objectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overlapping Relationships and Professional Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overlapping Relationships in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overlapping Relationships and Practice Adaptations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reframing Overlapping Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Pressure and Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Pressure in Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Adaptations for Community Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reframing Community Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Generalist Practice and Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Generalist Practice in Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Adaptations for Generalist Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reframing Generalist Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interdisciplinary Collaboration and Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interdisciplinary Collaboration in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Adaptations for Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reframing Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professional Development and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professional Development in Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Adaptations for Professional Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Critical Incidents and Ethical Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contextualizing Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professional Ethics in Rural Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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J. L. Malone (*) PAA Psychologists’ Association of Alberta, Edmonton, AB, Canada e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_7

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Abstract

Some of the best lessons for rural and remote practicing psychologists arise from context-specific critical incidents. It is important to identify areas of professional ethics to best respond to the rural and remote practice context both for practice but also to inform training and professional development in rural and remote practice. Key general considerations include overlapping relationships and objectivity, community pressure and integrity, generalist practice and competency, interdisciplinary collaboration and confidentiality, and professional development and support. Specific considerations are born of characteristics of the community of practice interacting with the generalist nature of practice. That gives rise to necessary practice adaptations specific to the size and remoteness of the community. It is that element of rural practice that make adaptations necessary that could be used as a rationale or excuse for idiosyncratic variations to practice that are not justifiable and further increase ethical dilemmas. This risk is enhanced with insufficient awareness. In this chapter, some such adaptations are explored. Central to all are “boundary setting” and “consultation” as mechanisms for resolving dilemmas.

Introduction Psychologists must consider the content and context when assessing dilemmas in their ethical decision-making – psychology in rural and remote practice presents such a specific context. This setting increases our responsibility and our anxieties about ethical decision-making and fosters the need for those of us in rural and remote practice of psychology to have a mature and reflective understanding of ethics and professional practice. Context is everything. Indeed, professional codes of ethics differ across countries. A few examples include: International – http://www.iupsys.net/about/governance/universal-declaration-ofethical-principles-for-psychologists.html Canada – https://www.cpa.ca/docs/File/Ethics/CPA_Code_2017_4thEd.pdf Australia – https://www.psychology.org.au/getmedia/67370669-e701-4b1d-9ef9c5b8e0011da8/Code-of-Ethics-APS.pdf United States of America – http://www.apa.org/ethics/code/ Britain – https://www.bps.org.uk/news-and-policy/bps-code-ethics-and-conduct These have practice implications that impact practice in various rural, remote, or northern locations. Readers are challenged to reflect on their own context and ethical code in examining these issues. This chapter focuses on the professional ethics and conduct of psychologists and so reviews the required ethical and decision-making acumen for rural psychologists through both the ethical challenges that manifest in the rural or remote context and considerations for adaptations to practice norms to bridge these ethical concerns.

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Key general considerations in this exploration include overlapping relationships and objectivity, community pressure and integrity, generalist practice and competency, interdisciplinary collaboration and confidentiality, and professional development and support. This chapter will highlight the role of critical incidents and underscore key considerations of professional ethics for rural professional practice.

Overlapping Relationships and Objectivity An overlapping relationship (often called dual or multiple relationships) occurs when a psychologist enters into a second, nonprofessional relationship or role with a client. This may occur before, during, or after the professional relationship and may arise either by choice or by chance (Gripton and Valentich 2004; Haydar 2007; Lamb et al. 2004; Moleski and Kiselica 2005; Truscott and Crook 2004). Boundaries are the psychological spaces between people in relationships. Overlapping relationships increase the probability of boundary crossings and boundary violations and it is important to distinguish between these two concepts.

Boundaries Boundary crossings are benign overlapping relationships. They are more common in environments where the psychologist lives in close proximity to clients and may move in the same social circles. Boundary crossings are often unavoidable in rural practice and can be considered a normal and healthy part of rural living (Haydar 2007; Scopelliti et al. 2004; Yonge and Grundy 2006; Zur 2006). Boundary crossings include appropriate self-disclosure, home and community visits to clients, or other minor deviations from a strict professional role. In boundary crossings, the psychologist is not standoffish but continues to perceive all non-office or non-professional relationship as potentially risky (Zur 2006). Boundary violations, on the other hand, impair judgment and objectivity and have clear potential to be exploitative and harmful to the client, the professional relationship, and the profession of psychology. Treating members of one’s own family, close friends, or others with whom one has a significant nonsexualized relationship are boundary violations as are behaviors with clients such as touching, excessive self-disclosure, or involvement in sexual relationships. Boundary violations are never acceptable (APS 2004a; Haydar 2007; Nelson et al. 2007a; Scopelliti et al. 2004). Discriminating between a boundary crossing and a boundary violation occurs on a case-by-case basis and is dependent on context, such as the cultural background and theoretical orientation of the client and psychologist (APS 2004a; Endacott et al. 2006; Lamb et al. 2004). Understanding the difference between boundary crossings and boundary violations is complex, even when they appear harmless. Each requires due diligence and ongoing risk-benefit analysis (Barbopoulos and Clark 2003; Charlebois 2006; Moleski and Kiselica 2005; Zur 2006).

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Psychologists in urban practice may find it easier to maintain clear professional boundaries because they live in a less-embedded environment. Compared to rural psychologists, they may enjoy greater anonymity, neutrality, and objectivity, which facilitate boundary separation. Such boundaries are more difficult to maintain in rural practice. In rural communities, roles and relationships overlap and can blur professional and social relationships (Scopelliti et al. 2004; Womontree 2004; Younggren and Gottlieb 2004). Nonprofessional contacts are commonplace because of the many roles people play in rural areas (Campbell and Gordon 2003; Helbok et al. 2006; Schank and Skovholt 2006). Overlapping relationships become the normalized standard of care in rural practice because of the increased likelihood of family or friendship ties, chance encounters, co-involvement in community activities, and community norms that support overlapping relationships (Campbell and Gordon 2003; Gripton and Valentich 2004; Helbok et al. 2006; Zur 2006).

Overlapping Relationships and Professional Ethics Compelling psychologists to avoid overlapping relationships does not consider the necessary or therapeutic nature of some of these relationships (Austin et al. 2005; Helbok 2003; Yonge and Grundy 2006; Younggren and Gottlieb 2004). Some authors suggest that effectively managed overlapping relationships may increase the effectiveness of rural psychological services (Moleski and Kiselica 2005; Scopelliti et al. 2004; Yonge and Grundy 2006; Younggren and Gottlieb 2004). Behnke (2008b) has suggested that “finding oneself in a multiple relationship is not necessarily a sign that one has engaged in unethical behaviour. It may rather be a sign that one is fully engaged in the life of a community” (p. 62). This can enhance understanding of community needs and community members and can heighten the unique bonds between psychologists and clients (Johnson et al. 2005; Scopelliti et al. 2004). Often what rural people want and need is not impersonal clinical expertise but a strong friend to walk beside them through their pain and confusion, to share knowledge that will give hope, to identify with them yet demonstrate how to move out of their self-defeating behaviors and cognitive limitations. (Fair 2004, p. 57)

It also speaks to the artificiality of boundaries in therapeutic practice. A boundary is merely a metaphor for conceptualizing ethical issues. In reality, these relationships are one component of a complex series of interactions within the professional relationship (Austin et al. 2005). Typically, ethics codes state that overlapping relationships are not unethical if they do not exploit clients or impair objectivity. However, most ethics codes assert that psychologists are to refrain from overlapping relationships (Haydar 2007; Johnson et al. 2005; Truscott and Crook 2004; Yonge and Grundy 2006). The principle of nonmaleficience requires that psychologists avoid behaviors or practices that could cause harm. Overlapping relationships between professionals and clients

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are not equal as the professional has more power than the client. Psychologists are more aware of boundary issues and clients are less able to negotiate boundary expectations (Moleski and Kiselica 2005; Truscott and Crook 2004). Avoiding overlapping relationships, when possible, is one way of fostering client autonomy.

Overlapping Relationships in Practice Most rural and remote psychologists will routinely face unavoidable overlapping relationships in their professional practice. Rural practice reflects work in an embedded environment where professional and personal roles can overlap considerably. Some of these boundary struggles may impact family members. Sometimes, rural psychologists may develop friendships or unintended acquaintances with previous clients or those close to them. Consider the ethical dilemmas that can arise if friends become clients or have connections to clients. In a rural or remote context, prior clients could become colleagues. Current colleagues can become clients because of a lack of alternative services. There are times when the rural psychologist’s professional role will overlap with community relationships as there can be unplanned community involvement with previous clients. Rural psychologists may be expected to provide services to, or receive services from, other local professionals within the community or even within the agency in which the psychologist works (Staal and King 2000). What then of the struggle to balance information received through informal information sharing networks in overlapping relationships? The ethical dilemmas resulting from overlapping relationships are considered to be the most challenging for psychologists (Moleski and Kiselica 2005; Ridgeway 2005) and are intensified in isolated communities (Roberts et al. 2005). There are challenges to appropriately managing information sources in these settings. Having prior knowledge is more common in rural practice (Barbopoulos and Clark 2003; Nigro and Uhlemann 2004). It is important for the psychologist to resist undue influence of informally acquired client information and to protect clients from gossip and innuendo (Behnke 2008a; Endacott et al. 2006; Essinger 2006; Womontree 2004). Clear boundaries are essential, but not all overlapping relationship are avoidable. Many rural psychologists have little choice about engaging in overlapping relationships (Johnson et al. 2005; Younggren and Gottlieb 2004). Key is to focus on potential client impact. Research indicates that psychologists in rural practice tend to frame their ethical decision-making around the best interests of their clients (Endacott et al. 2006; Ridgeway 2005).

Overlapping Relationships and Practice Adaptations The ethical dilemmas inherent in overlapping relationships can and are managed in rural and remote professional practice through a variety of strategies and practice adaptations. Such relationships are handled with particular caution. Both supervision

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and consultation are beneficial for managing overlapping relationships. Consultation can provide an additional perspective, can highlight contextual issues, and can decrease the isolation possible in rural practice (Behnke 2004; Endacott et al. 2006; Schank and Skovholt 1997). Another common response is to establish particularly clear boundaries. Clear and reasonable expectations and boundaries strengthen professional relationships, especially in situations where out-of-therapy contact cannot be closely controlled. Research by Haydar (2007) indicated that psychologists in rural practice attempt to minimize these risks by developing progressively more strict boundaries, particularly with family and friends. Other rural psychologists may have creative arrangements with colleagues or through technology.

Reframing Overlapping Relationships Essential, however, is considering an alternative view of overlapping relationships. There are benefits and a normative nature to overlapping relationships in rural practice. There can be value in having prior information about a client. In rural and remote communities of practice, it can seem artificial to try to control unavoidable overlapping relationships. Psychologists seeking to make good ethical decisions about overlapping relationships must effectively balance personal and professional role conflicts in ways that are acceptable to the community that they serve (Schank and Skovholt 1997). Psychologists in rural practice need to explore how, not if, they can manage overlapping relationships (Moleski and Kiselica 2005; Scopelliti et al. 2004).

Community Pressure and Integrity In psychology, pressure is commonly defined as “the emotional experience of feeling compelled to respond to someone’s wishes or to external forces” (Reber and Reber 2001, p. 560). Community pressure is common in rural and remote communities which can be considered to be embedded environments. To provide competent and successful services, rural psychologists must be familiar with the specific values and culture of the area in which they practice and subsequent community expectations (APS 2004b; Helbok 2003; Jameson and Blank 2007; McDonald et al. 2005; Thorngren 2003; Womontree 2004). Community expectations are a significant consideration for rural psychologists (Endacott et al. 2006; Schank and Skovholt 2006; Womontree 2004) particularly as ethical action always takes place within a community and impacts more than just the psychologist and client (Austin 2007). There is often an assumption that rural psychologists will take the role of expert and leader in community development (Gale and Deprez 2003; Schank and Skovholt 2006; Womontree 2004). This may pressure a rural psychologist to work in a community psychology role or to work beyond the limits of their competence. Competency issues are discussed in more detail in the section “Generalist Practice and Competency.” The increased visibility

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of rural psychologists also causes pressure based on reputation, appearance, or behavioral expectations (Gale and Deprez 2003; Schank and Skovholt 2006; Womontree 2004). Rural psychologists are often expected to relate to community members at a social as well as a professional level. This may influence the ability of the psychologist to secure trust from key members of the rural social network, many of whom will have considerable knowledge about the psychologist’s personal life (APS 2004b; Helbok 2003; Schank and Skovholt 1997). Lack of anonymity may foster trust, but lack of privacy increases pressure for the psychologist (APS 2004b; Helbok 2003; Peterson 2002). Visibility also impacts the confidentiality of clients as community members are likely to be aware of who is using psychological services. Support staff may be familiar with clients and other agencies may openly share information about clients with the psychologist (Helbok 2003; Helbok et al. 2006). Charlebois (2006) found that distinctions needed to be made between confidentiality, anonymity, and privacy for rural clients. She suggests that only confidentiality can justifiably be offered to the client in a rural area. Essinger (2006) found rural communities often expect that psychologists will share information. In rural communities, personal information is more readily available (and is often offered to psychologists) through common informal-sharing networks or gossip (Fisher 2008; Green and Mason 2002; Helbok 2003; Kemp Brill 2003). These networks are often part of the protective community fabric and the expectation to share confidential information without consent is unlikely to be seen as a harmful act (APS 2004b; Schank and Skovholt 2006; Womontree 2004). There may also be expectations that psychologists provide practical and tangible services which may compel the psychologist to focus more on services that result in concrete problem solving rather than services aimed at self-actualization (Schank and Skovholt 2006). Community pressure is dependent on the context or culture of the rural community in which the psychologist practices and may become more pronounced as the community size decreases or when community isolation increases (Endacott et al. 2006; Helbok 2003; Scopelliti et al. 2004). In qualitative interviews, Schank and Skovholt (1997) found that 16 rural psychologists in the United States expressed anxiety in relation to perceived community pressure. This is consistent with Bauman’s (1998) suggestion that increased unspoken responsibility fosters anxiety. In a recent mail-out survey comparing the practices of over 400 rural and urban psychologists, Helbok et al. (2006) found that rural psychologists reported more community pressure, primarily in the form of multiple relationships. Interestingly, these rural psychologists also reported fewer ethical dilemmas related to this increased pressure.

Integrity The virtue of integrity is implicit in most codes of ethics (Haydar 2007; Truscott and Crook 2004; Yonge and Grundy 2006). Integrity in relationships is a particularly salient issue in the cultural context of embedded environments where overlapping relationships are more common. Ethically, rural psychologists need to balance both client and community needs (Schank and Skovholt 2006). Sinclair and Pettifor

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(2001) warn that “failures to meet expectations of integrity. . .have provided the basis for a large number of complaints against psychologists. Such failures can undermine scientific progress and public trust in psychology” (p. 72). Community pressure can pose risks to client confidentiality. The implied or explicit promise of the psychologist to keep client information private is central to the professional psychological relationship and the perception of integrity (Truscott and Crook 2004). This can be difficult when the psychologist has less ability to control disclosure of personal information. Increased visibility in rural practice means that the rural psychologist may unintentionally have more information about a client than that client consented to release. Similarly, the psychologist may be less able to control confidential client information (such as attendance at a therapy session) because of visibility. Psychologists are to be responsible to the communities in which they live and work and to acknowledge the need and value of the social structures in these communities (CPA 2017). They are required to convey respect for prevailing community norms and recognize how societal expectations may impact their practice (Sinclair and Pettifor 2001). This can be particularly difficult when community pressure undermines the integrity of rural psychologists or when visibility impacts client confidentiality.

Community Pressure in Context Most rural and remote psychologists can expect to experience community pressure. There can be concerns about how we are perceived by the community; one such perception is of the rural psychologist as a role model. Psychologists are expected to live up to assumptions arising from informal communication networks. They need to gain the trust of community members and leaders by being in a professional role at all times within the community (APS 2004b; Schank and Skovholt 2006; Womontree 2004). Another pressure is the need to be seen as an integrated community member. Cultural dimensions, like expectations of community involvement, can intensify ethical issues (Roberts et al. 1999). The suggestion that rural psychologists keep an extremely low profile in the community is likely to contradict culturally relevant practice (Behnke 2008a; Bishop 2005; Helbok 2003). Psychologists in rural and remote practice can also expect to encounter ethical dilemmas in relation to community expectations. A common issue may be pressure to provide more services than possible or services without a professional relationship. These issues are common among rural practitioners who often need to balance community expectations with their own needs and with client needs (Roberts et al. 2005). Another common issue relates to increased visibility in rural areas. Sometimes called “living in a fishbowl,” this visibility impacts clients and psychologists. Client confidentiality can also be compromised by psychologists’ family members who may not understand professional issues related to confidentiality. These kinds of social visibility and lack of anonymity can create barriers for rural clients (Barbopoulos and Clark 2003; Helbok et al. 2006; Zur 2006). But there are similar

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implications for rural psychologists who feel the impact of such visibility. This kind of pressure can result in anxiety for the rural psychologist. In recent research, Haydar (2007) found that psychologists in rural practice disagree about their ability to compartmentalize their professional and personal roles. Behnke (2008a) suggests that “psychologists must be able to integrate their personal and professional lives” (p. 45). This can be difficult in embedded environments.

Practice Adaptations for Community Pressure In practice, there are many valuable ideas for managing ethical dilemmas related to community pressure. One idea is working within a triage model. Triage models help psychologists to deal with demand by having cases prioritized and it allows for shared decision making on handling caseloads. Another idea is to set clear boundaries with community agencies. This should be done in a respectful and supportive way. Bradley (as cited in Kersting 2003) indicated that she overcame community pressure with simple friendliness and approaching community members in comforting ways. Further is the need to specifically establish clear boundaries with clients. Charlebois (2006) found that creating boundaries was vital to well-being and selfcare for counselors in a remote northern community of Canada. Many rural and remote psychologists are careful to carve out private time, often by keeping their personal telephone number private. There are many possible procedures for managing client privacy during chance community encounters. Most typically, these mean discussing such encounters early in the professional relationship. Typically, clients can be given control by having a choice about directing that interaction. Such practices fit with Helbok’s (2003) suggestion to be open with clients about community pressure.

Reframing Community Pressure Despite the challenges of community pressure, there are benefits to working in embedded environments. Visibility can be normalized by rural psychologists and have the potential to enhance our practices. Community pressure can be framed as opportunities to contribute to community development. Indeed, “psychologists become ‘participant/observers’ in the local culture, which allows the psychologist to view the reciprocal influence of the psychologist on the community and the community on the psychologist” (Behnke 2008a, p. 45).

Generalist Practice and Competency Rural practice conditions (such as lack of referral resources) often necessitate a generalist approach (APS 2004b; Harowski et al. 2006; Helbok 2003; Sawyer et al. 2006). Indeed, Dimogiannis (2000) found that most psychologists in rural practice

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define their practice as generalist in nature. Specialization is impractical as rural service needs require practitioners to be multi-skilled in dealing with diverse populations (Barbopoulos and Clark 2003; McIlwraith et al. 2005; Perkins et al. 2007). They also deal with a greater range of illnesses and conditions (Essinger 2006; Gale and Deprez 2003; Hourihan and Kelly 2006) and higher levels of co-morbid substance abuse (O’Kane and Tsey 2004; Roufeil and Lipzker 2007). Generalist practice can contribute to greater job satisfaction but also fosters ethical issues. It has been suggested that a diverse general practice can cause concerns about competence, scope of practice, and appropriate training. It may also challenge the confidence of the psychologist (Hays 2006; Helbok 2003; McIlwraith et al. 2005). Unfortunately, professional training specific to generalist practice in rural settings is rare. This is despite the need for rural psychologists to be prepared to provide consultation, outreach, community assessment, program development, and evaluations. Rural psychologists are also likely to work with rural health care systems and to collaborate on interdisciplinary teams (Harowski et al. 2006; Helbok 2003; McIlwraith et al. 2005).

Generalist Practice in Context Rural psychologists face the dilemma of providing needed services that may not exist without their efforts. Yet, the quality of such services may be compromised if they work outside their area of training (Kersting 2003; Nelson et al. 2007b). Rural psychologists must decide whether to cover needs themselves, refuse treatment (considering the ramifications for the client), provide limited service, or provide service outside their area of competence (Schank and Skovholt 2006). The scarcity of rural mental health resources may pressure psychologists to work as generalists, often beyond the limits of their education (Barbopoulos and Clark 2003; Gale and Deprez 2003; Turchik et al. 2007). In addition to the lack of alternative professionals, there is often limited access to specialists. The primary challenge is to provide optimal care, often with a minimum of resources, without violating the competency principle of ethics codes (Essinger 2006; Helbok 2003; Schank and Skovholt 2006; Womontree 2004). The Australian Psychological Society noted that limited competence is one of four most commonly cited ethical issues for rural and remote practitioners (APS 2004b). Psychologists working in rural areas with limited services often work with clients or issues beyond their level of expertise and with limited professional consultation much like rural general medical physicians (Gale and Deprez 2003; Hays 2006; Smith 2003; Stamm et al. 2007). In the Manitoba program mentioned earlier, supervisors role model ways to deal with limits of competence. Common supervisory discussions involve dealing with pressure to provide services, selfawareness about limits of competence, and identifying when additional supervision or consultation is required (Dyck et al. 2008). Competence is one of the cornerstones of professional practice and the reason that many clients choose to seek the services of a psychologist. However, most ethical

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codes do not clearly define competence (Helbok 2003). Generally, competence is considered to be a multidimensional concept comprised of knowledge, skills, judgment, and diligence in the provision of professional services (Truscott and Crook 2004). Even when trained as generalists, it is not possible to be competent in the provision of all psychological services to all client groups. Psychologists in rural practice need to assess their competencies within the context of community and client needs, professional expectations for specialization and competency, and ethical standards (Schank and Skovholt 2006). A key ethical dilemma concerning generalist practice is the perceived need to provide a full and diverse range of services when there are few available alternatives. Lack of alternative services has been shown to foster or intensify ethical dilemmas for rural psychologists (Roberts et al. 1999, 2005). Even when there are alternative community resources, there might be issues that prompt dilemmas for rural psychologists such as lack of transportation or privacy in other services.

Practice Adaptations for Generalist Practice Rural psychologists may have a moral responsibility to provide some creative and flexible services beyond their scope of training. This may be questionable ethical practice in urban settings but a defensible ethical stance when working with isolated rural clients. Helbok et al. (2006) hypothesized that American rural psychologists would experience difficulty maintaining their competency in generalist practice. In their recent self-report survey, this hypothesis was not supported. Indeed, my own research with practicing rural psychologists in Canada found that it was common to practice outside of scope of practice but that this occurred with careful balance between competency and client welfare when there are limited services. Generalist practice considerations are rarely part of formal training and so this can cause considerable adjustment and ethical angst for the rural psychologist (Helbok 2003; Kersting 2003; McIlwraith et al. 2005; Roufeil and Lipzker 2007). Generalist practice can be well managed in rural and remote professional practice. Self-awareness is integral to setting personal and professional limits. Indeed, rural psychologists must be intimately aware of their own comfort levels, their strengths and weaknesses, and how far outside their area of expertise they may be practicing (Helbok 2003; Yonge and Grundy 2006). There is also a need to articulate those limits to others. The pressure to practice broadly is a prompt for rural psychologists to seek consultation and supervision specific to generalist practice.

Reframing Generalist Practice Key, again, is to consider an alternative view of generalist practice. Perhaps the real issues stem from psychology’s urbanization; consider, for example, the requirement that psychologists do not practice outside their scope of training. Indeed, generalist

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practice may be one of the benefits of rural practice – practitioners may enjoy the variety and challenge of an extended scope of practice that is necessary in rural and remote locations. Psychologists tend to stay in rural practice by choice (Dimogiannis 2000). And rural practice can be characterized by groups of highly skilled and committed clinicians willing to go beyond the call for their communities (Greenhill et al. 2009).

Interdisciplinary Collaboration and Confidentiality There are many forms of collaboration in professional practice. The literature refers to interagency relationships, multidisciplinary teams, transdisciplinary work, and interdisciplinary collaboration. Interagency relationships refer to work between agencies that may involve professionals of varying disciplines (Schank 1997). Interagency relationships imply that collaborations are only with other professionals or agencies. In multidisciplinary teams, members cooperatively provide disciplinespecific contributions. Cooperative processes, such as those in multidisciplinary teams, are not sufficient as no discipline is rurally focused. Transdisciplinary work means collaborative work that evolves beyond discipline-specific contributions (Austin et al. 2008). Transdisciplinary collaboration exceeds the level of integration that is typical in rural collaborations. Interdisciplinary collaboration is “the deliberate pooling and exchange of information and knowledge that crosses traditional disciplinary boundaries” (Crossley et al. 2008, p. 231). Interdisciplinary collaborations are useful for addressing complex, multifaceted problems and goals and for achieving common ground (Austin et al. 2008; Van Vliet 2009). As a best practice, such professional interactions, common for rural psychologists, are an effective way of providing for an integrated community response (Bock and Campbell 2005; Donoghue et al. 2004).

Interdisciplinary Collaboration in Practice Unfortunately, psychologists in rural practice are rarely trained in working collaboratively with professional and paraprofessional community supports (Bock and Campbell 2005; McDonald et al. 2005; Turchik et al. 2007). Effective collaborations with health care professionals, teachers, and social workers may facilitate referrals (Benson 2003; Jackson et al. 2007; Schank and Skovholt 2006; Turchik et al. 2007). These collaborations may also increase the services available to rural community members in otherwise underserved areas (Barbopoulos and Clark 2003; Linzmayer 2003; Sawyer et al. 2006; Stamm et al. 2007). For the rural health professional, collaboration can help prevent burnout, work overload, and a sense of isolation (APS 2004b; Helbok 2003; McIlwraith and Dyck 2002). Valuable resources in rural settings may include naturally occurring community supports such as those in families, schools, churches, and community groups (Bock and Campbell 2005; Schank and Skovholt 2006; Turchik et al. 2007). Indeed, McDonald et al. (2005)

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found that many psychologists in rural practice do use natural support systems to reduce isolation for themselves and their clients and to provide for more holistic and informed crisis intervention (Bock and Campbell 2005; McDonald et al. 2005; Smith 2003). Along with its benefits, interdisciplinary collaboration fosters concern. These include an enhanced risk of blurred roles resulting in compromised client confidentiality (Helbok 2003; Helbok et al. 2006; Schank and Skovholt 2006; Womontree 2004). The more casual sharing of information in rural areas may mean that colleagues and co-workers discuss cases openly without consent or expect this of psychologists. In these settings, even general discussions can be misinterpreted as being about specific clients (Schank and Skovholt 2006). Psychologists in rural practice who decline to share confidential information, or who challenge the behavior of other professionals, may alienate themselves and lose referral sources (Helbok 2003; Kersting 2003; Schank and Skovholt 2006). In reviewing rural mental health, Sawyer et al. (2006) reported that interdisciplinary collaboration is often hindered by insufficient communication, professional specialization, and a poor integration of mental health and primary health care. Again, confidentiality is another fundamental component of professional psychology; confidentiality is key in collaborations. It is a foundation of codes of ethics in psychology and is only limited in extreme circumstances such as dangerousness. Breaches of confidentiality can undermine the professional relationship and cause harm. Psychologists must ensure that client information is not revealed to anyone without consent except in a few conditions that relate to likelihood of harm (Truscott and Crook 2004). Although it can be a foreign concept in highly interconnected small communities (Wihak and Merali 2007), confidentiality plays a vital role in the provision of psychological services and breaking confidentiality may increase the stigma around seeking psychological services (Helbok 2003).

Practice Adaptations for Collaboration Most psychologists are not trained in interdisciplinary collaboration yet rural practice often involves such collaborations (Greenhill et al. 2009). These collaborations may involve work with other professionals or naturally occurring community supports (Bock and Campbell 2005; Crossley et al. 2008; Donoghue et al. 2004). Rural psychologists commonly experience interdisciplinary collaborations. A common ethical dilemma in these relationships is the need to advocate for the distinct role of psychology. Other dilemmas arise because of different expectations of professionalism. Rural psychologists make more use of naturally occurring community resources (Dimogiannis 2000; Helbok et al. 2006). Paraprofessionals may lack necessary knowledge complicating these collaborations which may be ineffective (Adams et al. 2006). In particular, there are difficulties in maintaining confidentiality in interdisciplinary collaborations. There can be pressure to share confidential information. Maintaining client confidentiality is a common challenge (Roberts et al. 1999;

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Roberts et al. 2005), particularly in communities where this is a foreign concept. Wihak and Merali’s (2007) study of remote practitioners found that confidentiality “posed unfamiliar challenges in the highly interconnected, small communities where they lived and worked” (Wihak and Merali 2007, p. 176). This can create a sense of obligation to colleagues from other professions. Such transactional stressors likely reflect the psychologist’s overall involvement in the informal information-sharing network common among rural referral networks (Barbopoulos and Clark 2003; Helbok et al. 2006; Zur 2006). There is a need to balance exposure risks for clients and the psychologist’s relationships with community partners (Endacott et al. 2006; Essinger 2006).

Reframing Collaboration The ethical dilemmas experienced in relation to interdisciplinary collaboration can be well managed in rural and remote psychological practice. A main strategy is to establish strong and clear boundaries – respectfully. The need to be clear on the roles and responsibilities of each team member is common in effective interdisciplinary collaborations (Greenhill et al. 2009; Sawyer et al. 2006). As is the need to develop effective working relationships, rural psychologists need to be skilled in interdisciplinary intervention. Training in this area has been recommended (Crossley et al. 2008, p. 231) and has potential to enhance the recruitment and retention of rural providers (Meyer et al. 2005). Again, consider alternative views of interdisciplinary collaborations. Such relationships can enhance the rural psychologist’s work. Greenhill et al. (2009) found that many rural practitioners genuinely enjoy interdisciplinary work even when not trained in collaborative models. Teamwork can assist the rural practitioner to deliver more effective services (Bock and Campbell 2005; Smith 2003).

Professional Development and Support Although psychologists require ongoing professional development and support, particularly in ethics (Morrissey and Symons 2006), rural-specific professional development is not common. The literature suggests that there is insufficient professional psychology training or placements specific to rural practice (Barbopoulos and Clark 2003; Jameson and Blank 2007; Stamm et al. 2007). The field of psychology tends to be urban-centric and psychologists in rural practice rate their undergraduate and postgraduate professional training in psychology as only somewhat adequate for rural practice (Jameson and Blank 2007; Harowski et al. 2006; McIlwraith and Dyck 2002). Specifically, they reported receiving insufficient training in the area of ethics (Roufeil and Lipzker 2007; Schank and Skovholt 2006). In a quantitative comparison, Dimogiannis (2000) found that rural psychologists rated their training as less adequate for the nature of their practice than urban psychologists.

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Another consideration is the availability of consultation and supervision for those in rural practice. Regular peer consultation and clinical supervision is essential for good practice and maintaining competence (Schank and Skovholt 2006; Truscott and Crook 2004), particularly for those who work in relative isolation (APS 2004b; Helbok 2003; McIlwraith and Dyck 2002; Sawyer et al. 2006; Schank and Skovholt 2006). In qualitative interviews, Charlebois (2006) found that Canadian rural counselors wished they had more access to peer consultation. In a comparative survey, Womontree (2004) found that psychologists in rural American practice reported less satisfaction with the availability of consultation and support when compared to their urban counterparts. Options for supervision and consultation are often limited by geographical, environmental, and economic difficulties (Schank and Skovholt 2006; Wood et al. 2005). There are also concerns related to appropriate ongoing professional development. Continuing education, additional training, and retraining are important ways to stay professionally current. Johnson, Brems, Warner, and Roberts (2006) found that psychologists in rural practice had great interest in continuing professional education on ethics, particularly the management of clients with special issues. Unfortunately, qualitative (Charlebois 2006) and quantitative (Womontree 2004) studies of rural practitioners confirm that they have fewer opportunities for continuing education and find participating in professional development more difficult. In her quantitative study of psychologists in rural practice, Womontree (2004) found three primary barriers to professional development. The first was a lack of financial support for the increased costs of accessing classroom training, workshops, conferences, and Internet support. The second was geographical barriers to centres of higher learning or other resources. The third was a dearth in resources, training, or professional development that specifically addressed the concerns of psychologists in rural practice. Finally, psychologists in rural practice often deal with personal and professional isolation (APS 2004b; Barbopoulos and Clark 2003; Schank and Skovholt 2006; Jameson and Blank 2007). Professional isolation results in fewer opportunities to consult on difficult cases, engage in collaborative work, or conduct research. This can result in a decreased sense of accomplishment and fewer opportunities for intellectual stimulation, collegial support, and sharing of ideas (Barbopoulos and Clark 2003; Helbok et al. 2006; Jameson and Blank 2007; Schank and Skovholt 2006). This is compounded by the fact that most psychologists in rural practice work individually in private practice causing further isolation (Dimogiannis 2000). The limited access to peers for supervision and consultation can undermine competency. In the absence of collegial feedback, rural psychologists may rationalize nontraditional practices, be less aware of unethical behavior, and compromise standards due to isolation (Helbok 2003; Weigel and Baker 2002). It is more difficult for rural psychologists to become involved in professional organizations as they may feel misunderstood or disempowered by their urban counterparts (Schank and Skovholt 2006). Personal isolation can result from feeling isolated from cultural or medical resources (Schank and Skovholt 2006; Womontree 2004).

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Professional Development in Context Perceived or actual isolation can impact recruitment, retention, and turnover of psychologists in rural practice (Helbok et al. 2006). An extreme manifestation of isolation can be compassion fatigue or burnout. This may present as emotional exhaustion, loss of purpose and energy, depersonalization or cynical attitudes, and loss of a sense of personal accomplishment (DeStefano et al. 2005; Helbok et al. 2006). Rural practice poses increased risk for burnout (APS 2004b; DeStefano et al. 2005; Helbok 2003; Kee et al. 2002), particularly when there are high workloads (DeStefano et al. 2005; Schank and Skovholt 2006). Other risk factors for burnout include difficulties setting limits (Gardiner et al. 2005; Smith 2003), significant travel (Kee et al. 2002; Schank and Skovholt 2006; Schopp et al. 2006), and lack of resources and support (DeStefano et al. 2005; Schopp et al. 2006). Psychologists in rural practice are also at risk for burnout related to community pressure (Helbok et al. 2006; Jameson and Blank 2007; Schank and Skovholt 2006) and a need to adapt to the local culture (Smith 2003; Wihak and Merali 2007). Diligent psychologists continually attend to their skills and professional judgment so that their competence is not compromised (Helbok 2003; Morrissey and Reddy 2006; Truscott and Crook 2004). Indeed, many jurisdictions require continuing professional development. Consultation, supervision, and engagement (as opposed to isolation and burnout) are essential for maintaining ethical awareness and sensitivity. A common issue for rural and remote practice is lack of training in rural practice. Rural practice characteristics make ethical dilemmas more complex (Thorngren 2003) which implies the need for specific training and support in this area (Johnson et al. 2006). Roberts et al. (2005) found that rural mental health clinicians lacked sufficient training in ethical dilemmas for their practice setting. Few practitioners receive formal training specific to rural psychology and therefore lack the benefits of having had professional training and exposure to a rural role (Dimogiannis 2000; Eley et al. 2007). Rural psychologists also experience difficulties in accessing suitable consultation and supervision. Insufficient access to ethical consultation is considered common in rural practice (Roberts et al. 2005) and may intensify ethical dilemmas (Roberts et al. 1999). Similarly, there are concerns about being able to supervise others in rural practice. Limited access to supervision and consultation can increase risks of rationalization, lower awareness of boundaries of competence and unethical behavior, and can increase feelings of isolation (Cottone 2004; Weigel and Baker 2002; Womontree 2004). Accessibility of appropriate ongoing professional development is another common issue. One type of barrier is geographic distance. Geographic barriers to professional development often increase the associated time commitment and expense. This fits with Womontree’s (2004) findings that two of the three primary barriers to professional development were lack of financial support for the inherent increased costs and geographical barriers to access. The third primary barrier is lack of resources and professional development that addresses concerns of rural practice. Further, professional development activities are rarely specific to rural practice.

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A final professional development and support issue is a sense of isolation for many practitioners. The literature indicates that isolation is related to risks of burnout. Rural practice in psychology does pose increased risk for burnout due to the high workloads, difficulties setting limits, community pressures, and a lack of resources and support (APS 2004b; DeStefano et al. 2005; Gardiner et al. 2005; Kee et al. 2002). Interestingly, research has indicated that rural psychologists do not indicate more burnout. Instead, rural practitioners have been found to experience high levels of personal achievement and empathy for their clients (Helbok et al. 2006; Schank and Skovholt 2006).

Practice Adaptations for Professional Development Rural psychologists can, and do, manage their needs for professional development and support. Many do so through consultations with networks of geographically separated peers. These consultative networks may also include professionals other than psychologists who understand rural practice (Helbok 2003; Schank and Skovholt 2006). Some use technology for consultation and professional development. The importance of staying involved in professional development activities despite the barriers is becoming easier through expanded use of technology (Sawyer et al. 2006; Weigel and Baker 2002; Wood et al. 2005). Technology can reduce professional isolation and improve access to consultation and continuing professional development, but it is not a panacea to these difficulties (Jameson and Blank 2007; Meyer et al. 2005; Nigro and Uhlemann 2004). Also, communication technologies are not always easy to use (APS 2005; McIlwraith and Dyck 2002; Sawyer et al. 2006; Schopp et al. 2006). Key is to consider that not all rural and remote psychologists have issues with professional development and support. Some have access to appropriate consultation that assists psychologists to identify issues, challenges psychologists to examine and learn from ethical challenges, and builds community among colleagues. Others do not perceive access to professional development as a difficulty.

Critical Incidents and Ethical Development Critical incidents like inadequate community connection, insufficient awareness of competence, unclear client consent, or boundary struggles can contribute to higherorder learning about ethical processes. The experience of such critical incidents can facilitate a psychologists’ internalized ethical stance as they present potential personal and professional growth opportunities. Such experiences appeared to foster reflection and higher order learning, particularly when there are opportunities for consultation and supervision on these issues. Critical incidents impact ethical development. Ethical practice and the development of an internalized ethical stance is complex (Jones 2008). An important

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component of this process can be the experience of critical incidents. Critical incidents are situations where the response of the psychologist could have a significant impact on the psychologist, the client, or the profession. These are incidents that are stressful and challenge decision-making (Clarke 2008; Cope and Watts 2000; Preskill 2006). There are potential personal and professional growth opportunities in the experience of critical incidents. Rural psychologists experience critical incidents but may not be easily able to articulate these which reflects the deeper level of reflexivity required to recall and describe such incidents. The critical incidents in rural and remote practice reflect a wide variety of often unanticipated practice situations. Critical incidents can arise in relation to having insufficient connection with the rural community of practice. When a psychologist is insufficiently aware of local resources and needs how can they adequately assess issues and provide appropriate services? Rural psychologists require community knowledge to adequately negotiate ethical issues and dilemmas in these settings. This underscores the need to understand and develop connections within the local culture as a key aspect of developing and maintaining competence for rural practice. Competence may be tested in experiences of critical incidents specific to nonmaleficence. Working outside the limits of one’s competence may put the welfare of clients at risk. Although not a rural-specific critical incident, the scarcity of rural mental health resources may fuel a pressure to provide a large range of services. Although such services may not exist otherwise, rural settings also mean that relevant professional consultation options are also likely limited. When psychologists work outside their area of expertise, they also risk harm to their own confidence and to the profession overall. Competence, one of the cornerstones of professional practice, can be one of the reasons that clients choose to seek the services of a psychologist. Critical incidents can be learning experiences, particularly when explored through consultation and supervision (Cope and Watts 2000). Rural psychologists learn to change practices because of the experience, or near experience, of critical incidents. This can foster a maturing awareness of the need for more formal consent processes. Informal community and professional participation can be common in rural areas (Coakes 2002; Schank and Skovholt 2006). Community norms must be balanced with the potential for such relationships to become or appear exploitative or harmful to the client, the professional relationship, or the profession of psychology. Ethical schema can change with experience, evolving through critical thinking, and professional and personal reflection. Some of the most telling critical incidents involve boundaries in rural practice. The mere potential of a boundary violation, coupled with a desire for nonmaleficence, can lead to personal and professional growth. These could be boundaries with colleagues. The differentiation between boundary crossings and boundary violations may be clearer for relationships with clients but what about relationships with other professionals, particularly when there are few other professionals in the community? Rural psychologists are likely to enhance service provision and combat isolation through collaboration (Bock and Campbell 2005; Schank and Skovholt

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2006; Turchik et al. 2007), but roles within such relationships are likely to be blurred (Helbok et al. 2006; Schank and Skovholt 2006). When a psychologist also enters into nonprofessional relationships or roles, particularly an intimate role, with a professional colleague, these boundaries are likely to blur even further. Other boundary experiences involve clients. Ideally, awareness of a boundary issue prevents unethical behavior. Rural psychologists must consider their level of engagement with the client and the potential to harm the professional relationship. There are complex interpersonal relationships that rural psychologists have with their clients and particular responsibility in negotiating such processes. This is reflected in relational ethics as there is a personal facet involved in how such incidents might be processed. Emphasis on the psychologists’ role and behavior begets the mutual vulnerability inherent in such professional relationships (Austin 2006). Critical incidents can result in fundamental higher-level learning (Cope and Watts 2000) and can support the development of new practices. Critical incidents can impact ethical awareness and ongoing ethical development leading to the development of a more mature understanding of ethics. The experience of critical incidents can foster reflection and higher order learning (Clarke 2008; Preskill 2006), particularly when there are opportunities for consultation and supervision on these issues (Cope and Watts 2000). These experiences highlight how the path to ethical development is not always straightforward.

Contextualizing Ethics This chapter provided a brief foundation for considering the ethical issues and ethical decision-making acumen required for psychologists in rural and remote practice. The literature speaks primarily to overlapping relationships, community pressure, generalist practice, interdisciplinary collaboration, and professional development and support issues. Rural psychologists experience the ethical dilemmas in those areas but also manage these dilemmas whilst demonstrating some of the benefits of rural practice in relation to these experiences. Key to this management are confidentiality, boundaries, and competency. The crux of the experience of professional ethics in rural practice is the development of ethical schema for rural and remote psychologists, the internal ethical stance which fosters the ethical development of psychologists practicing in these settings. These include a fundamental commitment to professional ethics, the role of critical incidents in our ethical development, and the elusiveness of ethical reflexivity. It is important to identify areas of professional thinking to best respond to the rural and remote practice context. Some of our best lessons arise from contextspecific critical incidents. These serve to inform training and professional development in rural and remote practice. Key are characteristics of the community interacting with the generalist nature of practice that give rise to necessary adaptations to the size and remoteness of the community. Central to all are “boundary setting” and “consultation” as mechanisms for resolving dilemmas.

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Such considerations may well be quintessentially rural and remote and, as such, useful for training and development of psychologists for these settings. Rural psychologists have practice adaptations and reasons for those strategies; while these may not always represent the best ethical decisions, they remain useful accounts of actual practice. It can be difficult to study ethical reflexivity because of the abstract nature of ethics and because reflexivity may not be required to demonstrate wisdom and good practice. What is clear is the need to identify areas of professional thinking about rural ethical dilemmas that need further attention and development. Reflexivity may be most important as only one aspect in ethical decision-making. Perhaps ethical development is a more logical focus of study. The ethical development of rural and remote psychologists is impacted by ruralspecific critical incidents which could serve to inform training and professional development in rural practice. For now, there are tangible ideas for rural psychologists to manage the various ethical dilemmas in rural practice. General considerations for this are: set clear and reasonable expectations and boundaries; consult regularly with a community of peers that need not be bound by location; develop effective community relationships; use technology to decrease isolation and distance; develop contingency plans for common pressures; seek out creative alternatives for service provision; and engage in self-care. Essential are alternative conceptualizations of typical rural practice conditions. There can be benefits from having prior information about clients in rural areas and limitations of trying to artificially control benign overlapping relationships. Visibility can serve to normalize the psychologist, enhance their professional practice, and allow for the privilege of being a participant observer in community development. There is variety and challenge in generalist practice. Finally, well-managed interdisciplinary services can mean more effective services and a more rewarding practice. Key for those of us in rural and remote practice is a basic commitment to ethical practice, an awareness of ethical issues, the role of critical incidents in the developmental fine tuning of ethical decision making, and the centrality of “boundary setting” and “consultation” as mechanisms for resolving dilemmas.

Take Home Messages Professional Ethics in Rural Practice Rural practice along with the generalist nature of psychological practice in these settings fosters a specific context or culture of practice, which is a key consideration. The rural context gives rise to necessary practice adaptations, but these will be specific to the size and remoteness of the community under consideration. Central to any required adaptations or resolving key dilemmas of professional ethics likely to arise in rural practice involve boundary setting and adequate consultation.

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References Adams SJ, Xu S, Dong F, Fortney J, Rost K. Differential effectiveness of depression disease management for rural and urban primary care patients. J Rural Health. 2006;22:343–50. Austin W. Engagement in contemporary practice: a relational ethics perspective. Texto Contexto. 2006;15:135–41. Austin W. The ethics of everyday practice: healthcare environments as moral communities. Adv Nurs Sci. 2007;20:81–8. Austin W, Bergum V, Nuttgens S, Peternelj-Taylor C. A re-visioning of boundaries in professional helping relationships: exploring other metaphors. Ethics Behav. 2005;16:77–94. Austin W, Park C, Goble E. From interdisciplinary to transdisciplinary research: a case study. Qual Health Res. 2008;18:557–64. Australian Psychological Society. Code of ethics. Melbourne: Australian Psychological Society; 2004a. Australian Psychological Society. Guidelines for psychological practice in rural and remote settings. Melbourne: Australian Psychological Society; 2004b. Australian Psychological Society. Mentoring program for rural and remote psychologists. InPsych, April. Melbourne: Australian Psychological Society; 2005. Barbopoulos A, Clark JM. Practising psychology in rural settings: issues and guidelines. Can Psychol. 2003;44:410–24. Bauman Z. What prospects of morality in times of uncertainty? Theory Cult Soc. 1998;15:11–22. Behnke SH. Multiple relationships and APA’s new ethics code: values and applications. Monit Psychol. 2004;35:66–7. Behnke SH. Exploring ethics in rural settings: through the lens of culture. Monit Psychol. 2008a;39:44–5. Behnke SH. Multiple relationships: a vignette. Monit Psychol. 2008b;39:62. Benson E. Beyond ‘urbancentrism’. Monit Psychol. 2003;34(6):54. Bishop ML. Will advertising improve the organizational image or rural mental health service providers? J Rural Community Psychol. 2005;E8(2):117–136. Bock S, Campbell CD. Crisis intervention in rural communities: a cultural catch-22. J Rural Community Psychol. 2005;E8(1):79–88. Campbell CD, Gordon MC. Acknowledging the inevitable: understanding multiple relationships in rural practice. Prof Psychol Res Pract. 2003;34:430–4. Canadian Psychological Association. Canadian code of ethics for psychologists. 4th ed. Ottawa: Canadian Psychological Association; 2017. Charlebois J. Counsellors’ professional and personal perspectives on working and living in a remote northern community. Unpublished master’s thesis, Acadia University, Wolfville; 2006. Clarke I. Learning from critical incidents. Adv Psychiat Treatment. 2008;14:460–468. Coakes SJ. Defining the nature of participation in rural Australian communities: a qualitative approach. J Community Psychol. 2002;30:635–46. Cope J, Watts G. Learning by doing: an exploration of experience, critical incidents and reflection in entrepreneurial learning. Int J Entrep Behav Res. 2000;6:104–24. Cottone RR. Displacing the psychology of the individual in ethical decision-making: the social constructivism model. Can J Couns. 2004;38:5–13. Crossley M, Morgan D, Lanting S, Bello-Haas VD, Kirk A. Interdisciplinary research and interprofessional collaborative care in a memory clinic for rural and northern residents of western Canada: unique training ground for clinical psychology graduate students. Aust Psychol. 2008;43:231–8. DeStefano TJ, Clark H, Potter T. The impact of organizational factors on burnout among rural mental health staff. J Rural Community Psychol. 2005;E8(1):131–136. Dimogiannis T. Comparison of the work of psychologists in rural and urban settings: implications for professional training. Unpublished master’s thesis, Deakin University, Geelong; 2000.

158

J. L. Malone

Donoghue A, Hodgins G, Judd F, Scopelliti J, Grigg M, Komiti A, Murray G. Training case managers to deliver focused psychological strategies. Int J Ment Health Nurs. 2004;13:33–8. Dyck KG, Cornock BL, Gibson G, Carlson AA. Training clinical psychologists for rural and northern practice: transforming challenge into opportunity. Aust Psychol. 2008;43:239–48. Eley RM, Hindmarsh N, Buikstra E. Informing rural and remote students about careers in health: the effect of Health Careers Workshops on course selection. Aust J Rural Health. 2007;15:59–64. Endacott R, Wood A, Judd F, Hulbert C, Thomas B, Grigg M. Impact and management of dual relationships in metropolitan, regional and rural mental health practice. Aust N Z J Psychiatry. 2006;40:987–94. Essinger S. The application of the 2002 American Psychological Association’s ethics code and its standards of conduct for the psychologist practicing in a rural community as compared to the psychologist practicing in an urban community. Dissertation, Capella University; 2006. Fair TD. The practice of psychology in a rural area. J Psychol Christ. 2004;23:54–7. Fisher MA. Protecting confidentiality rights: the need for an ethical practice model. Am Psychol. 2008;63:1–13. Gale JA, Deprez RD. A public health approach to the challenges of rural mental health service integration. In: Stamm BH, editor. Rural behavioral health care: an interdisciplinary guide. Washington, DC: American Psychological Association; 2003. p. 95–108. Gardiner M, Sexton R, Durbridge M, Garrard K. The role of psychological well-being in retaining rural general practitioners. Aust J Rural Health. 2005;13:149–55. Green R, Mason R. Managing confidentiality in rural welfare practice in Australia. Rural Soc Work. 2002;7:34–43. Greenhill JA, Mildenhall D, Rosenthal D. Ten ideas for building a strong Australian rural health system. Rural Remote Health. 2009;9:1206. Gripton J, Valentich M. Dealing with non-sexual professional-client dual/multiple relationships in rural communities. Rural Soc Work. 2004;9:216–25. Harowski K, Turner AL, LeVine E, Schank JA, Leichter J. From our community to yours: rural best perspectives on psychology practice, training, and advocacy. Prof Psychol Res Pract. 2006;37:158–64. Haydar SH. Dual relationships and the psychologist’s inner circle: ethical decision making concerning multiple relationships with family and friends. Diss Abstr Int. 2007;67(9-B):5405. Hays KF. Being fit: the ethics of practice diversification in performance psychology. Prof Psychol Res Pract. 2006;37:223–32. Helbok CM. The practice of psychology in rural communities: potential ethical dilemmas. Ethics Behav. 2003;13:367–84. Helbok CM, Marinelli RP, Walls RT. National survey of ethical practices across rural and urban communities. Prof Psychol Res Pract. 2006;37:36–44. Hourihan F, Kelly B. National health policy: what does this mean for rural mental health research? Aust J Rural Health. 2006;14(2):49–50. Jackson H, Judd F, Komiti A, Fraser C, Murray G, Robins G, Pattison P, Wearing A. Mental health problems in rural contexts: what are the barriers to seeking help from professional providers? Aust Psychol. 2007;42:147–60. Jameson JP, Blank MB. Rural services: defining problems and developing solutions. Clin Psychol Sci Pract. 2007;14:283–98. Johnson WB, Ralph J, Johnson SJ. Managing multiple roles in embedded environments: the case of aircraft carrier psychology. Prof Psychol Res Pract. 2005;36:73–81. Johnson ME, Brems C, Warner TD, Roberts LW. The need for continuing education in ethics as reported by rural and urban mental health care providers. Prof Psychol Res Pract. 2006;37:183–9. Jones CM. From novice to expert: issues of concern in the training of psychologists. Aust Psychol. 2008;43:38–54. Kee JA, Johnson D, Hunt P. Burnout and social support in rural mental health counselors. J Rural Community Psychol. 2002;E5(1):119–125.

7

Professional Ethics in Rural Practice: Relational Territory

159

Kemp Brill MK. Rural ethics for rural psychologists. Dissertation, Tennessee State University, Tennessee; 2003. Kersting K. Professional pioneering on the frontier. Monit Psychol. 2003;34(6):68. Lamb DH, Catanzaro SJ, Moorman AS. A preliminary look at how psychologists identify, evaluate, and proceed when faced with possible multiple relationship dilemmas. Prof Psychol Res Pract. 2004;35:248–54. Linzmayer C. Integrated human services in rural areas: a social work approach. Rural Soc Work. 2003;8:25–37. McDonald TW, Harris SM, Leesurier EA. Mental health care issues in a predominantly rural and frontier state: results and implications from a comprehensive survey. J Rural Community Psychol. 2005;E8(1):99–108. McIlwraith RD, Dyck KG. Strengthening rural care – the contribution of the science and practice of psychology. ISBN#: 1-896538797. Ottawa: Canadian Psychological Association; 2002. McIlwraith RD, Dyck KG, Holms VL, Carlson TE, Prober NG. Manitoba’s rural and northern community-based training program for psychology interns and residents. Prof Psychol Res Pract. 2005;36:164–72. Meyer D, Hamel-Lambert J, Tice C, Safran S, Bolon D, Rose-Grippa K. Recruiting and retaining mental health professionals to rural communities: an interdisciplinary course in Appalachia. J Rural Health. 2005;21:86–91. Moleski SM, Kiselica MS. Dual relationships: a continuum ranging from the destructive to the therapeutic. J Couns Dev. 2005;83:3–11. Morrissey S, Reddy P. Maintaining ethical practice and ethical mindedness. In: Morrissey S, Reddy P, editors. Ethics and professional practice for psychologists. Melbourne: Thomson; 2006. p. 163–70. Morrissey S, Symons M. Teaching ethics for professional practice. In: Morrissey S, Reddy P, editors. Ethics and professional practice for psychologists. Melbourne: Thomson; 2006. p. 50–62. Nelson W, Lushkov G, Pomerantz A, Weeks WB. Rural health care ethics: is there a literature? Am J Bioeth. 2007a;6:44–50. Nelson W, Pomerantz A, Howard K, Bushy A. A proposed rural healthcare ethics agenda. J Med Ethics. 2007b;33:136–9. Nigro T, Uhlemann M. Dual relationship in counselling: a survey of British Columbian counsellors. Can J Couns. 2004;38:36–53. O’Kane A, Tsey K. Towards a need based mental health resource allocation and service development in rural and remote Australia. Australas Psychiatry. 2004;12:390–5. Perkins D, Larsen K, Lyle D, Burns P. Securing and retaining a mental health workforce in Far Western New South Wales. Aust J Rural Health. 2007;15:94–8. Peterson ZD. More than a mirror: the ethics of therapist self-disclosure. Psychother Theory Res Pract Train. 2002;39:21–31. Preskill H. The use of critical incidents to foster reflection and learning. Hum Resour Dev Q. 2006;7:335–47. Reber AS, Reber E. The Penguin dictionary of psychology. 3rd ed. London: Penguin Books; 2001. Ridgeway RB. Ethics dilemmas in forensic psychology: a comparison of practitioner choices in rural and urban settings. Diss Abstr Int. 2005;66(8-B):4499. Roberts LW, Battaglia J, Epstein RS. Frontier ethics: mental health care needs and ethical dilemmas in rural communities. Psychiatr Serv. 1999;50:497–503. Roberts LW, Warner TD, Hammond KG. Ethical challenges of mental health clinicians in rural and frontier areas. Psychiatr Serv. 2005;56:358–9. Roufeil L, Lipzker A. Psychology services in rural and remote Australia. InPsych. 2007;29(5):8–11. Sawyer D, Gale J, Lambert D. Rural and frontier mental and behavioural health care: barriers, effective policy strategies, best practices. Waite Park: National Association for Rural Mental Health; 2006. Schank JA, Skovholt TM. Dual-relationship dilemmas of rural and small-community psychologists. Prof Psychol Res Pract. 1997;28:44–9.

160

J. L. Malone

Schank JA, Skovholt TM. Ethical practice in small communities: challenges and rewards for psychologists. Washington, DC: American Psychological Association; 2006. Schopp LH, Demiris G, Glueckauf RL. Rural backwaters or front-runners? Rural telehealth in the vanguard of psychology practice. Prof Psychol Res Pract. 2006;37:165–73. Scopelliti J, Judd F, Grigg M, Hodgins G, Fraser C, Hulbert C, Endacott R, Wood A. Dual relationships in mental health practice: Issues for clinicians in rural settings. Austral New Zeal J Psychiat. 2004;38:953–959. Sinclair C, Pettifor J, editors. Companion manual to the Canadian code of ethics for psychologists. 3rd ed. Ottawa: The Canadian Psychological Association; 2001. Smith AJ. Rural mental health counseling: one example of practicing what the research preaches. J Rural Community Psychol. 2003;E6(2):13–31. Staal MA, King RE. Managing a multiple relationship environment: the ethics of military psychology. Prof Psychol Res Pract. 2000;31:698. Stamm BH, Lambert D, Piland NF, Speck NC. A rural perspective on health care for the whole person. Prof Psychol Res Pract. 2007;38:298–304. Thorngren JM. Rural mental health: a qualitative inquiry. J Rural Community Psychol. 2003;E6 (2):158–168. Truscott D, Crook KH. Ethics for the practice of psychology in Canada. Edmonton: University of Alberta Press; 2004. Turchik JA, Karpenko V, Hammers D, McNamara JR. Practical and ethical assessment issues in rural, impoverished, and managed care settings. Prof Psychol Res Pract. 2007;38:158–68. Van Vliet KJ. Interdisciplinarity and counselling psychology research: challenges and opportunities. Paper presented at the annual conference of the Canadian Psychological Association, Montreal; 2009, June. Weigel DJ, Baker BG. Unique issues in rural couple and family counselling. Fam J. 2002;10:61–9. Wihak C, Merali N. Adaptations of professional ethics among counselors living and working in a remote native Canadian community. J Multicult Couns Dev. 2007;35:169–81. Womontree M. Ethical concerns common to small community and rural mental health practice. Unpublished doctoral dissertation, The Adler School of Professional Psychology, Chicago, Illinois, United States of America; 2004. Wood JAV, Miller TW, Hargrove DS. Clinical supervision in rural settings: a telehealth model. Prof Psychol Res Pract. 2005;36:173–9. Yonge O, Grundy Q. Managing dual role relationships in rural settings. CAP Monit. 2006;24:2–4. Younggren JN, Gottlieb MC. Managing risk when contemplating multiple relationships. Prof Psychol Res Pract. 2004;35:255–60. Zur O. Therapeutic boundaries and dual relationships in rural practice: ethical, clinical and standard of care considerations. J Rural Community Psychol. 2006;E9:1–36.

Part II Professional Practice in Rural, Remote, and very Remote Mental Health

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Models of Service Delivery and Funding of Mental Health Services Sebastian Rosenberg and Russell Roberts

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Structure and Flow of Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accountability for Mental Health in Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural and Remote Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence and Burden of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural Mental Health Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural Mental Health Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural Mental Health Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Youth Mental Health Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Characteristics of Rural and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Better Approach to Funding Rural and Remote Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Money Talks: How Funding Shapes Rural and Remote Mental Health Care in Australia S. Rosenberg (*) Centre for Mental Health Research, Australian National University, Canberra, ACT, Australia Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia e-mail: [email protected] R. Roberts School of Management, Charles Sturt University, Bathurst, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_8

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Abstract

Mental health funding is neither neutral nor impartial. Decisions about funding shape the nature of care, its availability, duration, and the relationships between service providers. It is estimated that Australia spends $28.6bn on mental health annually, including funding for services, employment, disability support, and other payments. Almost $10bn is provided by Australia’s nine governments for mental health services specifically, with the states and territories providing $6bn, the Australian Government $3.4bn. Mental health funding is often tied to a model of care, a population or geographic group, or to provide general support for an organization. But in the Australian mental health “system” relationships are complex and fragmented. Repeated inquiries have revealed major gaps in the spectrum of care. Consumers, carers, and even providers are too often left lost, confused, and frustrated. This fragmentation is mirrored in the way mental health is funded. In fact, Australian mental health funding is not really any kind of joined-up system at all. Rather, multiple funders engage with a confounding and sometimes competing array of service providers, obscuring role clarity and diminishing accountability. Services operate in silos to overlapping or even conflicting goals. This situation applies to rural and remote areas as much as urban contexts. This chapter describes this chaotic situation and considers the implications arising for the organization and delivery of mental health services in rural and remote communities. Our findings suggest a situation so flawed fundamental changes in governance and accountability are necessary. These changes that would see capital city-based funders working collaboratively with local experts and rural leaders, with strong accountability to the rural communities they are supposed to serve. This would drive more integration in funding, reflecting local context, better supporting, and improving rural mental health.

Introduction Funding for mental health is both scarce and complex. In Australia generally, and in rural and remote communities particularly, mental health providers struggle to meet the community demand for services. This has been identified by the World Health Organization as “the treatment gap” (Patel et al. 2018). In the Australian mental health system, there are multiple funders, providers, service models, and myriad short-term projects. This complexity means that the evidence about “what works” in delivering effective mental health care often struggles to assert itself over the issue of “who pays.” The aim of this chapter is to describe these complex funding arrangements, their impact on rural mental health service provision, and propose better governance arrangements to help ensure the funding that is available is used more efficiently

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and effectively. The chapter will look at the consequences of funding confusion for the 30% of Australians who live in rural and regional communities. Data on psychological distress, funding flows, funding trends, workforce distribution, and service access will be presented and discussed as well. Multiple reviews and inquiries have made recommendations to improve the way funding is directed to rural and remote areas, calling for additional or new resources for services like telemedicine, video conferencing, or financial incentives to attract and retain a rural mental health workforce (Medibank Private 2013; National Mental Health Commission 2014; Senate Community Affairs References Committee 2018; Select Committee on Mental Health 2006; Productivity Commission 2019a). These have failed to spur useful, lasting reform. It should be noted from the outset that data are poor. Definitions vary. Funding and service accountability is opaque. It is not easy to track funding allocations, let alone describe how it is spent or its impact on inputs and outcomes. This is a key area for improved governance. On the other hand, there is little evidence that additional funding alone results in reducing the prevalence of mental illness or improving mental health (Jorm 2018). This may possibly be an artifact of the poor accountability referred to earlier. There is also a lack of investment in rural research and evaluation (Barclay et al. 2018). Consequently, much new funding is allocated to programs with little or no evidence base. There is little sound evidence on the impact of funding on mental health outcomes in non-urban areas. Despite nearly 30 years of national and state mental health plans, in most such plans rural mental health is barely considered (Roberts and Maylea 2019). But the country is not like the city. The fundamental inappropriateness of applying a one-size-fits-all approach to mental health planning represents a failure of public policy. Allocating additional funding to uncoordinated and fragmented service systems is not an efficient use of public funds. Mental health workforce issues, poor public access, higher levels of psychological distress, and suicide rates in rural communities are already well-known problems. Rather than repeat or perpetuate this process, this chapter argues that there is an urgent need for the planning, provision, and evaluation of rural mental health services to be controlled by rural people. New funding should be tied to sound accountability and governance structures managed by local communities. Planning, funding, and service provision should respect and reflect local expertise and the rights of rural people to have a voice and adhere to the principles of citizen participation (Roberts et al. 2021). The need for regional approaches to policy, planning, and funding of mental health care has been well-documented (Senate Community Affairs References Committee 2018; Productivity Commission 2019a). These reports recommend shifting from the control of centralised, city-based departments toward a model that better respects local community leadership and expertise (including experts by experience). If this aspiration is to be realised, it will depend on new and better ways of funding, accountability, and decision-making. This is a significant challenge. But

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given the state of mental health care in many rural and remote areas, it is a challenge that cannot be ignored.

Distinctive Features The Complexity of Mental Health Funding Total Funding Expenditure on mental health can take various forms: direct expenditure on service provision, non-direct expenditure (e.g., income support), and associated costs of mental illness (e.g., use of other medical and social services). Total expenditure to support mental illness has been estimated at $28.6bn annually. Of this, $13.8bn is for direct health expenditure. This figure includes services, medication, related drug and alcohol services, and spending on related comorbidities. This means that in fact the largest component of spending on mental health is actually not on services but on welfare and other support payments. $14.8bn is directed toward this non-health expenditure, particularly employment and welfare support, payments to carers, and other items (Medibank Private 2013). While the majority of Australian Government funding is directed to disability payments and carer support, this chapter will focus on the way direct services and programs are funded. This includes hospital care, community care, primary prevention, health promotion and mental health training, and mental health research. Direct mental health expenditure, that is, funding directed toward mental health services specifically rather than welfare payments more generally, is predominantly provided by the states and territories ($6bn) and the Australian Government ($3.3bn). However, smaller contributions are also made by local councils, private health insurers, charities, and philanthropic organizations. Service users themselves also contribute, by paying out-of-pocket expenses for mental health care. The complexity of mental health funding was illustrated in a 2013 report by Medibank Private (reproduced at Fig. 1). While the numbers are now different, the multiplicity of funding routes remains.

Funding Sources Under Australia’s federal system of government, responsibility for health care is split. The Australian Government takes responsibility for primary care, while the eight state and territory governments manage secondary- and tertiary-level care, including community care, residential, and inpatient care. Simplistically, the federal/ state split could also be seen to assign the care people with mild to moderate mental health problems to the federal government, while those with more severe problems are the responsibility of state-based services. In reality, the demarcation is not this simple and is littered with exceptions.

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Fig. 1 Components of health expenditure to support people with mental illness (Taken from Medibank Private (2013), p. 41)

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State and territory governments are the largest funders of direct mental healthcare services. Of total direct spending on mental health in 2017–2018 of $9.9bn, state and territory spending was $6bn or approximately 60%. The Australian Government provided $3.3bn, while $0.5bn came from private sources. In addition individual out-of-pocket expenses for people living with mental illness were approximately $300 m (Australian Institute of Health and Welfare 2019b). This federal/state split is written into the nation’s constitution, giving the states and territories significant autonomy over their health systems (Smullen 2016). Documents such as the 5th National Mental Health and Suicide Prevention Plan (Department of Health 2017b) propose joint processes of planning and communication. However, these proposals have typically failed to provide either the incentives or sanctions necessary to drive integrated mental health policy or planning. Each state and territory have their own mental health plan. This leaves all nine Australian governments working on largely separate and different service and political priorities. This is a recipe for fragmentation. This is illustrated in Table 1 which shows the disparity of funding effort between jurisdictions. Into this contested space come other organizations, non-government, primary health care, Aboriginal community controlled, etc., who attempt to navigate and survive between these nine funding streams and variable policy environments. This complexity is mirrored in other important areas of mental health funding and policy, such as community and social services.

Australian Government Funding Total Funding Growth Total funding to mental health has not materially changed since 1992. At the launch of the first National Mental Health Strategy (Australian Health Ministers’ Advisory Council 1992), mental health comprised was 7.3% of the total health budget, and in 2017–2018, it was 7.6% (see Fig. 2). Mental health’s share of total health spending has actually been in decline in the period 2013–2014 to 2017–2018 (Australian Institute of Health and Welfare 2019c). Also unchanged is mental health’s contribution to the overall burden of disease, at around 12%. There is no axiomatic reason why the funding to mental health should match its contribution to the overall burden of disease. However, the gap between the two is significant and consistent. This funding inertia may seem surprising to readers. Regular announcements give the impression of significant boosts to mental health. For instance, the 2011 “Delivering National Mental Health Reform” announcement promised $2.2bn for mental health reform. But after accounting for previous cuts and already committed funding, the impact for people living with mental illness “equals 85 cents extra per week: about enough for one cup of coffee a month” (Roberts 2011, p. 230). Funding Distribution The Australian Institute of Health and Welfare (2019c) provided some recent data, reporting that $9.9bn was spent nationally in 2017–18 on direct mental health care. Of that total amount, the state and territory governments provide by far the largest

Public psychiatric hospitals Specialized psychiatric units or wards in public acute hospitals Community mental health-care services Residential mental health services Grants to non-government organizations Other indirect expenditure Total

Vic 9.15 69.51 84.34 32.09 18.27 14.37 227.74

NSW 34.08 92.95 75.93 1.11 16.46 13.67 234.19

Per capita spending

Table 1 State and territory mental health spending 2017–2018

103.39 9.23 16.98 13.04 231.31

Qld 15.87 72.80 121.94 11.68 18.39 17.34 314.98

WA 34.33 111.29 100.77 19.67 18.23 7.18 268.15

SA 40.30 82.00 73.15 60.46 26.20 8.93 237.33

Tas 0.00 68.60 107.30 27.13 20.55 7.59 259.37

ACT 0.00 96.80

121.41 29.35 21.77 11.26 292.06

NT 0.00 108.27

91.03 15.10 17.68 13.43 243.76

National average 22.82 83.70

2,255,407 373,997 438,065 332,611 6,039,370

Total spend $’000 565,494 2,073,795

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Percentage

15.00 10.00 5.00 0.00

Mental Health as % of Total Health Spending Mental Health as % of Total Burden of Disease Fig. 2 Mental health expenditure and burden of disease 1992/1993 to 2017/2018

Fig. 3 Australian Government expenditure on mental health, 2012–2013 (National Mental Health Commission 2014)

component of the total funding, 60.6% ($6.0bn), the Australian Government 33.9% ($3.3bn), and private health insurance funds and other third-party insurers 5.5% ($544 million). These proportions have remained relatively stable over the last 10 years. The National Mental Health Commission (2014) data provided a concise summary of the $9.6bn spent by Australian Government in 2012–13 on mental health (see Fig. 3). Only 12.5% of total Australian Government mental health funding goes to mental health programs, with over 60% of funding provided as pensions and

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allowances to people living with disabling mental illnesses and their carers. Medicare and Pharmaceutical Benefits Schemes together comprise 17.5%. Put in context, for every $1 the Australian Government spend on mental health programs, $1.50 subsidizes MBS and PBS payments. General practitioners, private psychologists, psychiatrists, and pharmacists are the gatekeepers and recipients of $1.75bn of this funding. Virtually nothing is known about the effectiveness or efficacy of this spending. State and Territory Expenditure and Funding As stated earlier, the various and concurrent policies and plans across governments yield significant variation in the spending effort. For example, as shown in Table 1, Western Australia (WA) spends over 30% more per capita on mental health than New South Wales (NSW), Victoria (Vic), or Queensland (Qld). While Tasmania spends more than $60 per person on residential care, NSW spends just $1.11. Some jurisdictions continue to provide care in psychiatric specialist institutions, others do not. Are such variations justified and desirable? How do they marry with the evidence about how systems should be responding to mental illness? The nature of the care available to Australians varies markedly depending on where you live. Businesses and Organizations Businesses provide a substantial contribution to mental health care through their worker compensation insurance premiums, estimated at $106 m annually (Medibank Private 2013). Reports suggest that both the proportion and the amount that is directed to mental health service and payments is increasing dramatically (Allianz 2019; Deloitte Insights 2019). In addition to these premiums, businesses in Australia are increasingly alert to the impact of mental illness on productivity, either through sick leave, presenteeism, or other costs. Corporate expenditure on Employee Assistance Programs for mental health in 2010–2011 was estimated at $120 m (Medibank Private 2013). Internationally, and in Australia, spending on this type of support has been increasing (Allianz 2019) although precise and consolidated data are not available, and overseas research indicates this support has increased by 6% between 2016 and 2018 (Deloitte Insights 2019). Many businesses are choosing to invest significant sums in mental health literacy, resilience training, and similar corporate health and wellbeing type programs (Allianz 2019; Deloitte Insights 2019). Donations and Philanthropic Support Funding for mental health also comes from community donations and philanthropic organizations. For instance, Lifeline, the Salvation Army, St Vincent’s, and Anglicare (to name a few) all direct public donations to mental health well-being support and programs. Likewise, organizations such as Beyond Blue and the Royal Flying Doctor Service also direct community donations and financial support to providing mental health care. Philanthropic organizations such as the Paul Ramsay Trust also provide mental health support, for example, through funding the national suicide prevention trials.

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Service Users Many people living with mental illness subsidize their mental health care from their own pocket. This may be through full payment for the service they receive (e.g., some psychology consultations). However, most commonly, where mental health services are funded under Medicare (the Medicare Benefits Schedule), the MBS payment to the treating professional does not cover the entire fee for the service, leaving consumers to pay an additional out of pocket or “gap fee” to their service provider. In 2016–2017, 2.4 million Australians paid $282 m in out-ofpocket costs for Medicare-subsidized mental health services (Australian Institute of Health and Welfare 2019b). Many people also directly pay for mental health services via their private health insurance fund contributions. In 2017–2018 across Australia, the amount paid for mental health services by private health insurers was $544 m.

Funding Recipients Just as mental health funding comes from numerous sources, in a similar fashion, it is expended and deployed by an array of providers. State and Territory Government Services Just under half (43%) of state and territory mental health funding supports hospitalbased care (see Table 1). Another 44% goes to community residential or community care. While each state and territory have a different service model, a large part of their service provision is directed to people living with severe mental illness or moderate mental illness. They also allocate funding to research, evaluation, mental health promotion, and education; however, this funding is quite limited, impeding systemic capacity to implement clearly evidence-based care. Non-government, Community-Controlled, Not-for-Profit Organizations Over the life of the National Mental Health Strategy, since 1992–1993, mental health services provided by non-government organizations (NGOs) had been expanding but remained only a minor element of total mental health spending. In 1992–1993 NGO services accounted for less than 2% of total mental health spending by the states and territories. In 2017–2018 mental health NGOs accounted for over 7% of total expenditure on mental health (Australian Institute of Health and Welfare 2019c). Some of the larger NGOs have been working in Australia for decades and now employ more mental health staff than some small states and territories. Over recent years, NGO funding provided by the states and territories was augmented by the Australian Government, through financial support to establish programs such as Personal Helpers and Mentors (PHaMs) and Partners in Recovery. However, in recent years, and as part of establishing the National Disability Insurance Scheme (NDIS), most states and territories, as well as the Australian Government, re-directed their NGO funding to the NDIS. The NDIS model relied on individuals holding their own funding and making choices about desired services. This ended the block contracting and other arrangements under which NGOs had

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operated. It destabilized the funding and employment arrangements in an already fragile NGO sector in mental health. The future of NGOs in Australian mental health care is unclear, partly because the national commitment to psychosocial services has also been unclear. Australia’s response to mental illness has focused on the provision of clinical and health professional services. This has significant implications for rural and remote areas, where NGO services are vital. Private Health Providers Mental health funding also goes to a range of health providers, such as general practitioners (GPs), psychologists, and other allied health professionals. In 2017– 2018, these providers delivered 11.6 m service contacts under Medicare costing $1.24bn. GP practices and psychology and psychiatry practices typically operate as small businesses. This is a key consideration in understanding the nature and form of services provided. To continue to operate, they must trade as viable and profitable enterprises, relying on throughput to make more money. Medicare’s fee for service payments create an incentive to see more patients, more quickly, rather than spending the time and resources necessary to ensure patients receive appropriate and effective care. GPs also provide physical health care services for people living with mental illness. People living with mental illness die earlier and have poorer mental health than the general population. In Australia, people living with mental illness die on average 12–16 years earlier than the general population (Lawrence et al. 2013; Sara et al. 2019). The role of the GPs in screening and treating physical health conditions is vital to improving the mental health of people living with mental illness (Roberts et al. 2018; Roberts 2019). Poor physical health contributes to poor mental health. Research into the contribution of poor physical health to psychological distress suggests between 21% and 42% of subjective ratings of mental health are due to poor physical health (Mcnamara et al. 2018). Poor physical health is also a major correlate of suicidal behavior (Fässberg et al. 2016). The structure and form of Medicare payments heavily influences mental health practice. Medicare funding is provided as fee for service. Small and medium businesses cannot sustain unprofitable activities. There is strong evidence that fee for service funding militates against multidisciplinary team-based care (Senate Select Committee on Mental Health 2006; Hamilton et al. 2017).To expect GPs to attend collaborative care planning meetings, or planning workshops in business hours without remuneration, is unfair and naive. On the other hand, the MBS funds a 6-min consultation at the same rate as a 20min session. So, while an extended mental health consultation rate may seem to yield a similar return per minute as a standard (6–20) minute consultation, the reality is 6min consultations provide a much higher rate of return for the practice than the 60min extended mental health consultation. The current MBS medical rebate structure is an impediment to comprehensive and holistic mental health care (Institute of Medicine 2006).

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Table 2 Medicare mental health 2017–2018 Provider General practitioner (GP) Psychiatrists Clinical psychologists Registered psychologists and other allied health professionals Total

Number of services provided 3,624,992 2,422,166 2,301,747 3,321,491

Medicare spending $m 299 358 293 290

Cost per contact $82.49 $147.80 $127.29 $87.31

11,670,396

1241 m

$106.34

Psychiatry, psychology, and other mental health services also access Medicare funding in this way. The introduction of Better Access has seen the rapid expansion of psychology and allied health small businesses that provide mental health services. These GP, psychiatry, psychology, and allied health small businesses now receive $24m every week to deliver mental health services (see Table 2). Almost no research is available on the impact of this expenditure, raising questions about both value for money and mental health outcomes (Jorm 2018; Rosenberg and Hickie 2019). Primary Health Networks Primary Health Networks (PHNs) were introduced in 2015 to plan and coordinate the delivery of health care at a local level. The introduction of PHNs was partly in response to reviews highlighting the fragmented and uncoordinated state of mental health services at the local or regional level. The majority of PHN funding comes from the Australian Government, which has provided $1.45bn over 3 years (to 2021–22) to provide direct care and to commission mental health services at the local level. On average, this works out to be around $15.6m each year for each of the 31 PHNs. PHNs can also receive funding from the states and territories, as well as NGOs and philanthropic organizations. As a consequence, while PHNs were created to better integrate and coordinate care at the local level, to some extent this initiative just added additional service segmentation to an already fragmented mental health system. Private Hospitals Private hospitals provide inpatient clinics and admitted care. The reported expenditure on these services in 2017–2018 was around $500m (Australian Institute of Health and Welfare 2019b). Individual Mental Health Consumers People living with disabling mental illness receive a disability support payment related to their mental health conditions. Comprising $4.7bn per annum it constitutes half and by far the largest single component of the Australian Government total mental health expenditure (see Fig. 3). In addition, some carers of people living with

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mental illness also receive a support payment from the Australian Government. This support comprises 11% of the Australian Government mental health expenditure each year. There are other hidden payments to support people living with mental illness. For example, people may receive a Newstart allowance due to their inability to obtain work and maintain employment due to their mental illness. Teaching and Research Institutions About $70 m of total mental health spending is directed toward research (Australian Institute of Health and Welfare 2019c). Mental health’s share of overall health research funding is small, again out of proportion to its contribution to the overall burden of disease (Batterham et al. 2016). In rural Australia, there is a well-developed infrastructure of health education and research through the rural clinical schools and departments of rural health (Lyle and Greenhill 2018). However, the 30% of Australians living in rural communities do not get an equitable share of this funding. Of total funding provided by the National Health and Medical Research Council (NHMRC), only 2.4% was directed towards people who live in rural or remote Australia (Barclay et al. 2018).

Practice Implications Structure and Flow of Funding The previous sections have outlined the multiple funders and providers operating in mental health. The links between these stakeholders are not simple. Many funding recipients providing direct services also sub-contract out services to other providers. Examples here include PHNs, state and territory governments, and large NGOs. Anecdotally, one NGO reported holding up to 60 funding contracts in any 1 year so as to fund its operations. Organizations such as these are simultaneously funding recipients, service providers, funders, and contract managers. The deployment or style of funding arrangements also varies. Some services are paid through block grants or contracts, others through fee for service. Some are funded regionally and some to meet the needs of identified target groups. Funding can also flow through individually negotiated service specification contracts (as in the NDIS) or be strictly directed to provide highly regimented specific programs.

A Complex Picture The way mental health funding is arranged and spent is both messy and complex. Figure 4 outlines how general health funding is allocated, deployed, and expended. Whilst the pattern is not exactly the same for mental health funding, the overall

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Fig. 4 Health services funding and expenditure. (Taken from Australian Institute of Health and Welfare 2016a, 2018, p. 27)

picture is very similar, perhaps worse. For example, the National Mental Health Commission (National Mental Health Commission 2014) found, for example, that in 2012–2013 three Australian Government departments alone ran 64 programs with a total funding of $606 million allocated to 542 organizations.

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Accountability for Mental Health in Australia It is worth noting that accountability for mental health has been a significant concern since the publication of the first National Mental Health Strategy in 1992 (Australian Health Ministers’ Advisory Council 1992): There needs to be greater accountability and visibility in reporting progress in implementing the new national approach to mental health services. Currently, mental health data collection is inconsistent and would not be adequate to enable an assessment to be made of the relative state of development of the Commonwealth and each State/Territory in achieving the objectives outlined in the National Mental Health Policy. (p. 13)

The 1992 strategy therefore outlined two key objectives: • Nationally agreed outcome measures • Annual public reporting However, since then, and despite repeated commitments to improved accountability in five national mental health plans, two policies, one roadmap, one national action plan, and countless state policies and plans, in fact little has changed (Rosenberg and Salvador-Carulla 2017). This lack of progress was identified in the draft report of the Productivity Commission Inquiry into Mental Health (2019): Reforms to the governance arrangements that underpin Australia’s mental health system are essential to inject genuine accountability, clarify responsibilities and ensure consumers and carers participate fully in the design of policies and programs that affect their lives. (Vol. 2, p. 882)

This aspiration for accountability and consumer and carer engagement should apply equally to rural Australia. This lack of accountability and data means the picture around funding and service use right across mental health, including rural and remote, is not clear. Nevertheless, it is possible to examine some of the data which are available and construct a sense of the key issues. There have been dozens of parliamentary reports and statutory inquiries into mental health over decades (Mendoza et al. 2013). Most of these reports have produced findings or recommendations which call for new funding and new services. While there have been regular shifts in policy, consistent and coherent new funding for mental health has been elusive. This has an impact on mental health services across Australia but particularly in non-urban areas. This instability is perhaps the most fundamental flaw in Australian mental health care provision. In 2019 and 2020, two Royal Commissions and a Productivity Commission of Inquiry commenced. The end product of the conclusions and recommendations arising from these commissions remain to be seen.

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Rural and Remote Mental Health Prevalence and Burden of Disease In terms of the prevalence of mental illness overall, the number of people experiencing mental illness is similar right across the nation: around one in five people (Australian Bureau of Statistics 2008). Australia is a large country with a relatively small population that is concentrated in a small number of major cities. Nonetheless, almost one in three Australians live outside the major cities. Distance and isolation pose challenges for funders, policymakers, service providers, consumers, and their families in relation to the organization and delivery of quality mental health care. It should be noted that there are some protective factors against mental illness associated with living in rural and remote communities that are lacking in urban settings. Some rural communities can be more socially connected; specifically, health professionals and community service providers can work more closely together as they often know each other well and share a personal investment in the health of their community (Hoolahan 2002). Despite this, recent data suggest that the rate of people reporting high or very high levels of psychological distress is higher outside of major cities, as shown in Table 3 below (Productivity Commission 2019b). There are data to suggest a similar pattern in relation to young people (Lawrence et al. 2015), as shown in Table 4. The Centre for Rural and Remote Mental Health (Hazell et al. 2017) has noted that in every state in Australia, the rate of suicide among those who live outside the greater capital cities is higher than that for residents who live within them, and this rate has increased in rural areas over the period 2011–2015. As such a new

Table 3 Age-standardized rate of adults with high/very high levels of psychological distress, by area of residence Area of residence Major cities Inner regional Outer regional/remote

High/very high distress 12.7 14.0 14.5

Table 4 Proportion of 11–17-year-olds with high or very high youth reported K10 scores by remoteness Remoteness area Major cities of Australia Inner regional Australia Outer regional Australia Remote Australia or very remote Australia

High 13.5 11.4 15.7 21.7

Very high 6.8 6.8 4.7 7.5

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Age-standardised rate

1.2 1 0.8 0.6 0.4 0.2 0

Major cities

Inner regional

Outer regional

Remote

Fig. 5 Comparison of age-standardized YYL rate: Persons, 2015, Mental and substance use disorders (Australian Institute of Health and Welfare 2019a)

approach to rural suicide prevention and mental health care provision is needed (Perkins et al. 2019). All this contributes to a situation where mental health outcomes are different for people living in regional and remote Australia. This is demonstrated in data reported by the Australian Institute of Health and Welfare (2019a) in relation to years of life lost (YLL) due to disability by region (Fig. 5). The YLL rate in remote areas is twice as high as in the cities and the AIHW suggest that 54.3% of YLL in remote and very remote areas could have been avoided if the YLL rate was the same as in the major cities.

Rural Mental Health Expenditure In summary: “People living in rural and remote Australia make up 30 per cent of the population yet do not get anywhere near 30 per cent of funding and services for mental health” (Australian Mental Health Commissions 2018, p. 6). Beyond the complex and opaque nature of existing funding arrangements, there is a disparity in mental health funding depending on where you live. Figure 6 indicates that with increasing rurality the per capita Medicare expenditure decreases. People living in remote and very remote communities access between 16% to 33% of MBS funding of their major city counterparts on a per capita basis. In 2018–2019, per capita Medicare expenditure on mental health services in very remote areas was $8.80, whereas, by comparison, per capita spending in major cities was $55.39. This disparity is not isolated to very remote communities. Even residents in inner regional communities received 17% less Medicare funding per capita than their major city counterparts. This is probably due to the lack of approved Medicare providers (gateways to Medicare funding) in these communities. Across all Medicare items, the total impact of this precipitous fall in Medicare funding with

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Medicare expenditure per capita $, finacial year 2018/2019

180 60 50

$55.39 $46.19

40 $31.55

Psychiatrist

30 20

GP $18.47

Clinical psychologist $8.80

10

Psychologist other All -total #

0

Fig. 6 Australian Government Medicare expenditure on mental health-specific services per capita ($), by provider type, remoteness area, 2018–2019

increasing rurality has been estimated as a $2bn expenditure deficit to rural Australians (National Rural Health Alliance 2016). To a very limited extent, this deficit in Medicare spending is compensated by public health spending increasing by rurality (see Fig. 11). Per capita spending on public mental health is 30% higher in remote communities than average (see Fig. 11), but this does not offset the 300% higher Medicare expenditure per capita in the major cities (see Fig. 6).

Rural Mental Health Workforce The poor access to mental health services in rural Australia suggests developing a well-organized response to mental illness in rural Australia should be a priority. In fact, the reverse seems to be the case. Rural mental health workforce and policy is largely neglected in national and state mental health policy, plans, and strategy (Roberts and Maylea 2019). As such, it is not surprising that rural areas face large discrepancies in terms of the employment, training, and support of a mental health workforce. Figure 7 demonstrates that psychiatrists are three times more likely to work in major cities than elsewhere and nurses and psychologists around twice as likely to work in capital cities. (Australian Institute of Health and Welfare 2016b). A similar pattern is evident for other allied health mental health professionals (Fig. 8) (Australian Institute of Health and Welfare 2013). This reduced access to clinical care is reflected in the funding provided to different areas of Australia under Medicare (see Fig. 11).

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FTE per 100,000 population

90 80 70 60 50

Psychiatrists

40 30

Mental health nurses

20

Psychologsists

10 0

Major cities

Inner Outer Remote Very Regional Regional Remote

FTE per 100,000 population

Fig. 7 Psychiatrists, nurses, and psychologists 100,000 population by place of work 100 80 60

Pharmacists

40

Physiotherapists

20

Occupational therapists

0

Major cities

Inner Regional

Outer Regional

Remote/ Very Remote

Fig. 8 Geographic distribution of allied health workforce by remoteness (Australian Institute of Health and Welfare 2013)

Rural Mental Health Access Simply put, the scarcity of health professionals working in rural and regional communities means reduced access to services. The inequity delivered by Medicare in non-urban areas is understood (Australian Institute of Health and Welfare 2010; Meadows et al. 2015) and shows that increasing remoteness is consistently associated with lower service activity and service access (Australian Institute of Health and Welfare 2019c). While the overall level of access to mental health-related MBS services in Australian has increased by 165% over a 9-year period, the gap between major cities and remote communities in the percentage of population accessing these services has in fact, almost doubled over the last 9 years (Fig. 9). Medicare relies on registered psychologists and providers to access the funding streams. With the shortage of providers in non-urban areas comes the consequence

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Percent

8 6 4 2 0 Major cities Inner regional

2008-09

Outer regional

Remote

Very remote

2017-18

Fig. 9 Percent of population receiving Medicare-subsidized mental health-specific services, by remoteness, 2008–2009 and 2017–2018 (Australian Institute of Health and Welfare 2019c)

of reduced access to funding and services. This is evidenced by 2016–2017 data on the rate of access to Medicare-subsidized mental health-specific service by providers, showing the large and consistent reductions in access by rurality (Fig. 10). The findings of this research highlighted important socioeconomic and geographical disparities associated with the use of Medicare, including the Better Access Program. The Australian Government recently announced an additional $49.1 million over 4 years to support the mental health of people living in rural, remote, and very remote areas (Department of Health 2017a). However, put in context, this represents just 32 cents per year, per person living in rural Australia. In response to this situation, people living in non-urban areas are more likely to receive public mental health services provided by the state or territory government (Fig. 11) (Productivity Commission 2019a). However, overall growth in the rate of access to public mental health services has been difficult to achieve. This is not surprising given there has been no material increase of mental health funding since that time.

Youth Mental Health Access With 75% of all mental illness manifesting before the age of 25, it is critical that services are available to young people. However, the inequity of access to Medicare services also applies to young people, as shown in Table 5. Young people are at least twice as likely to have access to Medicare mental health services in urban areas as in remote and very remote areas. Australia’s recent willingness to invest in services like headspace (now at around $40 m annually) is laudable but must take the issue of equity of access into account.

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Fig. 10 People (rate per 100 population) receiving Medicare-subsided mental health-specific services, by provider type and rurality, 2017. (Taken from Australian Mental Health Commissions 2018, p. 17)

14 12

Percent

10 8 6 4 2 0 Major cities Inner regional Outer regional

Remote

Very remote

Public 2018

Public 2008

Private 2018

Private 2008

MBS/DVA 2018

MBS/DVA 2008

Fig. 11 Proportion (percent) of people receiving clinical mental health services by service type and remoteness area (age-standardized). (From Productivity Commission 2019b)

Other Characteristics of Rural and Mental Health According to the AIHW (Australian Institute of Health and Welfare 2019c), more than 80% of 2017–2018 state and territory mental health spending was directed to either acute hospital services or ambulatory care, often provided in outpatient clinics

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Table 5 Proportion of young people (aged 18 kg/m2. The MDT continued to communicate collectively via email with letters at longer intervals distributed to the whole MDT. Eventually the individual sessions with the psychologist ceased as did the family therapy sessions. The psychiatrist, dietician, and GP continued three monthly follow-up interviews for over a year after Sarah had recovered to prevent a relapse. During this entire episode of care, contact with the statewide eating disorder service was not required, and Sarah continued with her schooling and her parents managed to continue to work.

Case Study 2: A Regional Adult Mental Health Multidisciplinary Team

In a small rural regional town, the local public sector community mental health service (CMHS) meets weekly to discuss new adult (18–65 years of age) referrals, complex cases, and the closure of completed cases, as a MDT. The (continued)

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Case Study 2: A Regional Adult Mental Health Multidisciplinary Team (continued)

team consists of two mental health nurses, a social worker and an occupational therapist (who is also team leader/manager) in addition to a fly-in/fly-out consultant psychiatrist who attends irregularly in person and on occasions by teleconference. In order to enhance the MDT capacity and communication with key agencies in the region, a lead clinical member of the local alcohol and other drug service, mental health rehabilitation NGO, and local mental health inpatient unit clinical nurse consultant attend the meetings regularly. The team manager (occupational therapist) chairs the meeting and coordinates the allocation of new assessments (according to urgency and acuity as discussed by the team) and case management of newly assessed cases. Complex cases are discussed by the team, and care is coordinated between agencies and services. External agency attendees are considered important members of the MDT, enshrined in memorandums of understanding between organizations addressing issues such as information sharing, decision making and confidentiality. The MDT discusses team process and dynamic issues at the end of every clinical meeting as they arise. Concise minutes of the meetings are distributed to members of the MDT to facilitate communication, coordinate care, and document decisions made during the meeting. The team undertakes a review of its outcomes, processes, and membership at the end of each financial year in a separate meeting involving all stakeholders, including a representative from the service consumer and carer group.

Cross-References ▶ Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas ▶ General Practitioners ▶ Maintaining Control: The Importance of Self-Care to Effective and Enduring RRvR Mental Health Service Provision ▶ Peer Work in Rural and Remote Communities and Mental Health Services ▶ Rural and Remote Mental Health Practice: Nursing Roles ▶ Rural and Remote Psychiatry ▶ Social and Emotional Well-Being: “Aboriginal Health in Aboriginal Hands” ▶ Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand

References Abbott A. The system of professions: an essay on the division of expert labor. Chicago: The University of Chicago Press; 1988. Australian Medical Association. Rural workforce initiatives 2017. AMA Position Statement. 2017. https://ama.com.au/position-statement/rural-workforce-initiatives-2017. Accessed 15 Oct 2019.

288

M. Coleman

Battye K, Roufeil L, Edwards M, Hardaker L, Janssen T, Wilkins R. Strategies for increasing allied health recruitment and retention in Australia: a rapid review: Services for Australian Rural and Remote Allied Health (SARRAH); 2019. p. 52. https://sarrah.org.au/publication/strategiesincreasing-allied-health-recruitment-and-retention-rural-australia Bock GW, Zmud R, Kim YG, Lee JN. Behavioral intention formation in knowledge sharing: examining the roles of extrinsic motivators, social-psychological forces, and organizational climate. MIS Q. 2005;29(1):87–111. Burns T. Community mental health teams. Psychiatry. 2004;3(9):11–4. Canadian Collaborative Mental Health Initiative. Establishing collaborative initiatives between mental health and primary care services for ethnocultural populations. A companion to the CCMHI planning and implementation toolkit for health care providers and planners. Mississauga: Canadian Collaborative Mental Health Initiative; February 2006. Cited 15 Oct 19. Available at: www.ccmhi.ca Carrier J, Kendall I. Professionalism and inter-professionalism in health and community care: some theoretical issues. In: Owens P, Carrier J, Horder J, editors. Interprofessional issues in community and primary health care. London: Macmillan; 1995. p. 9–36. Chiocchio F, Lebel P, Dubé JN. Informational role self-efficacy: a validation in interprofessional collaboration contexts involving healthcare service and project teams. BMC Health Serv Res. 2016;16:153. Crosbie D, Rosenberg S. COAG mental health reform. Mental health and the new medicare services: an analysis of the first six months. Canberra: Commonwealth of Australia, Mental Health Council of Australia; 2007. Department of Health. National standards for mental health services 2010. Barton: Commonwealth of Australia; 2010. p. 60. Issue 6693 Department of Health. Department of Health 2016: Australia’s future health workforce – psychiatry. n.d. https://www1.health.gov.au/internet/main/publishing.nsf/Content/Australias-future-healthworkforce%E2%80%93psychiatry. Accessed 15 Oct 2019. Farhall J. Interdisciplinary teamwork: clinical psychology and the common good. Paper presented at the 33rd congress of the Royal Australian and New Zealand College of Psychiatrists. Melbourne; 1998. Fielding J, Walterfang M, Dakis J. The challenge of ongoing education in multidisciplinary mental health services. Australas Psychiatry. 2002;10(3):224–8. Fleury MJ, Grenier G, Bamvita JM, Chioccho F. Variables associated with work performance in multidisciplinary mental health teams. SAGE Open Med. 2017;5:1–12. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd Mead and Co; 1972. Gardiner FW, Coleman M, Teoh N, Harwood A, Coffee N, Bishop L, Laverty M. Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia. Med J Aust 2019;211(8):351–356. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246–51. Haines A, Perkins E, Evans EA, McCabe R. Multidisciplinary team functioning and decision making within forensic mental health. Ment Health Rev J. 2018;23(3):185–96. Isaacs AN, Pyett P, Oakley-Browne MA, Gruis H, Waples-Crowe P. Barriers and facilitators to the utilization of adult mental health services by Australia’s indigenous people: seeking a way forward. Int J Ment Health Nurs. 2010;19(2):75–82. Jefferies H, Chan KK. Multidisciplinary team working: is it both holistic and effective? Int J Gynecol Cancer. 2004;14(2):210–1. Lamb BW, Brown KF, Nagpal K, Vincent C, Green JS, Sevdalis N. Quality of care management decisions by multidisciplinary cancer teams: a systematic review. Ann Surg Oncol. 2011;18(8):2116–25. Leipzig RM, Hyer K, Ek K, Wallenstein S, Vezina ML, Fairchild S, Cassel CK, Howe JL. Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline. J Am Geriatr Soc. 2002;50(6):1141–8.

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McAllister M, Morrissey S, McAuliffe D, Davidson G, McConnell H, Reddy P. Teaching ideas for generating critical and constructive insights into well-functioning multidisciplinary mental health teams. J Ment Health Train Educ Pract. 2011;6(3):177–27. Mental Health Commission of Ireland. Multidisciplinary team working: from theory to practice. Dublin: Mental Health Commission of Ireland; 2006. p. 65. Mickan S, Rodger S. Characteristics of effective teams: a literature review. Aust Health Rev. 2000;23(3):201–8. Morrissey SA, Davidson G, McAuliffe D, McAllister M, McConnell H, Reddy P. Preparing mental health practitioners for multidisciplinary mental health placements: a distributed leadership approach to cross-disciplinary education and training. Strawberry Hills; 2011. p. 41. National Rural Health Alliance. Nurses in rural, regional and remote Australia: fact sheet. Deakin West; 2019. p. 2. NHS Quality Improvement Scotland. Standards for integrated care pathways for mental health. Edinburgh: NHS Quality Improvement Scotland; 2007. p. 120. Nic a Bháird C, Xanthopoulou P, Black G, Michie S, Pashayan N, Raine R. Multidisciplinary team meetings in community mental health: a systematic review of their functions. Ment Health Rev J. 2016;21(2):199–40. Oborn E, Dawson S. Knowledge and practice in multidisciplinary teams: struggle, accommodation and privilege. Hum Relat. 2010;63(12):1835–57. Onyett S. Responsibility and accountability in community mental health teams. Psychiatr Bull. 1995;19:281–5. Onyett S. The challenge of managing community mental health teams. Health Soc Care Community. 1997;5:40–7. Peck E, Norman IJ. Working together in adult community mental health services: exploring interprofessional role relations. J Ment Health. 1999;8(3):231–43. Perkins D, Lyle D. Is the far West mental health integration project making a difference? The general practitioner perspective. Aust J Prim Health. 2005;11(3):32–7. Psychology Board of Australia. Registration data tables – August 2011; 2011. www. psychologyboard.gov.au/About/Statistics.aspx. Accessed 15 Oct 2019. Ragusa A, Crowther A. I think it is the best job . . . I love it!’ Engendering workplace satisfaction in rural and remote Australian mental health nursing. Rural Soc. 2012;22(1):45–8. Raine R, Wallace I, Nic a Bháird C, et al. Improving the effectiveness of multidisciplinary team meetings for patients with chronic diseases: a prospective observational study. Health Ser Del Res. 2014;2. https://doi.org/10.3310/hsdr02370. Roberge ME, van Dick R. Recognizing the benefits of diversity: when and how does diversity increase group performance? Hum Resour Manag Rev. 2010;20(4):295–308. Schofiled RF, Amodeo M. Interdisciplinary teams in health care and human services settings: are they effective? Health Soc Work. 1999;24(3):210–9. Slade M, Rosen A, Shanker R. Multidisciplinary mental health teams. Int J Soc Psychiatry. 1995;41(3):180–9. West M, Alimo-Metcalfe B, Dawson J, et al. Effectiveness of multi-professional team working (MPTW) in mental health care. Final report, NIHR Service delivery and organisation programme. Southampton: National Institute for Health Research; 2012. p. 199. Woody CA, Baxter AJ, Harris MG, Siskind DJ, Whiteford HA. Identifying characteristics and practices of multidisciplinary team reviews for patients with severe mental illness: a systematic review. Australas Psychiatry. 2018;26(3):267–75.

Improving the Physical Health of Rural People Living with Mental Illness

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The fact that people with serious mental illness die an average of 20 years earlier than the rest of the population, the majority from preventable causes, is one of the biggest health scandals of our time, yet it is very rarely talked about. Professor Sue Bailey (Rethink 2013)

Contents Introduction: Background and Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specific Risks and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributing Factors and Implications for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medication Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . National and International Policy Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Working Effectively as Part of the Available Health System and Supports . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points for Effective Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist: Ten Evidence-Based Actions to Improve the Physical Health of People Living with Mental Illness (in Order of Priority) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Improving the physical health of people living with mental illness has become a national and international priority, and for good reasons. For every one person with a mental illness who dies from suicide, ten die prematurely due to avoidable physical health conditions such as cardiovascular disease, cancer, or respiratory disease. People living with mental illness can lead healthy productive lives. However, on average, people living with mental illness die between 50 and 59 years of age. While living with mental illness doubles the risk of early death, living with a mental illness in a rural community triples the risk of early avoidable death. Eighty percent of people with a mental illness also have a mortality-related physical health condition. Most of the causes of early premature death in people living with mental illness are avoidable and addressed with existing services and infrastructure; nonetheless, this disparity is growing. In Australia, the need to urgently address this issue is reflected in the physical health of people living with mental illness being listed as a priority in the Fifth National Mental Health Plan and the Equally Well National Consensus Statement. The reasons for the poor health and early death of people with mental illness are complex and interrelated. However, they include poor access to services, stigma and discrimination, smoking, lifestyle factors, and the side effects of medication. The rate of early death of people with mental illness is twice that of the general population; in rural Australia this increases to three times the rate of early death. This could be due to people living in rural Australia having a higher burden of disease, higher rates of comorbidities, and fewer services. The challenge of addressing these disparities is compounded by geographical distances and a shortage of allied health and general and specialist medical and screening services. This chapter reviews the epidemiology and the evidence on effective interventions and proposes a series of actions and clinical interventions for consumers, carers, and rural mental health workers. It also outlines actions rural clinicians can take to help address this national scandal, across the domains of a rights-based approach to care, ensuring physical health screening and treatment and lifestyle interventions and coordinating and integrating care. Finally, it provides examples of effective interventions in rural settings.

Introduction: Background and Context Every year tens of thousands of Australians living with mental illness die needlessly of physical health conditions (Roberts 2019). Despite the fact that this tragedy could be effectively addressed with resources already available within the Australian health system, the gap in life expectancy between people living with mental illness and the rest of the population continues to increase (Walker et al. 2015). People living with mental illness have the right to the same quality of life and life expectancy as every other Australian. This chapter will outline some of the recent research on the epidemiology, recent national and international policy developments, and the etiology and treatment approaches in the rural health-care context.

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Although people living with mental illness can live healthy, contributing lives, on average people living with mental illness die between 50 and 59 years of age (Lawrence et al. 2013). Countless studies and meta-analyses in Australia and internationally have consistently reported between 20 and 28.5 years of life lost for people diagnosed with mental illness (Bushe et al. 2010; Erlangsen et al. 2017; Olfson et al. 2015; Thornicroft et al. 2014; Walker et al. 2015). This gap is evident across countries, populations, study, and diagnosis. This early, preventable death is typically preceded by years or decades of poor health. On the other hand, the diagnosis of a serious physical illness can lead to mental illnesses such as depression and anxiety. The effect of illness diagnosis on mental health is beyond the scope of this chapter. This chapter focuses on the development of mortality-related physical health conditions in people living with mental illness, thus aligning with the priorities of the Fifth National Mental Health and Suicide Prevention Plan (Department of Health 2017) and the Equally Well National Consensus Statement: Improving the physical health of people living with mental illness in Australia (National Mental Health Commission 2016). People living with mental illness have three times the risk of respiratory disease (Australian Bureau of Statistics 2017), four times the rate of cardiovascular disease (Mangurian et al. 2016), and twice the risk of diabetes (Taylor et al. 2017). Death by suicide does contribute to the premature mortality of people diagnosed with mental illness, but ABS data indicate that for every one person living with mental illness who dies due to suicide, ten people die prematurely due to cancer, and cardiovascular or respiratory disease (Australian Bureau of Statistics 2017). People living with mental illness had seven times the risk of premature cancercaused death than the general population (Australian Bureau of Statistics 2017). Persons accessing mental health-related treatments comprise 12% of the Australian population and 55% of total deaths by cancer (Roberts et al. 2018) (see Table 1). Table 1 Annual number of cancer-caused deaths in the Australian population – age 15–74

Underlying cause of death Trachea, bronchus, and lung cancer Colon, sigmoid, rectum, and anus cancer Breast cancer Blood and lymph cancer Prostate cancer Total cancer-caused deaths Total number accessing MBS/PBS

Mental illness Row No. % 2567 56

Rest of population Row No. % 2031 44

Total population Row No. % 4598 100

1064

51

1018

49

2082

100

1012 895 523 6061

56 51 61 55

785 876 332 5042

44 49 39 45

1797 1771 856 11,103

100 100 100 100

2,806,407

12

21,507,719

88

0 24,314,126

0 100

Prorated and adapted from ABS (Roberts 2019)

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General population Persons with mental illness Persons with a psychotic disorder 0

0.5

1

1.5

2

2.5

3

Fig. 1 Risk of premature death. (Australian Bureau of Statistics 2017; Cunningham et al. 2014; Te Pou o te Whakaaro 2017)

Put another way: the 2.8 million people with mental illness accounted for 6061 cancer deaths; the 21.5 million remainder of the population contributed 5042 deaths. The above figures represent all Australians who accessed MBS or PBS mental health-related treatments. As such it comprises all mental illness including mild and moderate depression and anxiety. For people living with severe mental illness, the situation is much worse (see Fig. 1). They: • Are six times more likely to die from cardiovascular disease (Lambert and Newcomer 2009; Nordentoft et al. 2013; Royal Australian and New Zealand College of Psychiatrists 2015) • Are four times more likely to die from respiratory disease (Crump et al. 2013a, b; Cuijpers et al. 2014) • Are three to four times more likely to die prematurely (Brown 1997; Brown et al. 2010; Holt and Peveler 2010) • Are two to four times more likely to die from infectious diseases (Liu et al. 2017; Saha et al. 2007) • Are likely to die 20–28.5 years earlier than the general population (Brown et al. 2010; Holt and Peveler 2010) • Account for more than half of all avoidable deaths (Australian Bureau of Statistics 2017) While living with mental illness doubles the risk of early death, living with a mental illness in a rural Australian community triples the risk of early avoidable death (Australian Bureau of Statistics 2017). For males, the disadvantaged, and unemployed, these risks compound and increase. People in rural areas with cardiovascular disease are more likely to experience poor health and comorbidities, greater risk of alcohol dependence, smoking, and lack of exercise (Fennell et al. 2016). This is compounded by a lack of access to services, geographical distance, poor crosscultural communication, administrative burdens, and role definition issues (Happell et al. 2012). Australia is not making adequate progress in addressing this issue. In fact, the gap in life expectancy has increased during the last four decades (Walker et al. 2015).

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Comorbidity From the perspective of people living with mental illness, physical health includes functional mobility and health to participate socially and in practical activities of daily living (Happell et al. 2016a). Further, for these people, physical health is seen as connected to well-being, and the presence of physical illness adversely affects the quality of life and impedes recovery from mental illness (De Hert et al. 2011; Kisely and Simon 2006). Lorem et al.’s (2017) research concludes physical illness accounted for 12% of the total population effect on mental health symptoms. Australian research with people of Aboriginal and Torres Strait Islander descent found that poor physical health was by far the greatest contributor (42%) to psychological distress (McNamara et al. 2018). Similarly, the ABS found that the level of psychological distress in people with coexisting mental health and physical health conditions was twice that of those with only one health condition. Thus, addressing the physical health of people living with mental illness will also lead to significant improvement in mental health and emotional well-being. Almost all (94.1%) people reporting a mental and behavioral condition report having another coexisting long-term health condition (Australian Bureau of Statistics 2016). Eighty percent of people living with mental illness have a coexisting mortality-related physical illness (Australian Bureau of Statistics 2016), and 55% have two or more coexisting physical health conditions (Australian Institute of Health and Welfare 2017). In other words, four in every five clients of a mental health service will have a mortality-related physical health condition, but for many, these conditions are undiagnosed. These data underscore the imperative for people living with mental illness to have regular, comprehensive physical health assessments and necessary treatment.

Avoidable Physical Illnesses Cause More Premature Deaths than Suicide Suicide does contribute to the premature death rates for people living with mental illness. Intentional self-harm is the fifth most common cause of death for Australians accessing mental health MBS-/PBS-related services. However, between 80% and 94% of the causes of early death relate to physical illnesses (Lawrence et al. 2013; Saha et al. 2007). For every one person with a mental illness who dies due to suicide, ten die early due to cardiovascular disease, respiratory disease, or cancer (Australian Bureau of Statistics 2017; Roberts 2019). Put another way, in the 12 months from August 2011 to August 2012, 9506 people with mental illness died prematurely; of these 943 died of suicide (Australian Bureau of Statistics 2017). Suicide is tragic, but so is early, preventable death due to heart disease, and we should strive to save every life. Conversely, poor physical health increases to suicidality and suicidal behavior. There is good evidence that chronic poor physical health and associated functional disability is a significant contributor to suicidal behavior (Fässberg et al. 2016; Jorm et al. 1995). Thus, one of the effective interventions to reduce the suicide rate is to focus on treating chronic physical health conditions. It is not difficult to appreciate how chronic, unrelenting pain and illness, and its associated restriction

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on functional ability, contributes to psychological distress and feelings of hopelessness.

Specific Risks and Challenges Contributing Factors and Implications for Care There have been many reasons posited to account for the poor physical health of people living with mental illness. They include a set of interrelated, compounding factors such as stigma, smoking, lifestyle, poor access to care, poor quality care, the impacts of medication, and the impact of the mental illness itself. While the reasons for the poor health and early death of people living with mental illness are complex and interrelated, the key factors of discrimination, smoking, medication side effects, lifestyle, and community engagement have been repeatedly identified (Lawrence et al. 2013). These factors can guide and inform the focus of care and structure of recovery plans. These factors are addressed below.

Smoking Smoking kills 50% of long-term users (U.S. Department of Health and Human Services 2014). It is probably responsible for most of the deaths of people living with mental illness (Royal College of Physicians and Royal College of Psychiatrists 2013). However, in focus group discussions on the causes of poor health, people living with mental illness do not raise smoking as a physical health risk factor (Happell et al. 2016b). This presents a challenge for the rural mental health clinician. The other challenge is that many mental health professionals believe smoking is calming and good for mental health (Prochaska et al. 2017). The “self-medication hypothesis” (much of it funded by tobacco company research) has insidiously crept into health professionals’ consciousness and attitudes towards smoking (Prochaska et al. 2007). These attitudes possibly contribute to the fact that only about one-third of clinicians suggest quitting and offer support, advice, or guidance to help clients quit smoking (Sharma et al. 2017). Contrary to popular belief, people living with mental illness can quit smoking with the same success rate as the general population (Baxter et al. 2016), and systematic reviews have shown that quitting improved mental health and reduced depression, anxiety, and stress levels of people living with mental illness (Taylor et al. 2014). Nationally, reducing the percentage of the population who smoke has been one of Australia’s most outstanding public health successes. Unfortunately, due to widespread mistaken beliefs concerning mental illness and smoking, this public health success has not extended to those living with mental illness (Szatkowski and McNeill 2014). Encouraging and supporting smoking cessation efforts should be a priority action for all health professionals working with people living with mental illness.

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Medication Effects Antipsychotic medications have numerous detrimental side effects and have been associated with diabetes, cardiovascular disease, and obesity (Galletly et al. 2012; Vancampfort et al. 2013). Many of these side effects are related to poor health and increased risk of early death. Overall, however, it appears that the use of antipsychotics has a positive effect, improving the quality of life and increasing longevity (Baxter et al. 2016; Tiihonen et al. 2009). This is not an uncontested view however, with other studies indicating no effect or increased mortality-related risks associated with the use of second-generation antipsychotics (Saha et al. 2007; Weinmann et al. 2009). The differences in research findings may be related to treatment adherence, the population studied, the number of antipsychotics, and the type of antipsychotic a person is taking. For instance, the weight gain associated with antipsychotic use can vary from 4.4 kg to 16 kg depending on the type of antipsychotic used (Teasdale et al. 2017). In sum, it appears the use of antipsychotics improves functional ability, and reduces psychosis and suicidality. On the other hand, antipsychotics also tend to decrease physical activity and increase weight and the risk of developing diabetes and metabolic syndrome. In the face of rural allied health shortages, the mental health worker has an important role coordinating with other health professions, especially rural pharmacists and GPs (and if available rural psychiatrists) to review the prescription and use of antipsychotics and other medications. Polypharmacy poses a significant risk to the health of people living with mental illness. Both GPs and pharmacists are skilled and widely geographically dispersed professions. Engaging these professions in the review and thoughtful prescription of medications is a key way rural mental health workers can make a significant contribution to the physical health of people living with mental illness. The guidance to rural mental health workers is summarized in the Equally Well National Consensus Statement on improving the physical health of people living with mental illness: Impacts of medication (both positive and negative) should be regularly assessed, and alternatives should be considered if a medication has a potential negative impact. People living with mental illness have a much higher risk of developing metabolic syndrome. Therefore anyone prescribed antipsychotic medication should be given clear and understandable verbal and written information about the medication’s risks and benefits. Steps should be taken to limit side-effects such as obesity, cardiovascular disease and diabetes. People should be encouraged to have a support person and/or carer present during these discussions and be supported to make treatment decisions. (National Mental Health Commission 2016, p. 18)

Exercise Moderate exercise has been shown to improve physical and mental health and lessen cardiovascular disease risk even when not associated with weight loss (Rosenbaum

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et al. 2014). It has also been consistently found to lessen the symptoms of schizophrenia and depression (Schuch et al. 2016). For people living with depression, the effect is so significant that the authors recommend that exercise should form a routine part (step zero) of care planning and treatment. People living with mental illness face many barriers and challenges to engaging in regular moderate physical activity. These include cost, geographical distance, and lack of support and companionship (Shor and Shalev 2014). This is often compounded by poor physical health, poor mental health, low motivation, low self-efficacy, feelings of hopelessness, and poor self-esteem (Shor and Shalev 2014). These obstacles help explain why it is difficult for people living with mental illness (and indeed many in the general population) to meet recommended exercise guidelines. While there is a good deal of evidence indicating the effectiveness of exercise for people living with mental illness, there is also a good deal of evidence indicating the ineffectiveness of exercise programs (Baxter et al. 2016; Farholm and Sørensen 2016). As previously discussed, there are significant hurdles to overcome to increase exercise levels. The duration of engagement with exercise programs is significantly related to positive change. Managing motivation appears to be a key factor determining the effectiveness of these programs (Farholm and Sørensen 2016). These results underscore the importance of engaging, partnering, and maintaining client motivation to exercise and participate in exercise programs. Family members, carers, support people, and peer workers can boost motivation and provide companionship. Psychologists can assist in designing the motivational components of these programs. Finally, physiotherapists and exercise physiologists should be involved in the design of programs to ensure they are appropriate to the age and physical condition of the participants. The collaboration skills of the rural mental health workers are critical to locating, engaging, and coordinating specialist allied health professionals into an integrated, evidence-based program.

Diet Weight gain is a significant contributor to poor mental health and poor physical health. Rapid weight gain can occur within the first 12 weeks of starting antipsychotics and increase dramatically thereafter (Teasdale et al. 2017). The amount of weight gain varies considerably based on the antipsychotic used. In addition, the diet of people living with severe mental illness generally comprises fewer fruit and vegetables and is lower in fiber and higher in fat than the general population (Teasdale et al. 2017). While systematic reviews have found that nutritional interventions can lead to significant reductions in BMI, blood glucose, and weight (Teasdale et al. 2016), the most successful interventions have addressed the challenges of poor attendance, low motivation, and high sedentariness (Teasdale et al. 2016). A Cochrane review (Pearsall et al. 2016) found that mental health worker advice on nutrition and diet was frequently not evidence-based. This underscores the

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importance of the involvement of dieticians and nutritionists in care planning for people at risk of diabetes or obesity.

Social Inclusion People living with mental illness not in paid employment have six times the risk of premature death compared to those in full-time employment, and social disadvantage carries three times the risk of premature death (see Fig. 1). There is very likely a covariance between these variables, with poor health and poor mental health related to functional ability, employability, and social participation. However, this highlights the importance of developing goals of increased participation in work, education, and community. Social participation is both a marker and a predictor of mental and physical health. Working towards the goal of meaningful social participation helps all in the clinical team focus on the interim goals of good physical health and functional ability. Effective partnership with vocational, educational, and rehabilitation specialists helps the consumer, clinician, and carer to maintain focus on improving physical health, functional ability, and social participation.

National and International Policy Context In response to this national health crisis, Australia has produced a framework to prioritize action, The Australian National Consensus Statement, Equally Well: Improving the physical health of people living with mental illness in Australia (National Mental Health Commission 2016). Equally Well (www.equallywell.org. au) was launched in July 2017 and is the result of broad consultation during 2015 and 2016. More than 90 national organizations, including all state and territory governments and peak bodies, have signed up to “making the physical health of people living with mental illness a priority at all levels: national, state/territory and regional” (National Mental Health Commission 2016) (p.7). Subsequently, the physical health of people living with mental illness has been made a national priority of the Fifth National Mental Health and Suicide Prevention Plan (Department of Health 2017). Among other recommendations to improve the physical health of people living with mental illness, the Plan recommends implementing the actions of the Equally Well Consensus Statement. Improving the physical health of people living with mental illness is becoming an international priority, with New Zealand (Roberts et al. 2018) and the UK (Bell and Hughes 2019) also introducing Equally Well initiatives. In addition, the World Health Organization has released its guidelines for the management of physical health conditions and mental illness (World Health Organization 2018), and the Lancet Commission has published its blueprint for protecting the physical health of people with mental illness (Firth et al. 2019).

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The Commonwealth Department of Health has summarized the implications of Equally Well in its guidance to Local Health Networks/Districts and Primary Health Networks in which it requires: • Planning for early intervention and prevention activity to reduce the impact of mental illness on physical health, particularly addressing lifestyle issues early in disease. This could, for example, mean offering routine smoking cessation and support services. • Building in expectations of routine screening for physical health needs of people with mental illness and regular medication review. • Ensuring access to services for physical health needs is readily available when the screening process detects these needs; consideration of the mental health needs of people living with a chronic physical illness. • Introducing physical health questions to standard measures of consumer experience (e.g., through the Your Experience of Service Survey). (Integrated Regional Planning Working Group 2018) (p. 41).

The remainder of this chapter will address the practice implications of these national policies and international guidelines for rural mental health workers.

Practice Implications Working Effectively as Part of the Available Health System and Supports The implications of the research into the link between mental illness and physical health are wide-ranging and profound. The failure to effectively address this public health issue in Australia is a national scandal, especially when introducing a suite of simple interventions could prevent most of these physical health conditions (Australian Institute of Health and Welfare 2019). If rural mental health workers fail to consider and address physical health as part of their routine practice, this will result in chronic poor health and premature death for many of their clients. This early death is typically preceded by years of poor health and reduced functional ability. As previously discussed, the importance of this issue has been recognized nationally, but each rural mental health worker has a part to play in implementing this locally with individual clients. The practical, clinical implications of this research and the national policies relating to the poor physical health of people living with mental illness are dealt with in four parts: 1. 2. 3. 4.

Adopting a human rights-based response Ensuring physical health screening and appropriate medical treatment Addressing the key lifestyle factors Using an integrated-care approach

Adopting a Human Rights-Based Response If you are not doing human rights, you are not doing mental health care. (Maylea and Daya 2019)

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A Right to Equal Access to Quality Care Fundamentally the physical health of people living with mental illness is a human rights issue. The gap in life expectancy between people living with mental illness and the rest of the Australian population illustrates that people living with mental illness still are stigmatized and discriminated against in the health system. Currently, people living with mental illness do not get the same access to quality physical health care as the general population. As a consequence the 13% of the population who access mental health-related treatment constitute more than 50% of all the premature deaths (see Fig. 2). This disparity has been getting worse during the last 30 years (Walker et al. 2015) and will continue to do so, unless we do something different. Firstly, and fundamentally, rural mental health workers must advocate for the rights of people living with mental illness. They need to ensure their clients have equal access to quality physical health care across all stages of the health journey. This includes getting the same quality and level of access to screening, effective treatment, and the necessary medical interventions. A Right to Participate in Care Planning People living with mental illness and their carers have a right to be involved in decisions that affect their mental health, physical health, and well-being. Firstly, this means clinicians listening and taking their clients’ physical health concerns seriously. Consumers’ experience of mental health care is that clinicians often do not appreciate the importance or impact of their physical health concerns (Happell and Ewart 2016). This process of focusing on the mental health complaint and ignoring the client’s physical health concerns is called “diagnostic overshadowing” (Rethink 2013) which results in life-threatening conditions going undiagnosed and untreated leading to early and needless death. Clinicians must be attentive to any physical Percentage (12.9%) of populaon who accessed mental health MBS/PBS services Chronic lower respiratory diseases Prostate cancer Breast cancer Trachea, bronchus and lung cancer Diabetes Intentional self-harm Diseases of the urinary system Colon, sigmoid, rectum and anus cancer Blood and lymph cancer Dementia, including Alzheimer's disease Cirrhosis and other diseases of liver Heart failure Cerebrovascular diseases Ischaemic heart diseases 0%

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Fig. 2 Percentage of total population deaths of people with mental illness against population prevalence, by disease type. (Australian Bureau of Statistics 2017)

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health concerns raised by their clients. Further, they should actively seek information regarding each client’s physical health status (see Part II: Screening). Carers also report being ignored or excluded from care planning, and their insights from years of experience of caring and observing health-related behavior are mostly ignored (Happell et al. 2017). Not only is this contrary to recoveryfocused care, it also excludes invaluable information useful in developing a practical and sustainable wellness and recovery action plan. It also misses the opportunity to incorporate the support offered by carers as part of a coordinated approach to care. People living with mental illness actively seek control over their health journey. Ignoring the need of clients to be active partners in care planning is disempowering to clients and hinders their recovery (Ehrlich et al. 2017). Respect, Enhancing Autonomy, and a Partnership Approach to Recovery: Two Examples

An example of how respect for personal agency and autonomy has been integrated into recovery and care planning protocols can be found in the NSW Older Persons Community Model of Care (NSW Ministry of Health 2017b). This model provides a template and examples of a Consumer Wellness Plan which is developed jointly by the consumer, their carers, and the mental health worker. This approach is consistent with the Equally Well National Consensus Statement actions that: ‘people living with mental illness be an active partner in ongoing individualised care. . .’ and are ‘at the centre of decisions about their care, together with their families and other support people.’ (National Mental Health Commission 2016) (p.15)

In another example, a small NGO program considers a person’s health across 13 domains of well-being. As part of this process, they seek and ask their clients about their life goals. In conjunction with other services, their family, and carers, they then develop a shared wellness and recovery action plan to help their clients achieve these goals. Many people, who had been long-term clients of mental health services, said this was the first time anyone had ever asked them about their life goals, let alone develop a plan to help them achieve these goals (Roberts and Burmeister 2018).

Ensuring Physical Health Screening, and Medical Interventions Four of every five mental health clients will have a mortality-related mental health condition. (Australian Institute of Health and Welfare 2017)

Screening Ensuring regular screening for coexisting physical health conditions is perhaps the most important thing a mental health clinician should first do to improve the physical health their clients. If a clinician does not have the training to personally conduct a comprehensive physical health examination, then they must ensure that this is carried out by a suitable health professional, usually a GP. One of the first questions a rural mental health clinician should ask is, “Have you had a complete physical health checkup during the last 12 months?” If the answer is “no,” it is important a

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comprehensive physical examination is arranged and conducted as soon as possible. Many of the causes of early death of people living with mental illness are avoidable (Australian Institute of Health and Welfare 2019), but, due to the lack of screening, people with mental illness live for years with chronic conditions such as respiratory disease, heart disease, and diabetes before they are diagnosed and treated. Without screening we cannot deliver targeted, effective preventive interventions or care. Physical Health Conditions Cause Ten Times More Early Deaths than Suicide

During 2011–2012 the top nine causes of death resulted in 9502 people living with mental illness dying early; only 943 of these people died from suicide. Suicide risk assessment and screening is a routine, essential part of mental health care. This is a good and correct practice. Early death due to suicide is shocking and tragic, but early deaths due to physical health conditions are equally tragic. Ten times the number of people living with mental illness die prematurely as a result of preventable physical illness than of suicide (Australian Bureau of Statistics 2017). As such, physical health risk assessment and screening should also be a routine part of mental health care. Eighty percent of mental health clients will also have a mortality-related physical health condition (Australian Bureau of Statistics 2016) with 55% percent having three or more coexisting disorders (Australian Institute of Health and Welfare 2012). With four out of five mental health clients having a chronic physical illness, physical health screening must be a standard practice for all clients of mental health services. Practically all Australian state and territory mental health services now have standard policies and guidelines for conducting comprehensive physical health assessments (NSW Ministry of Health 2017a). Many also have a 12-monthly physical examination for mental health clients as a key performance indicator. There are many other very good guidelines and algorithms readily available, some of which have been adopted by clinical teams across Australia and internationally (Curtis et al. 2011) and are available on the Equally Well website (www.equallywell. org.au). Ensuring that regular physical health screening occurs is a vital first step to preventing the early death of people living with mental illness. From another perspective, improving physical health also significantly improves mental health. Poor health and associated functional disability is the largest contributor to poor mental health and psychological distress (Lorem et al. 2017; McNamara et al. 2018). Improving physical health has been shown to be one of the most effective ways to improve a client’s mental health and reduce suicidality (Fässberg et al. 2016; Fässberg et al. 2014; Lorem et al. 2017). Support and Advocacy: For Physical Health Screening It is not enough to simply advise a person living with mental illness to get a physical health checkup. People living with mental illness often delay seeking help due to cost, stigma, or past negative experiences in GP waiting rooms (Lawrence and Kisely 2010). One Australian study revealed that although 87% of people with psychosis visited a GP within the last 12 months, two-thirds did not receive a general or cardiovascular health check (Morgan et al. 2011). In addition, when people are

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experiencing poor mental health, they can lack the motivation to attend to physical health concerns (Blanner Kristiansen et al. 2015). Finally, the number of GPs per 10,000 population in rural settings is only 63% of the number in capital cities (Australian Institute of Health and Welfare 2016; Roberts 2018). This makes it even more challenging to arrange and secure a GP for a full physical health checkup. While many mental health workers do not have the training to conduct physical health assessments and do not see this as part of their role, they do have the skills to identify appropriate resources, arrange appointments, and, if necessary, follow-up treatment. When people living with mental illness do secure an appointment, many GPs report a high level of nonattendance at these appointments. Nonattendance at appointments has compounding stigmatizing effects for people living with mental illness. Thus, achieving high rates of attendance at physical health checkups is vital to primary health care. Practices to ensure people living with mental illness turn up for appointments may include reminder SMSs or phone calls or arranging for someone to accompany the client to the appointment (such as a peer worker, a carer, friend, primary health-care worker, or allied health assistant). Securing a bulkbilled appointment also helps. Investing in the relationship with the GP, the client, and their supporters dramatically increases the effectiveness of these strategies. It is only through the support and advocacy of rural mental health workers that many people living with mental illness will be able to secure a comprehensive physical health examination. Advocating for Quality Physical Health Care: “Don’t Just Screen: Intervene!” Physical health treatment rates for people living with mental illness are 50% lower than for those with a physical illness alone (Royal Australian and New Zealand College of Psychiatrists 2015), and less than 50% of people with a severe mental illness have had a complete physical health examination in the past 12 months (Morgan et al. 2011). When people living with mental illness do access physical health-care services, their physical health conditions are often overlooked or viewed as part of their mental health condition. This “diagnostic overshadowing” results in physical health conditions being undiagnosed and untreated and leads to avoidable early death (Rethink 2013). For many people living with mental illness even after screening and diagnosis, they are still denied access to effective interventions (Lawrence and Coghlan 2002). Generally, in Australia only about half of people living with mental illness with hypertension, diabetes, or high cholesterol use appropriate medication (Lawrence et al. 2000). As a group, people living with mental illness are disempowered and regularly suffer discrimination due to their mental health (see Fig. 3). Rural mental health clinicians must advocate to ensure their clients receive equal access to effective health-care interventions. Rural mental health workers can and should respectfully advocate for quality physical health care for their clients. In fact, this may be the most important mental health intervention they do. As part of advocating for clients, mental health workers can also provide up-to-date information on the physical health risks for people living

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with mental illness to other health-care professionals. For instance, the highest absolute number of people with mental illness die early from cardiovascular disease and lung cancer (see Fig. 4). However, the highest relative risk of early death is from lower respiratory disease, breast cancer, and prostate cancer (see Fig. 2).

Addressing Key Lifestyle Factors The previous section discussed the role of the rural mental health worker in the context of the available physical health-care services. This section focuses on direct actions the rural mental health worker should consider taking to improve the

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physical health of people living with mental illness. As with all care, this should be in undertaken conjunction with other medical and allied health professionals and supports available (see section “Using an Integrated Approach to Care”). Research combining the perspectives of patients and clinicians distilled a shared conceptualization of the causes of physical health problems (Blanner Kristiansen et al. 2015). The text in this section will follow the framework presented in the “lifestyle” textbox (Fig. 5). Failure to address these lifestyle issues (along with basic physical health screening and intervention) comprises a failure to provide quality care for clients. Smoking Cessation Smoking kills one in two heavy smokers (U.S. Department of Health and Human Services 2014). Helping someone with mental illness quit smoking may be the most impactful action a rural mental health worker takes. For every two people a rural mental health worker helps quit smoking, they will prevent one going to an early grave. Smoking significantly increases the risk of heart disease, respiratory disease, cancer, and many other physical illnesses. For the 12 percent of the population with mental illness that accounts for 55% of early deaths due to cancer, smoking is probably the main cause (see Table 1). Further, the financial costs of smoking consume approximately one-fifth of the pension for smokers on the disability support pension in Australia (Access Economics 2007). Although people living with mental illness make up 12.9% of the population accessing MBS or PBS funded services, they comprise the majority of the premature deaths due to trachea, bronchus, and lung cancer and lower respiratory disease (see Fig. 4) (Australian Bureau of Statistics 2017). Rural mental health workers are uniquely placed to advise, refer, and implement smoking cessation programs. However, a recent study found that while 80% of mental health-care professionals asked about smoking, only 45% advised clients to quit, and only a third referred to Quitline or offered cessation assistance (Sharma et al. 2017). This may be because most clinicians believe people living with mental illness are not interested in quitting. This belief has been supported by research and actions funded by the tobacco industry (Sheals et al. 2016). Nonetheless, motivation

Fig. 5 Consumers’ conceptualisation of the causes of physical health problems. (Blanner Kristiansen et al. 2015)

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to quit is about the same as the general population (Ashton et al. 2010), and quit attempts are common (Stockings et al. 2012). Rural mental health workers can also deliver evidence-based smoking cessation interventions within the context of usual treatment. Even a brief intervention may trigger a quit attempt and result in cessation, especially if it includes referral to evidence-based help. As a minimum rural mental health workers should: Ask all clients: Advise:

Help:

“Do you smoke (tobacco or anything else)?” Seek permission to give advice about smoking and how it might be interacting with the presenting condition: “Stopping smoking improves mental health and well-being.” Make an enthusiastic offer of help and provide self-help material, advice regarding pharmacotherapy, and offer referral to Quitline or a stop smoking specialist.

Poor Nutrition Poor nutrition is a major contributor to the poor health of people with mental illness. Weight gain after the start of antipsychotic medication is usually rapid, averages 16 kg (Pérez-Iglesias et al. 2014), and can frequently be up to 50 kg (Maylea and Daya 2019). The impacts of this weight gain on everyday activities and self-esteem are enormous. Once body weight has increased significantly, it is extremely difficult and almost impossible to reverse without surgical intervention (Rosenbaum 2019). Thus, early intervention is absolutely critical. Working collaboratively with dieticians has been shown to improve intervention effectiveness, and rural mental health workers can support their clients through the challenges of reduced motivation, lack of attendance at appointments, and higher sedentariness. Inactivity The physical activity levels of people living with mental illness have been found to be much lower than the total population. Given the extreme challenges of clients losing weight after it has been gained, a key, achievable aim should be to increase physical activity. The goal of physical activity is to improve cardiovascular fitness. Even moderate increases in levels of physical activity have been shown to have demonstrable effects on cardiovascular fitness and thereby overall health (Rosenbaum 2019). For everybody, motivation and ongoing participation are the crucial elements for the success or failure of exercise programs. Cost, ease of access, and lack of companionship are barriers to ongoing participation in physical exercise (Shor and Shalev 2014). A key component of effective care planning is addressing and removing these barriers. The rural context provides challenges and advantages in this respect. There may be a lack of free exercise classes and groups in the community, so finding low-cost or free programs that are easily accessible would help. The rural mental health worker

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could arrange for a carer, peer, or peer-worker to provide support, encouragement, or companionship. Finally, the use of a variety of support and motivational techniques such as reminder, encouragement, and congratulation SMSs and phone calls could also assist. Working with the support of physiotherapists or exercise physiologists to help ensure that activity programs are suitable and well-designed and with the support of psychologists to help design motivational methods is another way the rural mental health worker can make a difference. In many rural communities, finding and engaging professionals from these disciplines is often difficult and may require the use of visiting professionals. Nonetheless, this is a key role and function the rural mental health worker should fulfill. Physical exercise improves mental health. In addition to improving physical health, there is strong research indicating the beneficial effects of exercise on mental health. Systematic reviews and meta-analyses indicate that exercise significantly improves mental health (Vancampfort et al. 2015). A recent meta-analysis showed exercise to be an efficacious treatment for depression, equal to medication, or cognitive behavior therapy, and it should be an essential and standard part (step zero) of treatment for depression (Schuch et al. 2016). Substance Use Alcohol has been linked with numerous medical conditions. Alcohol misuse has been found to be the condition associated with the highest risk of premature mortality, and individuals with coexisting mental health and addiction have poorer health outcomes than people living with mental illness alone (Erlangsen et al. 2017). Alcohol misuse is a common presentation in clinical practice. Twelve-month DSM-5 prevalence rates are 17% for men and 10% for women (Grant et al. 2015). There are treatments with strong evidence of efficacy (Connor et al. 2016; Kavanagh et al. 2014). However, diagnosis and treatment are delayed an average of 18 years after onset (Chapman et al. 2015). Early screening and intervention are vital. It is important that rural mental health workers routinely screen and assess substance use and other addictive behaviors. There are several screening tools that are available online, including the AUDIT (Alcohol Use Disorders Identification Test) and the DAST (Drug Abuse Screening Test) which can help identify substance use issues. If problematic substance use is occurring, evidence-based interventions and strategies should be implemented. People with a dual mental illness-substance abuse diagnosis experience additional barriers accessing services. Integrated care is important in treating people with a dual diagnosis. Both of these issues will be addressed later. Medication The side effects of antipsychotic medication are well-established. “People living with mental illness have a much higher risk of developing metabolic syndrome. Steps should be taken to limit the side-effects such as obesity, cardiovascular disease and diabetes” (National Mental Health Commission 2016) (p. 18). It is not uncommon for people living with mental illness to gain 50 kg in the 36 months after starting

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antipsychotic medication (Maylea and Daya 2019). The impact of this weight gain on activities of daily living, physical health, and mental health is profound. The other challenge often facing people living with mental illness in rural communities is overmedication and polypharmacy. There are many reasons for this, including a lack of continuity of care due to contact with multiple, different prescribers, and overprescribing to manage risk in small communities (which have limited after-hour support services). Engaging public and community pharmacists in regular medication reviews is an achievable, tangible action that can significantly reduce unwanted side effects and dramatically improve a client’s quality of life. Thus, rural mental health workers should ask about medications, including when clients began taking them. Effectively managing diet and physical activity is vital to limiting and preventing the side effects, polypharmacy, overprescribing, and weight gain associated with many antipsychotic medications. Requesting the local GP to conduct a thorough medication review is another action that can help. Daily Structure and Social Participation Low levels of participation in work and social engagement are both a cause and symptom of poor mental health and poor physical health (Ewart et al. 2017; Shor and Roelfs 2015). Not only is it related to poor mental health, it is also strongly correlated with poor physical health. Low levels of community engagement, social disadvantage, and workforce participation are all strongly related to increased risk of early death for people living with mental illness (see Fig. 6) (Australian Bureau of Statistics 2017; Holt-Lunstad et al. 2010). Reviews have revealed the profound influence of social isolation and loneliness on mental health (Shor and Roelfs 2015; White et al. 2019). While people living with mental illness already have 2.5 times the base population rate of premature death, for those also of low SES or not in the workforce, this rate increases to 3 and 6 times that of the total population, respectively (see Fig. 3) (Roberts 2019). This data underscores the importance of 7 Total Australia

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setting social engagement goals and working with clients to help them achieve these goals (Roberts and Burmeister 2018). Strong social support networks are key correlates of mental health (White et al. 2019).

Using an Integrated Approach to Care The overall focus of this chapter is on improving the physical health of people living with mental illness. However, other domains of life also contribute to recovery, wellness, and physical health. Ensuring secure and stable housing and accommodation and living in a safe environment free from harassment, violence, and other forms of abuse are foundation stones of well-being. A holistic approach to care should also address diet, exercise, and addiction. Social inclusion and community participation are also predictors of physical and mental well-being. People living with mental illness who are not employed have six times the rate of premature death compared to those in full-time employment (Roberts et al. 2018), and social isolation and loneliness are major predictors of mental illness and mortality risk (Holt-Lunstad et al. 2010; Shor and Roelfs 2015). Therefore, comprehensive, effect mental health care, and recovery planning must encompass all the domains affecting mental and physical health. The best way to ensure effective and comprehensive care is through an integrated approach to care (Roberts et al. 2016). Integration is often poorly understood and conceptualized. Integrated care can occur horizontally, vertically, and across other dimensions (Roberts et al. 2017). Horizontal Integration Horizontal integration means integrating care across the various domains of health and well-being (see Fig. 7). As demonstrated earlier in this chapter, the elements of effective mental health care include social participation and work; reducing discrimination, exercise, and nutrition; and maintaining good physical health. When a mental health worker ignores these domains, they are depriving their clients of evidencebased, comprehensive mental health care. Effectively coordinating care across the domains of mental health and physical well-being is horizontal integration. Rural mental health workers are usually well-connected with other health and human service professionals in their region, and there are frequent local networking opportunities. An integrated care and comprehensive and holistic approach to recovery are easier when clinicians are already part of the same social and professional network. On the other hand, rural communities often suffer a lack of services and have fewer service options across the domains of mental health and well-being (see Fig. 7). The rural mental health worker, while not responsible for providing each component of holistic care, does have a responsibility to help access and integrate care across each of these domains to ensure a coordinated approach to holistic care. This may involve identifying and sourcing options in creative ways to enable access to tele-video services. In practice, this means an appreciation of the complex interaction of various life domains on mental health and ensuring that the client’s well-being is assessed and managed across each of these domains. As such, good mental health care and

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Fig. 7 Elements of horizontal integration. (From Nursing Midwifery and Allied Health Professions Policy Unit (2016))

recovery planning should consider and incorporate each of the domains in Fig. 7. There are various assessment tools to enable the mental health worker to systematically assess and address these domains (Centre for Disability Studies 2005). Each client’s wellness and recovery plan (and the client’s clinical file) should show evidence of assessment and consideration across each of the domains of mental health and physical well-being. The rural mental health worker can also demonstrate leadership by convening meetings of local health and human service workers to develop a shared wellness and recovery action plan for their clients (Roberts and Burmeister 2018) on a caseby-case basis. These plans help the local services to work as a coordinated team to support the journey of recovery across the domains of recovery (see Fig. 7). Vertical Integration and Stepped Care Vertical integration is the extent to which services are coordinated up and down the spectrum of care (see Fig. 8). A person’s mental illness and recovery journey may see them move between early signs of distress, initial symptoms, illness, severe

Fig. 8 Elements of a stepped mental health-care model. (Roberts et al. 2017)

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functional impairment, hospitalization, and recovery (Roberts 2019). In the process they may have contact with primary health care and secondary (community-based) and tertiary (inpatient or intensive) care. One of the main challenges for people living with mental illness in rural communities (where there can be a lack of services) is first accessing the right level of care and then moving between levels of care and, in the process, not getting lost between these steps. This is even more important when transitions in care levels may involve a transfer between different towns, away from family and existing community supports. Coordinating care up and down through primary, secondary, and tertiary care as a person’s mental health improves or deteriorates is a key role for a rural mental health worker. It is a time of high risk (Peterson et al. 2007), and clients “falling between the cracks” is a common experience and expression. Examples of this include a when a person is discharged from an inpatient unit without their local mental health worker being notified. Ideally people should move seamlessly up and down the levels (or steps) of care. Unfortunately this is often not the case. The Australian government has committed to a stepped care approach (Department of Health 2015; Integrated Regional Planning Working Group 2018). In this approach a person enters contact with services at the appropriate level and then “steps up” or “steps down” according to the severity of the mental illness. The rural mental health worker can facilitate vertical integration by proactively following their client up and down the different levels of care. The “good shepherd” model involves maintaining full and ongoing communication and advocacy as the client moves between the levels of care. This requires regular and proactive follow-up (good shepherding) by the rural mental health worker, sometimes to a distant mental health inpatient unit, to ensure good discharge planning and communication. Other Dimensions of Integrated Care Integration can also occur at the local community level, where the partner agencies put in place systems and arrangements to facilitate collaboration and coordination. At the system level, vertical integration requires collaboration (enhanced communication and referral, care coordination) and agreed protocols. These arrangements can be modest or extensive. In rural clinical practice, this can range from light (informal local service network meetings) to moderate (shared referral and intake forms, service level agreements) through extensive integration (joint funding, joint positions, joint clinical governance, and fully integrated services) (Fuller et al. 2011; O’Flynn 2009). The degree, depth, or extent of collaboration is another dimension of integrated care. Integration is also a progressive process that occurs over time. The initial communication, the development of trust, joint planning, development of local collaborative activities, and partnerships all take time (Roberts et al. 2017). Over time, successful partnerships mature and strengthen. Both of the above forms of integration are more pertinent to service managers and planners and will not be discussed in detail here. Case examples of system changes to improve integrated care at the community level are presented in the text boxes.

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Concluding Comments and Recommendations People living with mental illness have much poorer health and die on average 20 years earlier than the rest of the population. Each year ten times more people living with mental illness die prematurely due to avoidable physical illness than complete suicide. This chapter has outlined several actions that rural mental health workers can readily implement that will have a profound impact on the quality of life of their clients. These actions will help enhance the physical health of people living with mental illness. The physical health of people living with mental illness has been made a priority in Australia and many other countries. The current poor health and early death of people living with mental illness is simply unacceptable. Improving physical health improves mental health, the quality of life, and social participation. Improving a client’s physical health will add years and perhaps decades to their longevity. In the context of existing workforce challenges (Roberts and Maylea 2019), rural mental health workers need to work together to help redress and reverse the national scandal of people living with mental illness needlessly suffering poor health and dying prematurely. People living with mental illness have the right to equal quality of life and equality in life. Working in rural mental health has its challenges and opportunities. Generally professionals in rural communities are better networked and connected. On the other hand, there are fewer services, and this is made more difficult with the allied health, nursing, and medical workforce and shortages in rural communities which result in high levels of “churn,” fly-in fly-out services (Perkins et al. 2006) and extended vacancies in key positions. These challenges require a greater attention to partnership-focused activity (Jackson et al. 2019). Partnering and care coordination skills are not taught in most universities but are vital for effective integrated care. Using an integrated care model requires frequent, repeated contact and communication with other health and human service professionals. This is a strength of rural settings. There are several actions rural mental health workers can readily enact to enhance individual care and local service collaboration. Together, we can make a difference.

Key Points for Effective Practice • Preventable physical illness leads to one person with mental illness dying (prematurely) every hour of every day in Australia. • Adopting a human rights-based approach to care will help address stigma and equal access to quality health care for people with mental illness. • People living with mental illness are at greater risk of premature death and poor physical health due to: • Stigma and discrimination • Lack of basic physical health screening • Smoking • Poor nutrition and lack of physical activity

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• Polypharmacy and the side effects of medication • Low levels of social participation • Mental health clinicians are also primary health-care clinicians and are ideally placed to take action to improve the physical health of people living with mental illness. • An integrated care approach is vital.

Checklist: Ten Evidence-Based Actions to Improve the Physical Health of People Living with Mental Illness (in Order of Priority) People living with mental illness have a very high risk of poor health and dying early due to preventable chronic physical health conditions. These conditions also impact negatively on their mental health. The following ten actions are probably the most important things to do to improve the mental health and physical well-being of your clients. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Ensure comprehensive physical health checkups every 6/12 months. Follow-up to ensure appropriate treatment is being offered. Encourage smoking cessation and offer support to quit. Arrange medication review (with a pharmacist if possible). Strongly encourage, arrange, and support participation in regular physical activity. Pay attention to good diet (with a dietician and psychologist if possible). Assess and address alcohol and illicit drug misuse. Support employment, social connection, and community participation. Ensure secure housing and personal safety. Take an active role in coordinating and integrating care.

In each of the above actions, the advocacy of the rural mental health worker is vital to ensure the client gets fair access to this support. You may be the only person able and available to do this. Based on current research, without advocacy, it is unlikely your client will get equal access to these potentially life-saving services.

Case Studies Case Study 1. Mental Health Clinic in a GP Practice

In Mudgee, NSW, a local health team with the support of their executive director set up a regular weekly clinic at a local general practice. In this service the GP booked out one morning a fortnight to see clients of the public mental health service. The appointments and clients’ attendance were organized by (continued)

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mental health workers to ensure all appointment times were used. Evaluations showed this straightforward, local arrangement was highly regarded by the consumers, carers, the mental health workers, GPs, and reception staff. Most importantly, it improved the physical health and mental health of the clients, resulting in a dramatic decrease in hospital admissions. This program has been running for more than 10 years across successive GPs. It required no additional funding or staffing, proving this approach is sustainable, provided it is supported by existing local mental health staff (Fitzpatrick et al. 2018; Perkins et al. 2010). It is an example of how local partnerships and coordination can lead to dramatic improvements in care and outcomes, with little additional effort and no additional costs.

Case Study 2. MOU with an Aboriginal Community Controlled Health Service

In Broken Hill, NSW, three specialist mental health workers have been placed in an Aboriginal community-controlled primary health-care organization. Supported by a memorandum of understanding (MOU), the mental health workers, who are employed by NSW Health, are placed, managed, and governed by the Aboriginal Health Corporation. In this way, the delivery of mental health services is totally integrated with a primary health-care service and governed by the Aboriginal community board, but maintains close links with existing local mainstream public health services. The service has a holistic approach to health and social-emotional well-being, with good capacity in physical health-care provision. Although based at the Aboriginal primary health-care organization, the mental health workers fully participate in the clinical governance process of the state mental health service, such as case allocation, clinical review, case presentations, clinical supervision, and professional development. Running for more than 15 years, this model has been cited as an exemplar in culturally appropriate cooperation between Aboriginal health and mainstream mental health services (Ridgeway, 2004). This model allows for the provision of comprehensive care, including complete physical health checkups. It also coordinates changes in the level of care, supporting clients when they need to “step up” or “step down” during their recovery journey.

Case Study 3. NGO Innovation

A small/medium nongovernment mental health organization has deployed one of its staff to be a specialist primary (physical health) care nurse. This staff (continued)

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member conducts basic physical examinations, arranges GP appointments, and ensures necessary follow-up treatment is conducted. This simple change has transformed the practice of this team and resulted in dramatic improvements in the physical health of the clients of the service. All clients now have a regular comprehensive physical health examination and any needed follow-up treatment. This arrangement has changed clients’ lives. For example, the primary care nurse observed a female client who was losing her hair. This, in fact, had been occurring for some years. The nurse was concerned that this may indicate the presence of cancer and arranged the necessary screening and assessment. After a thorough investigation, it was discovered that the client was chronically severely malnourished. Working closely with a dietician, this has been addressed, and the client’s physical health and mental well-being has improved dramatically. Before the introduction of the physical health nurse, this basic health condition had gone unrecognized for years.

Cross-References ▶ General Practitioners ▶ Integrated Primary Mental Health Care in Rural and Remote Contexts: The Australian Experience ▶ Models of Service Delivery and Funding of Mental Health Services ▶ Multidisciplinary Teams in Rural and Remote Mental Health ▶ Promotion and Prevention of Mental Health Problems in Rural and Remote Context ▶ Suicide and Self-Harm: It’s Everyone’s Business

References Access Economics. Smoking and mental illness: costs. Report. Canberra: SANE Australia; 2007. Ashton M, Miller CL, Bowden JA, Bertossa S. People with mental illness can tackle tobacco. Aust N Z J Psychiat. 2010;44(11):1021–8, 44(11), 1021–8. https://doi.org/10.3109/00048674.2010. 497753. Australian Bureau of Statistics. National Health Survey: Mental Health and co-existing physical health conditions, Australia, 2014–15. Canberra: ABS; 2016. Retrieved from http://www.abs. gov.au/AUSSTATS/[email protected]/Lookup/4329.0.00.004Main+Features12014%20-%2015? OpenDocument Australian Bureau of Statistics. Mortality of people using mental health services and prescription medications. Analysis of 2011 data. (4329.0.00.006). Canberra: ABS; 2017. Retrieved from http://www.abs.gov.au/ausstats/[email protected]/mf/4329.0.00.006 Australian Institute of Health and Welfare. Comorbidity of mental disorders and physical conditions 2007. Canberra: AIHW; 2012.

318

R. Roberts

Australian Institute of Health and Welfare. Medical practitioners workforce 2015. AIHW: Canberra; 2016. Australian Institute of Health and Welfare. Chronic disease comorbidity. 2017. Retrieved from Canberra: http://www.aihw.gov.au/chronic-diseases/comorbidity/ Australian Institute of Health and Welfare. Australian burden of disease study: impact and causes of illness and death in Australia 2015 – summary report. Australian Burden of Disease Study series no. 18. Cat. no. BOD 21. Canberra: AIHW; 2019. Baxter A, Harris MG, Khatib Y, Brugha T, Bien H, Bhui K. Reducing excess mortality due to chronic disease in people with severe mental illness: meta-review of health interventions. Br J Psychiatry. 2016;208:322–9. https://doi.org/10.1192/bjp.bp.115.163170. Bell A, Hughes S. Equally Well in the UK. Paper presented at the Equally Well in Action: implementing strategies to improve the physical health of people living with mental illness. Melbourne: RMIT; 2019. www.equallywell.org.au/symposium-speakers/ Blanner Kristiansen C, Juel A, Vinther Hansen M, Hansen A, Kilian R, Hjorth P. Promoting physical health in severe mental illness: patient and staff perspective. Acta Psychiatr Scand. 2015;132(6):470–8. Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry. 1997;171:502–8. Brown S, Kim M, Mitchell C, Inskip H. Twenty-five year mortality of a community cohort with schizophrenia. Br J Psychiatry. 2010;196(2):116. https://doi.org/10.1192/bjp.bp.109.067512. Bushe C, Taylor M, Haukka J. Mortality in schizophrenia: a measurable clinical endpoint. J Psychopharmacol. 2010;24(4_suppl):17–25. Centre for Disability Studies. I-CAN: instrument to classify support needs of people with disability. Sydney: University of Sydney; 2005. Chapman C, Slade T, Hunt C, Teesson M. Delay to first treatment contact for alcohol use disorder. Drug Alcohol Depend. 2015;147:116–21. Connor JP, Haber PS, Hall WD. Alcohol use disorders. Lancet. 2016;387(10022):988–98. Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiat. 2013aa;70(9):931–9. Crump C, Winkleby MA, Sundquist K, Sundquist J. Comorbidities and mortality in persons with schizophrenia: a Swedish national cohort study. Am J Psychiatr. 2013bb;170(3):324–33. Cuijpers P, Vogelzangs N, Twisk J, Kleiboer A, Li J, Penninx BW. Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses. Am J Psychiatr. 2014;171(4):453–62. Cunningham R, Peterson D, Sarfati D, Stanley J, Collings S. Premature mortality in adults using New Zealand psychiatric services. N Z Med J. 2014;127(1394):31–41. Curtis J, Newall H, Samaras K. Positive Cardiometabolic health: an early intervention framework for patients on psychotropic medication. 2011. Retrieved from Sydney: https://www.iphys.org. au/algorithm-and-adaptations De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas, M, Cohen, D, Asai, I, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52. https://doi.org/10.1002/j.2051-5545.2011.tb00014.x Department of Health. Australian government response to contributing lives, thriving communities–review of mental health Programmes and services. Canberra: Australian Government Department of Health; 2015. Department of Health. The Fifth National Mental Health and Suicide Prevention Plan. 2017. Retrieved from Canberra. Ehrlich C, Chester P, Kisely S, Crompton D, Kendall E. Making sense of self-care practices at the intersection of severe mental illness and physical health-an Australian study. Health Soc Care Community. 2017; https://doi.org/10.1111/hsc.12473. Erlangsen A, Andersen PK, Toender A, Laursen TM, Nordentoft M, Canudas-Romo V. Causespecific life-years lost in people with mental disorders: a nationwide, register-based cohort study. Lancet Psychiatry. 2017;4(12):937–45.

14

Improving the Physical Health of Rural People Living with Mental Illness

319

Ewart SB, Happell B, Bocking J, Platania-Phung C, Stanton R, Scholz B. Social and material aspects of life and their impact on the physical health of people diagnosed with mental illness. Health Expect. 2017;20(5):984–91. https://doi.org/10.1111/hex.12539. Farholm A, Sørensen M. Motivation for physical activity and exercise in severe mental illness: a systematic review of cross-sectional studies. Int J Ment Health Nurs. 2016;25(2):116–26. https://doi.org/10.1111/inm.12217. Fässberg MM, Östling S, Braam AW, Bäckman K, Copeland JR, Fichter M, et al. Functional disability and death wishes in older Europeans: results from the EURODEP concerted action. Soc Psychiatry Psychiatr Epidemiol. 2014;49(9):1475–82. Fässberg MM, Cheung G, Canetto SS, Erlangsen A, Lapierre S, Lindner R, et al. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Ageing Ment Health. 2016;20:166–94. https://doi.org/10.1080/13607863.2015.1083945. Fennell K, Berry N, Meng R, Wilson C, Dolman J, Woodman R, et al. Self-reported physical health, mental health and participation in health-promoting behaviours of rural and urban South Australian adults with a history of cardiovascular disease (CVD). Heart Lung Circ. 2016;25: S321–2. Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019;6(8):675–712. https://doi.org/10.1016/S2215-0366(19)30132-4. Fitzpatrick SJ, Perkins D, Handley T, Brown D, Luland T & Corvan E. Coordinating Mental and Physical Health Care in Rural Australia: An Integrated Model for Primary Care Settings. Int J Integrated Care, 2018;18:1–9. Fuller JD, Perkins D, Parker S, Holdsworth L, Kelly B, Roberts R, et al. Building effective service linkages in primary mental health care: a narrative review part 2. BMC Health Serv Res. 2011;11 (1):66. Galletly CA, Foley DL, Waterreus A, Watts GF, Castle D, McGrath J, et al. Cardiometabolic risk factors in people with psychotic disorders.The second Australian survey of psychosis. Australian and New Zealand Journal of Psychiatry, 2012;46:753–61. Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on alcohol and related conditions III. JAMA Psychiat. 2015;72(8):757–66. Happell B, Ewart SB. ‘Please believe me, my life depends on it’: physical health concerns of people diagnosed with mental illness. Aust Nurs Midwifery J. 2016;23(11):47. Happell B, Scott D, Platania-Phung C, Nankivell J. Rural physical health care services for people with serious mental illness: a nursing perspective. Aust J Rural Health. 2012;20(5):248–53. Happell B, Gaskin CJ, Stanton R. Addressing the physical health of people with serious mental illness: a potential solution for an enduring problem. Int J Soc Psychiatry. 2016a;62(2):201–2. https://doi.org/10.1177/0020764015621771. Happell B, Ewart S, Platania-Phung C, Bocking J, Scholz B, Stanton R. What physical health means to me: perspectives of people with mental illness. Issues Ment Health Nurs. 2016b;37(12):934–41. Happell B, Wilson K, Platania-Phung C, Stanton R. Physical health and mental illness: listening to the voice of carers. J Ment Health. 2017;26(2):127–33. https://doi.org/10.3109/09638237.2016. 1167854. Holt RIG, Peveler RC. Diabetes and cardiovascular risk in severe mental illness: a missed opportunity and challenge for the future. Pract Diabetes Int. 2010;27(2):79–84. https://doi.org/ 10.1002/pdi.1451. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316. Integrated Regional Planning Working Group. Joint regional planning for integrated mental health and suicide prevention services. Canberra: Department of Health; 2018. Jackson K, Roberts R, McKay R. Older people’s mental health in rural areas: converting policy into service development, service access and a sustainable workforce. Aust J Rural Health. 2019;27 (4):358–65. https://doi.org/10.1111/ajr.12529.

320

R. Roberts

Jorm A, Henderson A, Scott R, Korten A, Christensen H, Mackinnon A. Factors associated with the wish to die in elderly people. Age Ageing. 1995;24(5):389–92. Kavanagh D, Connor J, Gullo M. Substance use disorders. InPsych. 2014;36(5):13. Kisely S, Simon G. An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome. J Psychosom Res. 2006;60(2):125. https://doi.org/10.1016/j.jpsychores.2005.06.064. Lambert T, Newcomer JW. Are the cardiometabolic complications of schizophrenia still neglected? Barriers to care. Med J Australia. 2009;190(4):S39–42. Lawrence D, Coghlan R. Health inequalities and the health needs of people with mental illness. N S W Public Health Bull. 2002;13(7):155–8. https://doi.org/10.1071/NB02063. Lawrence D, Kisely S. Review: inequalities in healthcare provision for people with severe mental illness. J Psychopharmacol. 2010;24:61–8. Lawrence D, D’Arcy C, Holman J, Jablensky AV, Threfall TJ, Fuller SA. Excess cancer mortality in Western Australian psychiatric patients due to higher case fatality rates. Acta Psychiatr Scand. 2000;101(5):382–8. https://doi.org/10.1034/j.1600-0447.2000.101005382.x. Lawrence D, Hancock K, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ. 2013;346(7909). https://doi.org/10.1136/bmj.f2539. Liu N, Daumit G, Dua T, Aquila R, Charlson F, Cuijpers P, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry. 2017;16(1):30–40. https://doi.org/10.1002/wps. 20384. Lorem GF, Schirmer H, Wang CE, Emaus N. Ageing and mental health: changes in self-reported health due to physical illness and mental health status with consecutive cross-sectional analyses. BMJ Open. 2017;7(1):e013629. Mangurian C, Newcomer J, Modlin C, Schillinger D. Diabetes and cardiovascular care among people with severe mental illness: a literature review. J Gen Intern Med. 2016;31(9):1083–91. Maylea C, Daya I. Physical health as a human rights issue. Paper presented at the Equally Well in Action: Implementing strategies to improve the physical health of people living with mental illness, RMIT, Melboune; 2019. ISBN 978-1-86-4673654. www.equallywell.org.au/speakersabstracts/#chrismaylea. McNamara BJ, Banks E, Gubhaju L, Joshy G, Williamson A, Raphael B, Eades S. Factors relating to high psychological distress in indigenous Australians and their contribution to indigenous– non-indigenous disparities. Aust N Z J Public Health. 2018;42(2):145–52. Morgan VA, Waterreus A, Jablensky AV, Mackinnon A, McGrath J, Carr V, Bush R. People living with psychotic illness 2010. Report on the second Australian national survey. 2011. Retrieved from Canberra. National Mental Health Commission. Equally Well Consensus Statement. Improving the physical health and wellbeing of people living with mental illness in Australia. Sydney: NMHC; 2016. Nordentoft M, Wahlbeck K, Hällgren J, Westman J, Ösby U, Alinaghizadeh H, et al. Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS One. 2013;8(1):e55176. NSW Ministry of Health. NSW health physical health care of mental health consumers guidelines. North Sydney: NSW Government; 2017a. NSW Ministry of Health. Specialist Mental Health Services for Older People (SMHSOP) community services – model of care guideline. Sydney: NSW Health; 2017b. Nursing Midwifery and Allied Health Professions Policy Unit. Improving the physical health of people with mental health problems: actions for mental health nurses. 2016. Retrieved from London. O’Flynn J. The cult of collaboration in public policy. Aust J Public Adm. 2009;68(1):112–6. Olfson M, Gerhard T, Huang C, Crystal S, Stroup T. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiat. 2015;72(12):1172–81.

14

Improving the Physical Health of Rural People Living with Mental Illness

321

Pearsall R, Praveen KT, Pelosi A, Geddes J. Dietary advice for people with schizophrenia. Cochrane Libr. 2016. https://doi.org/10.1002/14651858.CD009547.pub2. Pérez-Iglesias R, Martínez-García O, Pardo-Garcia G, Amado JA, Garcia-Unzueta MT, TabaresSeisdedos R, Crespo-Facorro B. Course of weight gain and metabolic abnormalities in first treated episode of psychosis: the first year is a critical period for development of cardiovascular risk factors. Int J Neuropsychopharmacol. 2014;17(1):41–51. Perkins DA, Roberts R, Sanders T, Rosen A. Far West Area Health Service mental health integration project: model for rural Australia? Aust J Rural Health. 2006;14(3):105–10. Perkins D, Hamiliton M, Saurman E, Luland T, Alpren C, & Lyle D. GP Clinic: promoting access to primary health care for mental health service clients. Aust J Rural Health, 2010;18:217–222. Peterson D, Pere L, Sheehan N, Surgenor G. Experiences of mental health discrimination in New Zealand. Health Soc Care Community. 2007;15(1):18–25. https://doi.org/10.1111/j.1365-2524. 2006.00657.x. Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: what role has the tobacco industry played? Schizophr Bull. 2007;34(3):555–67. Prochaska JJ, Das S, Young-Wolff KC. Smoking, mental illness, and public health. Annu Rev Public Health. 2017;38(1):165–85. https://doi.org/10.1146/annurev-publhealth-031816044618. Rethink. Lethal discrimination. Why people are dying needlessly and what needs to change. London: Rethink mental illness; 2013. Roberts R. Stronger rural health strategy: where is allied health? Aust J Rural Health. 2018;26 (3):144–5. https://doi.org/10.1111/ajr.12443. Roberts R. How does promotion, prevention and early intervention apply to people living with an enduring mental illness? in Maylea C, Roberts R, Peters D, editors. Equally Well in Action: Implementing strategies to improve the physical health of people living with mental illness. Proceedings of the First National Equally Well Symposium, RMIT, Melbourne, Vic. March 2019: Charles Sturt University; 2019:102-12 Roberts R, Burmeister O. Evaluation of Marathon health’s partners in recovery care coordination model (Specialist support coordination team program). Summary of findings. Bathurst: Charles Sturt University; 2018. Roberts R, Maylea C. Is rural mental health workforce a policy imperative? Aust J Rural Health. 2019;27(6):1–5. https://doi.org/10.1111/ajr.12541. Roberts R, Buss R, Perkins D, Fuller J. Stepped care and integrated mental health: What does this mean in rural and remote Australia. Paper presented at the Mental Health Reform in Rural Australia – Working together, integrating care. 8th Australian Rural and Remote Mental Health Symposium, Kingscliff, NSW; 2016. https://mentalhealthaustralia.org.au/rural/16/bop16.pdf. Roberts R, Perkins D, Fuller J. So much planning in Australian mental health, so little change: towards an implementation toolkit. Paper presented at the 4th World Congress on Integrated Care, Wellington, NZ; 2017. Roberts R, Lockett H, Bagnall C, Maylea C, Hopwood M. Improving the physical health of people living with mental illness in Australia and New Zealand. Aust J Rural Health. 2018;26(5):354– 62. https://doi.org/10.1111/ajr.12457. Rosenbaum S. Lifestyle and physical activity. in Maylea C, Roberts R, Peters D, editors. Equally Well in Action: Implementing strategies to improve the physical health ofpeople living with mental illness. Proceedings of the First National Equally Well Symposium, RMIT, Melbourne, Vic. March2019: Charles Sturt University. www.equallywell.org.au/speakers-abstracts/ #simonrosenbaum. Rosenbaum S, Tiedemann A, Sherrington C, Curtis J, Ward PB. Meta-analysis physical activity interventions for people with mental illness: a systematic review and meta-analysis. J Clin Psychiatry. 2014;75(9):964–74. https://doi.org/10.1016/j.jsams.2014.11.161. Royal Australian and New Zealand College of Psychiatrists. Keeping mind and body together. Melbourne: RANZCP; 2015.

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R. Roberts

Royal College of Physicians and Royal College of Psychiatrists. Smoking and mental health. London: RCP; 2013. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64(10):1123–31. Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B. Exercise improves physical and psychological quality of life in people with depression: a meta-analysis including the evaluation of control group response. Psychiatry Res. 2016;241:47–54. https://doi.org/10. 1016/j.psychres.2016.04.054. Sharma R, Meurk C, Bell S, Ford P, Gartner C. Australian mental health care practitioners’ practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness. Int J Ment Health Nurs. 2017. https://doi.org/10.1111/inm.12314. Sheals K, Tombor I, McNeill A, Shahab L. A mixed-method systematic review and meta-analysis of mental health professionals’ attitudes toward smoking and smoking cessation among people with mental illnesses. Addiction. 2016;111(9):1536–53. https://doi.org/10.1111/add.13387. Shor R, Shalev S. Barriers to involvement in physical activities of persons with mental illness. Health Promot Int. 2014;31(1):116–23. Shor E, Roelfs DJ. Social contact frequency and all-cause mortality: a meta-analysis and metaregression. Soc Sci Med. 2015;128:76–86. Stockings E, Bowman J, McElwaine K, Baker A, Terry M, Clancy R, et al. Readiness to quit smoking and quit attempts among Australian mental health inpatients. Nicotine Tob Res. 2012;15(5):942–9. Szatkowski L, McNeill A. Diverging trends in smoking behaviors according to mental health status. Nicotine Tob Res. 2014;17(3):356–60. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014;348:g1151. Taylor J, Stubbs B, Hewitt C, Ajjan R, Alderson S, Gilbody S, et al. The effectiveness of pharmacological and non-pharmacological interventions for improving glycaemic control in adults with severe mental illness: A systematic review and meta-analysis. PLoS One. 2017;12 (1):e0168549. https://doi.org/10.1371/journal.pone.0168549. Te Pou o te Whakaaro. The physical health of people with mental health conditions and/or addictions. 2017. Retrieved from Auckland. Teasdale S, Ward P, Samaras K, Rosenbaum S, Curtis J, Lederman O, et al. Nutrition interventions in people with severe mental illness: novel strategies for addressing physical health co-morbidity in a high-risk population. Eur Psychiat. 2016;33:S620. Teasdale S, Samaras K, Wade T, Jarman R, Ward PB. A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps. J Hum Nutr Diet. 2017;30:545–53. Thornicroft C, Wyllie A, Thornicroft G, Mehta N. Impact of the “like minds, like mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination. Aust N Z J Psychiatry. 2014;48(4):360–70. Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A, Haukka J. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet. 2009;374(9690):620–7. https://doi.org/10.1016/S0140-6736(09)60742-X. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the surgeon general. Atlanta: DHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. Vancampfort D, Wampers M, Mitchell AJ, Correll CU, Herdt A, Probst M, Hert M. A meta-analysis of cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia versus general population controls. World Psychiatry. 2013;12(3):240–50. https:// doi.org/10.1002/wps.20069.

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Vancampfort D, Stubbs B, Ward P, Teasdale S, Rosenbaum S. Integrating physical activity as medicine in the care of people with severe mental illness. Aust N Z J Psychiatry. 2015;49 (8):681–2. Walker E, McGee R, Druss B. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiat. 2015;72(4):334–41. https://doi.org/10. 1001/jamapsychiatry.2014.2502. Weinmann S, Read J, Aderhold V. Influence of antipsychotics on mortality in schizophrenia: systematic review. Schizophr Res. 2009;113(1):1–11. White C, Green RA, Ferguson S, Anderson SL, Howe C, Sun J, Buys N. The influence of social support and social integration factors on return to work outcomes for individuals with workrelated injuries: a systematic review. J Occup Rehabil. 2019;6:1–24. World Health Organization. Guidelines for the management of physical health conditions in adults with severe mental disorders. Geneva: WHO; 2018. Retrieved from http://www.who.int/ mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en/.

Part III Role of Different Professions in Rural, Remote, and very Remote Mental Health Practice

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural and Remote Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Development of Open Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Our Psychosis Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Northern Saskatchewan Reserves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phenomenology of Rural and Remote Psychiatric Practice – Getting to Experience . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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L. Mehl-Madrona (*) Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Department of Psychiatry, University of Vermont, College of Medicine, Burlington, VT, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA e-mail: [email protected] P. McFarlane Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_15

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Abstract

The pronounced differences between rural and urban areas relate to access to care and psychiatric resources with nearly every rural county (96%) having a shortage of psychiatrists. Studies on urban-rural differences in psychiatric disorders have shown that urban environments are associated with increased risk for mental illness generally and with a greater range of psychiatric disorders. Urban-rural differences lie in social networks. Barriers to care include having an ideal of self-reliance and believing that mental illness is a weakness. The maturing field of rural health research supports the robust impact of the “neighborhood effect” on health, which includes community and social networks, and finds, in rural areas, that immersion in traditional cultures and networks are health-enhancing. Moving from rural to urban areas is often found to be a risk factor for mental illness, though the odds ratio for substance abuse disorders has been found to be the same. Providers and organizations in rural areas struggle with issues of access, recruitment, and professional burnout or exhaustion in traditional models. Systems of training must be considered for rural psychiatry that tap traditional and communitybased systems of healing and health care; assess and intervene with “neighborhood” community, family, and social networks; and are less enamored with psychopharmacology. Primary care teams have an essential role in the treatment of rural mental illness and are most effective when inserted into a collaborative care model for disease management. Affiliating and understanding the natural helpers and social networks in any location is a key aspect to being in rural and remote psychiatry. Open Dialogue was developed in a rural and remote part of northwestern Finland. The implementation of Open Dialogue style approaches which are highly compatible with most indigenous cultures (Western Lappland in Finland is the traditional home of the Lapp people) puts psychiatry in a new perspective for rural and remote mental health – psychiatrists are considered to be just another team member and not necessarily the leader or the most important team member. The difficulty inherent in telemedicine approaches is the lack of community engagement. Psychiatry, like anthropology, has garnered distrust in rural and remote communities related to its “helicopter” approach of coming to a community with little knowledge of the traditions, beliefs, customs, and ideas about mind and mental health, applying a biomedical model of diagnosis and treatment, prescribing medications, and leaving. Effective rural psychiatry will recruit well-trained psychiatrists akin to rural primary care providers who enjoy and value a broader scope of practice and who, while they are experts in pharmacotherapy, also desire to practice psychotherapy and systems development that advantage already existing community social networks and helpers.

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Introduction Men are so necessarily mad, that not being mad would be being mad through another trick that madness played. (Pascal). It is not by locking up one’s neighbor that one convinces oneself of one’s own good sense. (Dostoevsky, from a Writer’s Diary)

Idyllic rustic scenes of bucolic fields and stands of forests and even the stately architecture of asylums sitting on lovely hilltops give rise to the notion that once upon a time we took care of patients with mental illness in the rural United States. We seemed to consider aesthetics and the needs of then working middle-class families who could no longer afford to care for relatives in an age of industrialization and its subsequent commodification of “care.” Psychiatry became a function of the superintendent of the asylum, and state hospitals became the community for these patients, ever more tangentially than their families. Since the end of the nineteenth century, rural mental health care has been the bailiwick of specialty psychiatrists, primary care physicians, and a host of other professions and providers in varying degrees of availability, including psychologists, social workers, ministers, occupational therapists, various types of counselors, lay providers, and communities of support. In the mid-twentieth century, an awareness arose that the widespread use of asylums and state psychiatric institutions could sideline human beings from the common collective irrespective to the human rights of the individual and that these facilities could be boorish places where the medicine wasn’t medicinal and the community, though contained, alienated people. Pinel stated, in the famous story of the deliverance of the alienated of Bicetre asylum told by Foucault (2006), “Citizen, I am convinced that these alienated are only so intractable because they are deprived of air and liberty.” As American asylums and state hospitals came under greater scrutiny, and lawsuits began to challenge this manner of care, the political response toward deinstitutionalization and community-based mental health seemed like a good idea. However, without resources and infrastructure for rural mental health, since the 1980s, those who previously had been in the institution have often been relegated to imprisonment in the United States where it is estimated that 26% of those incarcerated have had serious psychological distress in the past 30 days (Bronson 2017) and that between 50 and 60% of inmates have mental problem or mood issues. In jails, it’s worse, with 75% of women and 63% of male inmates having mental health problems (Fazel et al. 2016). In 2016, the Justice Department found that one in six inmates in federal prison and one in four in jails were psychotic. It is said that jail is now de facto how the United States addresses its problems with mental health, and jails are also a place where treatment and intervention often don’t occur. Jails

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and prisons have become a major player in housing the mentally ill from rural and remote areas of the United States. Regarding the burden of psychiatric illness in rural areas, it has been well established that rates in rural areas are the same as in urban areas. The pronounced differences relate to access to care and psychiatric resources with Thomas et al. (2009) finding that nearly every rural county (96%) had a shortage of psychiatrists. Three-quarters had a “severe shortage,” and a significant number had significant shortages of nonpsychiatric mental health professionals as well. In rural counties, 590 psychiatrists serve 27 million Americans (Guerrero et al. 2018; Thomas et al. 2009). Psychiatric constructs and incidence rates vary by culture and region, but worldwide the global disease burden of mental illness is a “distant first” in terms of disability-adjusted life years and represents 32.4% of the burden of years lived with disability according to several analyses (Vigo et al. 2016). The prospective Zurich cohort study found that the chance to experience any mental disorder from ages 20 to 50 was 73.9% (Angst et al. 2015). Of these mental disorders, it is generally accepted that approximately 30% will be substance use disorders, 15% anxiety disorders, 10% depression or mood disorders, 5% attentional/executive function disorders, 2% bipolar depression, and 1% schizophrenia. The incidence and prevalence of mental illness is similar in rural and urban settings, though rural areas experience greater obstacles, including lack of resources, transportation challenges, and lack of personnel (McCall-Hosenfeld et al. 2014). Drug abuse was more common among metropolitan (8.7%, p ¼ 0.018), compared to nonmetropolitan (5.1% suburban, 6.1% rural) participants. A one-category increase in rurality was associated with decreased odds for war-related trauma (OR ¼ 0.86, 95% CI 0.78– 0.95). Rurality was not associated with risk for any other lifetime psychiatric disorders or trauma exposure. Missing from this accounting are the developmental, somatic, personality, neurologic, and cognitive disorders if one uses Western psychiatric diagnostic tools such as the International Classification of Diseases (ICD-10; American Medical Association 2017) or the Diagnostic and Statistical Manual (DSM; American Psychiatric Association 2013) which have both been challenged and criticized (Pickersgill 2014). One often undervalued paradigm of mental illness relates to developmental trauma, or what Ross called the trauma model (Ross 2000). Benjet in a large study of 69,000 people across 24 countries found that 70% of respondents reported a traumatic event, with 30.5% of the respondents having four or more types of traumatic events, noting that exposure to interpersonal violence predicted most strongly subsequent traumatic events, all of which is highly correlated with negative physical and mental health conditions and outcomes (Benjet et al. 2016). For adolescents, no association has been observed between urbanicity and the prevalence of major depression, with or without statistical adjustments. For adults, no differences were found in the prevalence of major depression or serious mental illness between large metropolitan areas and rural areas, but the prevalence of both was slightly higher in the two intermediate urbanicity categories than in large metropolitan areas, with statistically significant odds ratios after adjustment ranging

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from 1.12 to 1.19 (Breslau et al. 2014). Studies on urban-rural differences in psychiatric disorders have shown that urban environments are associated with increased risk for mental illness generally and with a greater range of psychiatric disorders (Vassos et al. 2016). Mental disorders are associated with an increased risk of medical comorbidities ranging from 1.5 to 13.3% greater incidence (Scott et al. 2016). Medical care is also more of a challenge in rural and remote areas.

Rural and Remote Psychiatry Myths abound about rural and remote living and mental health (Breslau et al. 2014). Like any good humor, elements of truth make them relevant, but exaggeration is useful for the punch line (Scott et al. 2007). The exaggerations are that rural mental health has more suicides, more psychosis, more loneliness, more people in witness protection programs, more outlaws, and more fringe people. In fact, people seek refuge, safety, and solace in rural and remote living (Pateman 2011). The urban-rural differences lie in social networks (Hofferth and Iceland1998). Consider the character of “Old Mike” in the memoir The Curve of Time by Muriel “Capi” Wylie Blanchet, who wrote about her summer boat trips along remote British Columbia. Old Mike was a logger from Michigan who lived alone in a remote cabin. He told Capi about being beaten within an inch of his life, and he found solace among the fjords and mountains of remote British Columbia but he wasn’t lonely. He made a social network from the community of passersby who brought him books and magazines. Capi writes, “I don’t think anyone could sum up a book better than that logger from Michigan. Atlantic Monthly’s, Harpers, he loved them and the ideas that connected them and us. I would leave a pile for him, and at the end of the summer when we called again, he would discuss the articles and books with zest and intelligence. . . (Blanchet 2011; p. 10).” Old Mike was able to seek safety. Others may lack choices, social networks, and face stigma. Labys et al. (2016) described help-seeking behavior in rural KwaZuluNatal and informal networks and informal care providers addressing psychosis, finding that two-thirds of the 32 interviewees were never seen by a formal provider. Their social network supported them with only 1 in 8 accessing a psychiatric hospital, which was actually correlated with functional and social deterioration. If someone was psychotic, if they still had social reciprocity within their social network (s), they were “treated” in the community informally. In rural Ghana caregivers in families and social networks were interviewed about their experience with people who had serious mental disorders. Ayuurebobi Ae-Ngibise et al. (2015) described emotional distress, stigma, financial stress, social exclusion, and negative health impacts when a decentralized mental health service was not available. They suggested that decentralized mental health services such as social networks ameliorated the burden created by public policy. Willging (2006) examined gender minority access to rural mental health care. Barriers to care included having an ideal of self-reliance and believing that mental illness is a weakness. Fundamentally, a lack of social networks precluded access to

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both formal and informal care. When people did access assistance, it was largely family and community ties that led them to secular and sacred (indigenous, religious) care. This theme of familial and social networks recurs in the quantitative and qualitative literature and applies equally to urban and rural communities. Connected people receive care more often than disconnected people. Primary and specialty psychiatric care that is effective uses these networks to support not only the individual but also their caregivers and their community. An example of this in the United States is the opiate crisis in which layers of policy, education, support, and networks across legal, medical, public health, and community resources distribute overdose medications, encourage treatment, reduce stigma, and address and develop systems of care to manage addiction and recovery. The maturing field of rural health research supports the robust impact of the “neighborhood effect” on health, which includes community and social networks, and finds in rural areas that “immersion in traditional cultures and networks are health-enhancing. Those who experience transition away from those cultures and networks have more stress that is associated with mental illness and adverse cardiovascular health (Hartley 2004).” When considering traditional versus innovative approaches to rural specialty care and psychiatry, we should remember that the “health-care system” makes a relatively small contribution to health outcomes, including life expectancy, quality-adjusted life years, or mortality. Estimates of the impact of medical care on health show that it accounts for only approximately 15% of the variance (Donkin et al. 2018). To us, this emphasizes the need for rural primary care and psychiatry to assess and intervene with social networks, “neighborhoods,” and systems. We must examine rural communities in transition from traditional to more modern networks and systems. For example, moving from rural to urban areas is often found to be a risk factor for mental illness, though the odds ratio for substance abuse disorders has been found to be the same in rural as in urban environments (Peen et al. 2010). An April 2018 article in U.S. News and World Report (Levine 2018) asked: How much of a struggle is it to get mental health care in rural areas? The authors explored the state of the art in terms of rural provision of psychiatric services and found that providers and organizations in rural areas struggled with issues of access, recruitment, and professional burnout or exhaustion in traditional models. They suggested systems of consultation in collaborative models where the psychiatric provider works in a hub and spoke model with rural primary care providers in multidisciplinary teams across organizations and professions. One criticism in this model was “. . .no one was doing direct practice with the severely ill,” so the psychiatrist in this example had a one day a week practice that focused on that population, while the rest of the week worked in collaborative care models (Levine 2018), integrated primary care psychiatry (Weiner 2018), utilizing telemedicine/ telepsychiatry, and collaborative distributed consultative care which we explore in more depth later in this chapter. The American Association of Medical Colleges and the Centers for Medicare and Medicaid Services are designing psychiatric curriculum to support integrated care models noting the 2012 Cochrane Review of 79

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studies that found Collaborative Care to be effective in the treatment of anxiety and depression (Archer et al. 2012). Of course, systems of training must be considered for rural psychiatry to enhance the use of these models of care while developing others that can tap traditional and community-based systems of healing and health care and assess and intervene with “neighborhood” community, family, and social networks and to be less enamored with psychopharmacology. One method of reducing professional isolation while promoting rural psychiatric and primary care training and clinical research is to develop and maintain academic affiliations for interprofessional training and practice. Ng et al. (2013) argued that rural psychiatry creates value for academic institutions by determining how to maintain a bridge that leverages resources, provides for inquiry along with clinical work, and provides a base for training and recruiting psychiatrists and the myriad of multidisciplinary providers necessary to affect networks of care and provide comprehensive mental health services. Our whole society is affected by untreated mental illness. It affects people’s ability to work, build relationships, and contribute to their communities. (Anna Ratzliff, MD, PhD, as quoted by Stacy Weiner in the AAMC News Patient Care Column Addressing the escalating psychiatrist shortage, a publication of the American Association of Medical College, Feb 13, 2018)

There may even be as yet unforeseen advantages to living in a rural environment. For example, there are known links between persistent inflammatory states and psychiatric disturbances. Greater immune activation has been found in urban upbringings in the absence of pets (Böbel et al. 2018). Childhood urbanization affects prefrontal cortex mediation of anxiety and interacts with the polygenic risks for depression (inflammation, etc.) (Zhang 2018). Children raised in rural environments may have an advantage in this respect. Thus, rural is not always worse. In fact, it may be better in many respects. The problem lies in how services are delivered. Models for Care Delivery. Hedrick et al. (2003) compared collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provides a treatment plan to the primary care provider, telephones patients to support adherence to the plan, reviews treatment results, and suggests modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatrists or nurse practitioners operating within the primary care clinic. They randomly assigned patients to a treatment model. They enrolled 168 collaborative care and 186 CL patients with diagnoses of major depression and/or persistent depressive disorder. They measured outcomes with the Hopkins Symptom Checklist (SCL-20), the Short Form (SF)-36, and the Sheehan Disability Scale. Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months, there was no significant difference. Collaborative care increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion

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of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. The authors concluded that collaborative care resulted in more rapid improvement in depression symptomatology and a more rapid and sustained improvement in mental health status compared to the more standard model. They reported that evidence is mounting to show that collaboration between primary care providers and mental health specialists improves depression treatment and supports the necessary changes in clinic structure and incentives. For rural and remote practice, this could mean collaborative care via telemedicine, which would not be possible in the more conventional CL model. The CL model would require practitioners on the ground, unlike the collaborative care model which is more conducive to telemedicine or to scheduled interval visits of consultants to rural and remote communities. Practice-based collaborative care improves depression outcomes in numerous randomized effectiveness trials (Katon et al. 1999; Katon et al. 1996; Rost et al. 2001; Wells et al. 2000; Unützer et al. 2002; Alexopoulos et al. 2005; Bruce et al. 2004). Fortney et al. (2013) write about the difficulties of implementing practicebased collaborative care in smaller primary care practices that lack on-site mental health staff. They note that telemedicine-based collaborative care can co-locate and integrate mental health providers into primary care settings. They conducted a study to compare the outcomes of patients assigned to practice-based and telemedicinebased collaborative care. They screened patients at federally qualified health centres serving medically underserved populations for depression and enrolled 364 patients who screened positive, following them for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone and a psychologist and a psychiatrist via video conferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity. Significant group main effects were observed for both response (odds ratio ¼ 7.74, 95% CI ¼ 3.94–15.20) and remission (odds ratio ¼ 12.69, 95% CI ¼ 4.81–33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group. They concluded that contracting with an off-site telemedicine-based collaborative care team could yield better results than implementing practice-based collaborative care with locally available staff. In 1999, only 25% of US primary care practices had on-site mental health specialists (Williams et al. 1999). In two studies, treatment outcomes for depression were improved with small to medium effect sizes in small primary care clinics lacking on-site mental health practitioners through training on-site nurses to be depression care managers (Gensichen et al. 2009; Rost et al. 2001). Moreover, based on the results of a meta-analysis of randomized trials of practice-based

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collaborative care, Gilbody et al. (2003) conducted a meta-analysis of randomized trials of practice-based collaborative care and concluded that collaborative care interventions with more mental health specialist involvement have larger effect sizes than those with less. Telemedicine technologies can render possible virtual co-location of mental health specialists and primary care providers. Telemedicinebased collaborative care involves a team of mental health providers collaborating from a distance with on-site primary care providers using telephones, video conferencing, and electronic health records. A multisite randomized trial in the US Veterans Affairs (VA) health system showed telemedicine-based collaborative care more effective than usual care in small satellite primary care clinics (Fortney et al. 2013; Pyne et al. 2010). Despite the obvious drawbacks of using off-site practitioners, patients and providers have reported high levels of satisfaction with video conferencing (Callahan et al. 1998, Germain et al. 2010, Rohland et al. 2000, Simpson 2001), and evidence exists to support the results of psychiatric (Hailey et al. 2008; O’Reilly et al. 2007; Ruskin et al. 1998, 2004) and psychological treatments delivered via telemedicine to be similar to those obtained from face-to-face encounters (Bouchard et al. 2004; Frueh et al. 2007; Germain et al. 2009; Morland et al. 2010; Nelson et al. 2003). Fortney et al. (2013) studied five federally qualified health centres serving Arkansas’ Mississippi Delta region and the Ozark Highlands, finding that threequarters of federally qualified health centre patients live in poverty, half live in rural areas, one-third are uninsured, and one-third are from minority populations. Mental health problems are the most commonly reported reasons for visits to federally qualified health centres (Hunt et al. 2012), yet only 5.5% of encounters are with on-site mental health specialists (Fortney et al. 2013). They compared the outcomes of patients with a diagnosis of depression who were randomly assigned to telemedicine-based collaborative care or practice-based collaborative care in small, remote primary care clinics that lacked on-site mental health specialists (Fortney et al. 2007). Dham et al. (2018) conducted a retrospective chart review of telepsychiatry assessments via videoconference for older adults in rural and remote regions of South Australia over 24 months from 2010 to 2011. They measured satisfaction following the assessment with a 5-point Likert scale, asking patients, communitybased clinicians, and the psychiatrists participating in these 134 consecutive assessments from April to November 2012. The mean age was 75.89 years (SD 7.55), 60.4% (n ¼ 81) were females, and 71.6% (n ¼ 96) lived independently. Patients had a broad range of psychiatric disorders, including mood disorders, delirium, and dementia with comorbid medical illness in 83.5% (n ¼ 112). Mean satisfaction scores ranged from 3.88 to 4.41 for patients, from 4.36 to 4.73 for clinicians, and from 3.67 to 4.45 for the psychiatrists. Inpatients were significantly less satisfied than outpatients (chi sq. ¼ 0.808, p < 0.05), as well as being significantly less satisfied with the wait time (U ¼ 163.0, p < 0.05) and visual clarity (U ¼ 160.5, p < 0.05). Audio clarity was the most common aspect of dissatisfaction among patients. Psychiatrists preferred telepsychiatry over face-toface assessment (55.4%) except for patients with cognitive or sensory disabilities.

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The authors concluded that, in rural and remote areas, a community-based telepsychiatry program can be a useful adjunct for psychiatrist input in the care of older adults. Rojas et al. (2018) state that primary care teams have an essential role in the treatment of depression and are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. They tested the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas. They conducted a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial. Physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n ¼ 111) or to usual care (n ¼ 139). The remote collaborative care program used web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment. Six-month follow-up assessments were completed by 84.4% (n ¼ 221) of patients. The remote collaborative care program achieved higher user satisfaction (OR ¼ 1.94, 95% CI 1.25–3.00) and better treatment adherence rates (OR ¼ 1.81, 95% CI 1.02–3.19) at 6 months compared to usual care. There were no statistically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of a remote collaborative care program were observed at 3 months for mental health-related quality of life (beta ¼ 3.11, 95% CI 0.19–6.02). They concluded that technology-assisted interventions could help rural primary care teams in the management of depressive patients. Cross-cultural psychiatry. In an extensive meta-analysis, Gone and Alcantara (2007) found only two controlled studies with adequate sample sizes and interpretable results relative to the identification of evidence-based practices among American Indians and Alaska Natives for psychotherapy. Thus, recommendations for evidence-based practices cannot really be made. Few models exist for working with indigenous people. The French psychiatrist Henri Collomb stands out as an ethnopsychiatrist (Scheider 2010). He went to the Fann Hospital in Dakar in January 1959 to head the Department of Neuropsychiatry affiliated with a new university. He collaborated with traditional healers. He insisted that family members accompany patients admitted to the psychiatric hospital and predated what is called “Open Dialogue” by bringing all the stakeholders into group meetings in which everyone contributed to the discussion about how to help the identified patient. Collomb’s first effort was to “open the doors” and transform the prison-militaristic atmosphere of the psychiatric unit. He did this through collaborating with colleagues in the Faculty of Arts and Humanities during 1961 and 1962, resulting in a multidisciplinary team of arts, humanists, and medical personnel. An

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anthropologist (Andras Zempleni 1968) worked with the team to understand traditional local explanations of misery and unhappiness, traditional healing procedures, and how local practitioners classified what Westerners call mental illness. Collomb used this research to create genuine dialogue and collaboration with local healers who worked both inside and outside the hospital with shared patients. He engaged in open dialogue with patients, family members, community members, artists, humanists, traditional healers, and psychiatric staff to move toward finding what would help the patient. A similar approach arose in the very rural area of West Lappland in Finland where the nearest psychiatric hospital was a 7 hour drive away. Beginning over 20 years ago, mental health clinicians in the area resolved to find ways to manage psychosis within the community in order to avoid transportations to hospital and away from family and social connections. Open Dialogue arose in the context of the Finnish Turku project and National Schizophrenia project (Alanen et al. 1991). An individualized needs-adaptive approach (NAA) was seen as a continuous process in which different treating methods were combined to meet the therapeutic needs of each individual patients as well as their social networks (Alanen 2009). NAA was then applied and studied in several multicentre programs, including the Finnish national Acute Psychosis Integrated (API) Treatment Project, conducted in six psychiatric catchment areas in the early 1990s (Lehtinen et al. 2000). In the catchment area of the western parts of Finnish Lapland, the NAA was further modified to become the Open Dialogue in Acute Psychosis (ODAP I and ODAP II) projects (Seikkula et al. 2011). By the mid1990s, a process of gradual development had led to a new way to organize the entire psychiatric treatment system within the area, based on seven principles (Aaltonen et al. 2011; Seikkula et al. 2011). Open Dialogue was developed in a rural and remote part of northwestern Finland. It serves as a model for how psychiatrists can interrelate to other health professionals in an interdisciplinary team model. The principles of Open Dialogue are valid for any rural and remote service. They are: 1. Immediate help. People are seen within 24 hours of initial contact with a goal of preventing hospitalization, which means expensive transportation away from family and support systems and toward a potential hostile culture in more urban centres. 2. A social network perspective. Meetings, including psychotherapy, always include family members and other relevant members of the patient’s social network. These other members can include other authorities, fellow workers, neighbors, and friends. This principle is completely opposite to how psychiatry is routinely practiced in the United States. 3. Flexibility and mobility. Services are adapted to the needs of the individual, including some meetings taking place in the patient’s home. 4. Responsibility. Whatever staff member makes the first contact becomes the point person for organizing the treatment team and interfacing with the patient’s community.

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5. Psychological continuity. The initial team remains the treating team for as long as services are being provided. 6. Tolerance of uncertainty. Meetings are arranged as quickly as possible and as often as necessary without jumping to conclusions in the crisis phase. Neuroleptic medication is not introduced at the initial meeting and then only started if all other efforts prove insufficient. Meetings may happen every day for the first 2 weeks in times of crisis. This avoids premature conclusions and treatment decisions (such as overreliance on medication). 7. Dialogue. All issues are discussed openly in the presence of all persons. The goal is to create a shared understanding of the situation and for patients and families to increase their sense of agency in their lives. The implementation of Open Dialogue style approaches which are highly compatible with most indigenous cultures (Western Lappland in Finland is the traditional home of the Lapp people) puts psychiatry in a new perspective for rural and remote mental health – just another team member and not necessarily the leader or the most important team member. Open Dialogue approaches have demonstrated superior outcomes across 19 years, summarized by Bergstrom et al. (2018). Cross-cultural psychiatry can be a complex and nuanced enterprise. Typically, psychiatry as a profession assumes it is above culture because it is scientific (Salamonsen and Ahlzén 2018). Ethan Watters (2010) writes about the difficulties that occurred when Western psychiatry brought the mainstream diagnoses of schizophrenia to Africa, post-traumatic stress disorder (PTSD) to Sri Lanka, anorexia nervosa to Hong Kong, and depression to Japan. Albert Marshall has created a concept of “two-eyed seeing,” which presents the idea that indigenous wisdom is equal to scientific wisdom, albeit different (Institute for Integrative Science and Health 2018). This notion of explanatory pluralism argues that indigenous perspectives on mental health are as valid as biomedical medicine. In practice, what that means is the difficult process of interacting with community members and local traditional practitioners about their views and how they think their suffering community members can best be helped. This process has been called community-based participatory approaches (CBPA) (Virginia Department of Health 2019). This approach is recognized as an important strategy for addressing health inequities among socially disadvantaged and marginalized communities. From the beginning of any effort, community members are included in decision-making with all other involved parties. CBPA recognizes the community as a unit of identity, builds on collective strengths and shared resources within the community, facilitates partnerships and capacity building, and involves a long-term process and commitment. The most trusted members of the community or the “gatekeepers” must be engaged from the beginning. The difficulty inherent in telemedicine approaches is the lack of community engagement. Psychiatry, like anthropology, has garnered distrust in rural and remote communities related to its “helicopter” approach of coming to a community with little knowledge of the traditions, beliefs, customs, and ideas about mind and mental health, applying a biomedical model of diagnosis and treatment, prescribing

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medications, and leaving. Telemedicine has been criticized on the same grounds. Participatory, community-based approaches are initially slower to implement and more expensive but more effective in the long run. Psychiatric training for rural and remote areas. Across the world, psychiatry is a limited resource often misaligned with needs and severity of psychiatric illnesses. In 2008, the World Health Organization suggested a model for integrating and distributing resources for mental health care that focused on psychiatry as a resource for primary care, general hospital care, community-based mental health care, and then long-term facilities and specialized psychiatric care focused on severe and persistent mental illness (WHO 2004). It could be assumed that rural and remote psychiatry is a function of training for rural and remote psychiatry. That assumption, however, may or may not be true, but it is certain that, worldwide, various strategies in training and recruitment programs have value. Cultivating and prioritizing students from rural communities, as well as screening candidates for indicators of intention, seem important. Efforts to match students and trainees with meaningful rotations in communities that maximize community and system exposure seem to encourage postgraduate placement of psychiatrists (Berntson et al. 2005). The Canadian Psychiatric Association position paper developed recommendations for increasing skills and building partnerships in psychiatric training in rural and remote areas which included that universities and communities demonstrate commitment to this work by having meaningful rural faculty appointments. These new positions could then leverage all of the resources of the university for rural faculty and rotations. Hoeft (2018) suggested that leveraging task sharing in rural settings between natural helpers, community caregivers, primary care and multidisciplinary providers, and psychiatrists could be a way to extend quality psychiatric service in rural communities. We need training that includes purposeful and meaningful use of multidisciplinary and integrated care, remote methods of secure clinical communication, cultivation of natural community social networks, to serve identified patients in their community and/or family setting, while supporting primary care/general practice providers.

Practice Applications Guerrero et al. in their editorial in Academic Psychiatry (2018) recommended consideration of 13 actions: 1. Develop and/or maintain formal affiliations with academic medical centres to establish clinical learning environments for rural psychiatric practice and/or essential high-yield components of psychiatric care that include telepsychiatry. 2. Develop integrated care models that bridge primary care that assist them in screening for mental disorders and managing more complex problems.

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3. Designate and support faculty champions for rural psychiatry to assist with specialty care for children and adolescents, geriatrics, and substance abuse. 4. Explore models that enable even urban-based faculty to work part time in rural settings so they contribute to rural program development, training, and academics. 5. Include cultural and regional education so resident psychiatrists appreciate the demographics, norms, and customs of the rural areas in which they serve. 6. Identify local mental health personnel in schools, hospitals, and community health centres who help to introduce and endorse outside residents and psychiatrists to the community. 7. Expand primary care in psychiatry education to enable psychiatrists to manage common medical conditions and side effects in rural settings. 8. Build experience in psychotherapy modalities practical for rural settings (e.g., cognitive behavioral therapy and problem-solving skills training for families). 9. Encourage graduates who enter rural psychiatric practice to maintain academic connections (volunteer faculty appointments, participation in grand rounds, and remotely available forums for academic questions and exchange). 10. Encourage multidisciplinary training and rounds around primary care and psychiatry needs in rural communities. 11. Collaborate with the institution’s graduate medical education committee and offices to seek funding and support for rural practice (stipends for travel, housing, loan repayment, visa waivers, and creative recruitment/retention models). 12. Advocate for state and federal funding to support rural mental health and research on clinical and social services. 13. Survey rural psychiatrists and develop structures (e.g., association of rural psychiatry/rural primary care and psychiatry groups), and develop action plans based on that information. (Singh et al. 2017; Weigel et al. 2018). Utilizing rural models like extension education and network models of affiliation like the extension for community healthcare outcomes (Project ECHO 14), models that allow reduced professional isolation and the siloing of specialized information and experience (Arora et al. 2011; Sockalingam et al. 2017). We contend that one important component of rural psychiatric practice is the role of the medical humanities and narrative medicine in psychiatric training. Rural psychiatrists must be both an expert in medicine and, at the same time, a generalist in the humanities and organizational and community psychiatry to understand any patient’s context and story to promote effective systems of care while being far less enamored with having “the” answer or with the power of psychiatry or psychotropic medications. Psychiatry is at its best when it alleviates suffering and minimizes harm, and all psychiatric systems, like all other medical systems, are inherently political and potentially oppressive. They should follow the example of Collomb or the Open Dialogue team in building community engagement and eliciting the help and involvement of all who cared about the patient’s well-being, including local spiritual leaders.

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Conclusions Consideration of anti-oppressive assessment in psychiatry is a key to psychiatric care being more liberating than oppressive in a population. The consideration of antioppressive assessment in psychiatry is a key to psychiatric care being more liberating than oppressive in a population. Veltman and La Rose (2016) suggest that adopting an anti-oppressive approach involves a commitment to social justice, including minimizing power imbalances, promoting equity and empowerment for patients, and self-reflection on one’s own social location to enhance a clinician’s understanding of the predisposing, precipitating, and perpetuating factors in a patient presentation.

Take-Home Messages 1. Rural mental health practice relies upon relationships and social networks. Efforts to build community and to strengthen these networks will improve mental health. 2. Psychiatrists should recognize that medications are only part of an integrated approach to rural mental health and sometimes not the priority at all, so that team work is essential and all team members deserve recognition and respect. 3. Psychiatrists should collaborate with other health professionals and community members in an effort to build participatory circles in which all stakeholders contribute to deciding what clinical care should be. 4. The social determinants of health (unemployment, food insecurity, homelessness or housing insecurity, etc.) are powerful, often far more so than biological factors. 5. Circle processes, such as talking circles, restorative justice circles, and the like, facilitate nonhierarchical communication and the involvement of providers and community members in clarifying policy and determining how to proceed.

Case Studies The Development of Open Dialogue Open Dialogue arose from the Finnish Psychosis Project in Western Lapland in the 1980s. It arose from a basic indigenous idea – getting everyone involved in a problem into communication with each other. Treatment emphasizes the inclusion of meetings with the patient and his or her family members and extended social network. The need arose from the closest hospital being 7 hours driving distance and not always accessible in winter. Colleagues have told us that these clinicians (including Jaakko Seikkula and Markku Sutela) were influenced by the indigenous Sami people of that part of Finland. The psychiatrists decided to concentrate on curiosity and improvisation. Related to this, they realized that language shapes our reality and that one’s language and thought arises in the contexts of the stories that we carry about how to see the world. The therapeutic work is then to forge a shared

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story about the problem using a shared language. After 5 years (1992–1997) of Open Dialogue treatment in Lapland, 81% of participants had no remaining psychotic symptoms, and 81% had returned to full employment. Only 35% had used antipsychotic drugs (Seikkula et al. 2011). In the United States less than 20% of people diagnosed with schizophrenia would be symptom-free after 5 years, with almost all of them on antipsychotics. In their view, psychotic symptoms were seen as the result of a strategy to survive trauma and other difficult experiences, a sane response to insane situations. They are trying to communicate experiences for which they have no language. Open Dialogue involved all stakeholders, professional, and nonprofessional in a collaborative process to resolve distress in a rural and remote environment. They put in place Bakhtin’s view that healing occurs through genuine dialogue among people in which all voices are heard and given equal weight. In such a process, new solution can be created. In Open Dialogue, decisions about the person in distress are made only within these group meetings network meetings in which everyone participates equally. The emphasis is on generating dialogue in which the members of the dialogue generate their own solutions in this iterative process. The clinicians do not control the dialogue or push their own agendas, but enter into a spontaneous conversation to see where it will go, beginning with the story told by family members and close friends about what has happened In Open Dialogue, understanding is a gradually developing process. It may be that no important decisions are taken for first two or three meetings, even when the distress is severe. In Open Dialogue, healing occurs when the speaker is moved. If the clinician remains in the moment, open to authentic human warmth, present in Bakhtin’s “once occurring participation in being,” he or she will be sensitive to the “moments of aliveness” in which a participant is touched by something new and potentially transformative.

Our Psychosis Project We work in a rural setting in which we see people intensively for several days in a row and then take a break and then repeat. This is due to problems of transportation and our belief that intensive interaction with a break to practice new patterns of social interaction and life skills is more valuable than weekly appointments. We base our approach on narrative, indigenous, dialogical ideas. We recently (at the European Psychiatric Association annual meeting in Warsaw, Poland) reported qualitative and quantitative data on a group of 69 motivated adult patients with psychosis who worked with us and were able to manage with minimal or no medication. Patients engaged in dialogical psychotherapy, medication management, and integrative medicine practices for at least 6 months. An additional 209 patients presented for treatment but did not continue for 6 months. An anonymous, matched comparison group of 69 patients was generated from electronic health records. We measured symptoms serially with the MYMOP-2, the Positive and Negative Syndrome Scale, the MADRS, the Clinical Global Inventory, and the BASIS. Narrative interviews generated qualitative data.

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Of our 69 patients, 39 managed psychosis without the use of medication. Another 25 managed well on low-dose antipsychotic medications. Four individuals required progressively higher levels of medication, and one decompensated. Our patients functioned at significantly higher levels than the comparison populations and at significantly lower levels of medication. The overall cost-benefit was favorable in creating fewer hospitalization, crises, and diminished suicidal. The results support the idea that motivated patients can engage in an approach that combines integrative medicine, psychotherapy, and conventional medication management in association with involvement of family and friends in a community effort and can recover without or with low doses of conventional medications. Not all patients can participate in such a program.

Northern Saskatchewan Reserves LMM worked for some years as a psychiatrist in rural and remote reserves in Northern Saskatchewan. These were fly-in reserves. In the winter, one could drive across frozen lakes and rivers, though at increasing peril related to global warming. In the summer transportation was impossible. LMM flew into these communities monthly. He experienced flying in all manner of conditions. He visited these communities monthly and was available by telemedicine at other times. This blended approach worked better than just telemedicine. LMM made a point of meeting with local spiritual leaders (who often did not have conventional titles of seeming importance) and asking their advice for how to work collaboratively and be most helpful to the people in their community. The communities were complicated blends of Roman Catholicism and traditional Deneh spirituality. This blend made it hard to intuitively grasp how to proceed and required local consultation. LMM and the community residents worked together to determine how best to care for people who were emotionally suffering. LMM’s usefulness lay in the areas of diagnosing and managing dementia, considering the psychiatric effects of medical illnesses and medications, and evaluating the mental effects of substance abuse and negotiating withdrawal and/or reduction from addicting substances. Another role LMM played was signing short-term disability forms for people who were overly stressed. Their solution to stress was to leave “civilization” for 3 months and disappear into the bush. They would return refreshed, renewed, and ready to return to work, which in that area was mostly mining. During his tenure, he observed nine patients become acutely psychotic. He was present to offer medications, which all nine refused. Their families explained that the caribou which they ate had altered their blood and they could not take medications from “down south,” that being Saskatoon. For all the patients that he observed, the family surrounded them and protected them, preventing them from wondering outside in the winter, which could have been dangerous. This was possible because the only exit from these communities was an expensive flight. All patients reconstituted over a period of 6 to 12 months and were back to their usual selves. These observations challenged his understanding of psychosis, since conventional

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biomedicine would not predict these results. The differences consisted of a radical acceptance of family members about their disturbed relative and a complete faith that things would turn around Family had a complete acceptance of their affected member and believed that the symptoms would resolve, since the symptoms were spiritual. Their faith was born out and symptoms did completely resolve. I realized that this would not have happened if the patient had lived further south, for the patient could have left the community and come to the attention of the police and then be taken to hospital. LMM had fascinating conversations with community members. One woman told him that she had planned to kill herself. She had driven her skidoo as far as she could go into the bush until it ran out of gas. She planned to freeze to death. However, she related that a wolf appeared and tugged on her sleeve to follow it. (She was a member of the Wolf Clan, so she found this meaningful.) The wolf walked her back to her home. When she saw the lights of her house, the wolf departed. The key here was the constant appearance of the same person each month for several days at a time and his availability at other times to speak by telephone or telemedicine. Community interventions and cultural enhancements were more important than medications. These community interventions included talking circles and encouragement of traditional cultural activities.

Phenomenology of Rural and Remote Psychiatric Practice – Getting to Experience Living on Navajo or Dine’ Nation in the Chuska Mountains or what that Dine’ calls NíłtsąDził, or Rainy Mountain, taught PM about the different climates and microclimates in the high desert plateau and mountains, but also the microclimates of the people and communities of the Nation, which is the largest indigenous reserve in the United States. The school where he worked, a vestige of the historic and notorious Bureau of Indian Affairs boarding schools, had both dormitory and day students. The dorm students were most often children from families with less resources than the day students whose parents could afford to travel to and from school, often hours from their homes. The dorms were difficult places, as was the school, one of the oldest on the reservation heralding back some 100 years to the start of public education in the United States, where it held purchase on the side of a mountain in Tohaali, a historic place with a famous trading post for fine weavers and rugs and where the great Chief Narbona was shot in August of 1849 when, in the view of US troops, some negotiation had failed. PM met Micah for the first time when he was referred for an evaluation by his teachers for special education eligibility, but also to determine what services might help this behaviorally challenged boy. Being a “bilagaana,” or white man from away, PM had already experienced a challenge to most of his beliefs about what it was that he was doing employing the standardized instruments of psychology and psychiatry in this ancient culture of “the people,” with their language, dialects, beliefs, and

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culture and microcultures. Nothing in his career thus far had made so plain to him that the constructs of professions that are imposed on vulnerable people have not been standardized on those people, including giving Micah a standardized intelligence scale. And Micah was having none of it. He wouldn’t sit down at all, and he kept telling PM in not so subtle ways that PM had no idea what he was doing. So PM and Micah made paper airplanes. They made a lot of paper airplanes and even got a book from the library which taught us both how to complicate our designs and improve them. It was while making paper airplanes that PM first noticed that when Micah did sit down for a minute or two, he left a slight stain on the chair that turned out to be blood. It took a week’s worth of paper airplane meetings for Micah to tell PM that he didn’t sleep and that his Uncle’s house (Hogan) wasn’t a safe place for him and that PM was the dumbest person on campus because everyone else knew already that his Uncle was “gay,” as he put it, so his Uncle would come home drunk and have sex with him and that was why he was so angry, and didn’t want to sit down. He had come to live with his Uncle because his mother was an alcoholic, who lived now in Gallup and Albuquerque. The school officials knew that something was happening with Micah, but they hadn’t known the specific details of what was occurring. Within a day of this new information being revealed, Micah’s matrilineal side of his family became involved, and they moved him into the dorms, with his Auntie’s taking him for the weekends. He settled down in school until PM learned years later that he stabbed another student who had threatened him in the area high school. What does one do with this information in rural or remote other cultural areas? Most psychiatrists train in academic centres, and without the infrastructure and rules, all one has is the clinical relationship and social networks, which can be powerful and problematic. It was PM’s experience on the Navajo Nation that there was a months- and years-long process of assessing the intention of the “bilagaana” and then a careful and considered approach to the available though often invisible family and social networks that he needed to know and leverage for the vulnerable people with whom he worked. It was frustrating for him at first because he couldn’t “see” that anything was happening, but were certainly events and occurrences transpiring that needed to be addressed. In Northern Michigan, in 1999, PM wrote an office of rural health grant to integrate primary care practices in Northwest Michigan with behavioral health providers. It took 3–4 years to convince physicians that the intention of putting a provider (psychologist, social worker, psychiatrist) in their offices wasn’t to take over, or “run them out of business,” but in fact to enhance their practice, and they could indeed be revenue neutral or positive by having this person in their office. At that same time, many private practice clinicians could no longer make a living with reimbursement rules of insurance companies and the government’s additional reporting requirements and regulations for health maintenance. When this was combined with preferred contracted provider type organizations, the capacity of private practice physicians to work with the mentally ill in rural areas became impaired.

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The outcome for patients, however, was that they could receive “specialty care,” at their primary care provider’s offices, and the stigma of going to the “shrink” was eliminated because they didn’t have to go anywhere for counseling and psychiatric services; it was part and parcel of showing up at their doctors office for an annual check-up and antibiotics for an infection, or to have their blood pressure checked. And as people began to trust this service at their general practitioner’s office, the networks and natural helpers of the community began to refer people in need. PM will never forget being approached by a family at the supermarket, who wanted to tell him that they knew of a child who identified as gay to his family and they put him out of their home because of their Christian beliefs and he was staying in a stall at the local fairgrounds, and they wanted to get this kid some “professional” help, and they would help him coordinate an appointment when they dropped off a food package to him at the fairgrounds. Affiliating and understanding the natural helpers and social networks in any location is a key aspect to being in rural and remote psychiatry. We teach our family medicine residents that coming to learn these systems is important both to tap into helpful networks and also to protect our patients from unhelpful networks. As an example, there was a professional counselor in one rural isolated Michigan town who was notorious for evaluating children and families and seeing “ritual and satanic abuse,” in many of her cases. This isn’t to say this kind of abuse doesn’t exist, but this particular clinician framed her clinical cases religiously, and, after having nearly 50 cases of child abuse reported by her to be satanic, ritualized abuse, it became clear that her network was more damaging than helpful to children and families, though it took years for the licensing board to react to this provider. While religious-based counseling in and of itself can be protective and very helpful, the helpfulness and wisdom of social networks must be assessed by those who are being helped or harmed by them, and this is critical data for psychiatrists’ and providers’ awareness.

References Aaltonen J, Seikkula J, Lehtinen K. The comprehensive open-dialogue approach in western Lapland: I. the incidence of non-affective psychosis and prodromal states. Psychosis. 2011; 3(3):179–91. Ae-Ngibise KA, Doku VCK, Asante KP, Owusu-Agyei S. The experience of caregivers of people living with serious mental disorders: a study from rural Ghana. Glob Health Action. 2015; 8(1):26957. Alanen YO. Towards a more humanistic psychiatry: development of need-adapted treatment of schizophrenia group psychoses. Psychosis. 2009;1(2):156–66. Alanen YO, Lehtinen K, Räkköläinen V, Aaltonen J. Need-adapted treatment of new schizophrenic patients: experiences and results of the Turku project. Acta Psychiatr Scandinavica. 1991;83 (5):363–72. Alexopoulos GS, Katz IR, Bruce ML, Heo M, Ten Have T, Raue P, Bogner HR, Schulberg HC, Mulsant BH, Reynolds CF 3rd. PROSPECT group: remission in depressed geriatric primary care patients: a report from the PROSPECT study. Am J Psychiatry. 2005;162:718–24. American Medical Association. Icd-10-cm the complete official codebook. Chicago: AMA Press; 2017.

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American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: APA Press; 2013. Angst J, Hengartner MP, Rössler W, Ajdacic-Gross V, Leeners B. A Swiss longitudinal study of the prevalence of, and overlap between, sexual problems in men and women aged 20 to 50 years old. J Sex Res. 2015;52(8):949–59. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. (2012). Collaborative care for people with depression and anxiety. Cochrane Reviews. https://www. cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety. Last accessed 19 Feb 2019. Arora S, Kalishman S, Dion D, Som D, Thornton K, Bankhurst A, . . . Yutzy S. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health affairs (Project Hope). 2011;30(6):1176–1184. https://doi.org/10.1377/ hlthaff.2011.0278. Benjet C, Borges G, Méndez E, Albor Y, Casanova L, Orozco R, Curiel T, Fleiz C, Medina-Mora ME. Eight-year incidence of psychiatric disorders and service use from adolescence to early adulthood: longitudinal follow-up of the Mexican Adolescent Mental Health Survey. European child & adolescent psychiatry. 2016;25(2):163–73. Bergstrom T, Seikkula J, Alakare B, Maki P, Kongas-Saviaro P, Taskila JJ, Tolvanen A, Aaltonen J. The family-oriented open dialogue approach in the treatment of first-episode psychosis: nineteen-year outcomes. Psychiatry Res. 2018;270:168–75. Berntson A, Goldner E, Leverette J, Moss P, Tapper M, Hodges B. Canadian Psychiatric Association Standing Committee on, E. Psychiatric training in rural and remote areas: increasing skills and building partnerships. Canadian Journal of Psychiatry, 2005;50(9). Blanchet MW. The curve of time. Vancouver: Whitecap Books; 2011. Böbel TS, Hackl SB, Langgartner D, Jarczok MN, Rohleder N, Rook GA, Lowry CA, Gündel H, Waller C, Reber SO. Less immune activation following social stress in rural vs. urban participants raised with regular or no animal contact, respectively. PNAS. 2018;115(20):5259–64. https://doi.org/10.1073/pnas.1719866115. Bouchard S, Paquin B, Payeur R, Allard M, Rivard V, Fournier T, Renaud P, Lapierre J. Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemed J E Health. 2004;10:13–25. Breslau J, Marshall GN, Pincus HA, Brown RA. Are mental disorders more common in urban than rural areas of the United States? J Psychiatr Res. 2014;56:50–5. https://doi.org/10.1016/j. jpsychires.2014.05.004. Epub 2014 May 14 Bronson, B. Indicators of mental health problems by prisoners and inmates. Bureau of Justice Statistics. 2017. http://www.bjs.gov/index.cfm?ty¼pbdetail&iid¼5946. Last accessed 19 Feb 2019. Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz II, Schulberg HC, Mulsant BH, Brown GK, McAvay GJ, Pearson JL, Alexopoulos GS. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291:1081–91. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemed J. 1998;4:363–9. Dham P, Gupta N, Alexander J, Black W, Rajji T, Skinner E. Community based telepsychiatry service for older adults residing in a rural and remote region- utilization pattern and satisfaction among stakeholders. BMC psychiatry, 2018;18(December). Donkin A, Goldblatt P, Allen J, Nathanson V, Marmot M. Global action on the social determinants of health. BMJ Glob Health. 2018;3(Suppl 1):e000603. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry. 2016;3(9):871–81. Fortney JCP, Edlund JM, Williams MJ, Robinson DK, Mittal DE, Henderson D, K. L. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med. 2007;22 (8):1086–93. https://doi.org/10.1007/s11606-007-0201-9. Fortney JC, Pyne JM, Mouden SB, Mittal D, Hudson TJ, Schroeder GW, et al. Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health

348

L. Mehl-Madrona and P. McFarlane

centers: a pragmatic randomized comparative effectiveness trial. Am J Psychiatr. 2013;170 (4):414–25. https://doi.org/10.1176/appi.ajp.2012.12050696. Foucault M. History of madness. New York City: Routledge; 2006. Frueh BC, Monnier J, Yim E, Grubaugh AL, Hamner MB, Knapp RG. A randomized trial of telepsychiatry for post-traumatic stress disorder. J Telemed Telecare. 2007;13:142–7. Gensichen J, von Korff M, Peitz M, Muth C, Beyer M, Güthlin C, Torge M, Petersen JJ, Rosemann T, König J. Gerlach FMPRoMPT (primary care monitoring for depressive patients trial): case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Ann Intern Med. 2009;151:369–78. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. CognBehavTher. 2009;38:42–53. Germain V, Marchand A, Bouchard S, Guay S, Drouin MS. Assessment of therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder. CyberpsycholBehav Soc Netw. 2010;13:29–35. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA. 2003;289:3145–51. Gone JP, Alcantara C. Identifying effective mental health interventions for American Indians and Alaska natives: a review of the literature. Cult Divers Ethn Minor Psychol. 2007;13(4):356–63. https://doi.org/10.1037/1099-9809.13.4.356. Guerrero APS, Balon R, Beresin EV, Louie AK, Coverdale JH, Brenner A, Roberts LW. Rural mental health training: an emerging imperative to address health disparities. Acad Psychiatry. 2018;41:1–5. https://doi.org/10.1007/s40596-018-1012-5. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatr. 2008;53:769–78. Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health. 2004;94(10):1675–8. Hedrick SC, Chaney EF, Felker B, Liu C-F, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon W. Effectiveness of collaborative care depression treatment in veterans’ affairs primary care. J Gen Intern Med. 2003;18:9–16. Hofferth SL, Iceland J. Social capital in rural and urban communities. Rural Sociol. 1998 Dec;63 (4):574–98. Hunt JB, Curran G, Kramer T, Mouden S, Ward-Jones S, Owen R, Fortney J. Partnership for implementation of evidence-based mental health practices in rural federally qualified health centers: theory and methods. Prog Community Health Partnersh. 2012;6(3):389–98. https://doi. org/10.1353/cpr.2012.0039. Institute for Integrative Science and Health. Cape Breton University (2018). Two-eyed seeing. http://www.integrativescience.ca/Principles/TwoEyedSeeing/. Last accessed 18 Feb 2019. Katon W, Robinson P, Von Korff M, Lin E, Bush T, Ludman E, Simon G, Walker E. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32. Katon W, Von Korff M, Lin E, Simon G, Walker E, Unützer J, Bush T, Russo J, Ludman E. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109–15. Labys CA, Sussen E, Burns JK. Psychosis and help-seeking behavior in rural KwaZulu Natal: unearthing local insights. Int J Ment Heal Syst. 2016;10(1):57–63. Lehtinen V, Aaltonen J, Koffert T, Räkköläinen V, Syvälahti E. Two-year outcome in first-episode psychosis treated according to an integrated model. Eur Psychiatry. 2000;15(5):312–20. Levine, D. How much of a struggle is it to get mental health Care in Rural Areas? U.S. News and World Report. 2018. In https://health.usnews.com/health-care/patient-advice/articles/2018-0420/how-much-of-a-struggle-is-it-to-get-mental-health-care-in-rural-areas. Last accessed 19 Feb2019.

15

Rural and Remote Psychiatry

349

McCall-Hosenfeld JS, Mukherjee S, Lehman EB. The prevalence and correlates of lifetime psychiatric disorders and trauma exposures in urban and rural settings: results from the National Comorbidity Survey Replication (NCS-R). PLoS One. 2014;11:e112416. https://doi.org/ 10.1371/journal.pone.0112416. Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P, Shore J, He Q, Frueh BC. Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial. J Clin Psychiatry. 2010;71:855–63. Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E Health. 2003;9:49–55. Ng B, Camacho A, Dimsdale J. Rural psychiatrists creating value for academic institutions. Psychiatr Serv. 2013;64(11):1177–8.23. O’Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58:836–43. Pateman T. Rural and urban areas: comparing lives using rural/urban classifications. Reg Trends. 2011;43:11. https://doi.org/10.1057/rt.2011.2. Peen J, Schoevers RA, Beekman AT, Dekker J. The current status of urban-rural differences in psychiatric disorders. Acta Psychiatr Scand. 2010;121(2):84–93. Pickersgill MD. Debating DSM-5: diagnosis and the sociology of critique. J Med Ethics. 2014;40:521–5. https://doi.org/10.1136/medethics-2013-10176. Pyne JM, Fortney JC, Tripathi SP, Maciejewski ML, Edlund MJ, Williams DK. Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression. Arch Gen Psychiatry. 2010;67:812–21. Rohland BM, Saleh SS, Rohrer JE, Romitti PA. Acceptability of telepsychiatry to a rural population. Psychiatr Serv. 2000;51:672–4. Rojas G, Guajardo V, Martínez P, Castro A, Fritsch R, Moessner M, Bauer S. A remote collaborative care program for patients with depression living in rural areas: open-label trial. J Med Internet Res. 2018;20(4):e158. https://doi.org/10.2196/jmir.8803. Ross CA. The trauma model: a solution to the problem of comorbidity in psychiatry. New York: Greenleaf Book Group; 2000. Rost K, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. J Gen Intern Med. 2001;16:143–9. Ruskin PE, Reed S, Kumar R, Kling MA, Siegel E, Rosen M, Hauser P. Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatr Serv. 1998;49:1086–8. Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Bradham DD, Hebel JR, Barrett D, Knowles F, Hauser P. Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. Am J Psychiatry. 2004;161:1471–6. Salamonsen A, Ahlzén R. Epistemological challenges in contemporary western healthcare systems exemplified by people’s widespread use of complementary and alternative medicine. Health. 2018;22(4):356–71. https://doi.org/10.1177/1363459317693408. Scheider, Frédéric. Voyage au cœur de la psychiatrie sénégalaise. 2010. https://www.nouvelobs. com/rue89/rue89-monde/20100916.RUE8515/voyage-au-c-ur-de-la-psychiatrie-senegalaise. html. Last accessed 18 Feb 2019. Scott A, Gilbert A, Gelan A. The urban-rural divide: myth or reality? Macaulay Institute: Aberdeen; 2007. Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, et al. Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA psychiatry. 2016;73(2):150–8. Seikkula J, Alakare B, Aaltonen J. The comprehensive open-dialogue approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis. 2011;3(3):192–204.

350

L. Mehl-Madrona and P. McFarlane

Simpson S. The provision of a telepsychology service to Shetland: client and therapist satisfaction and the ability to develop a therapeutic alliance. J Telemed Telecare. 2001;7(suppl 1):34–6. Singh NK, Ram D, Goyal N. Role of Spirituality in Mental Health Practice. Indian Journal of Psychiatric Social Work, 2017;8(1):44–49. Sockalingam S, Arena A, Serhal E, Mohri L, Alloo J, Crawford A. Building Provincial Mental Health Capacity in Primary Care: An Evaluation of a Project ECHO Mental Health Program. Academic psychiatry, 2017;42(4):451–457. https://doi.org/10.1007/s40596-017-0735-z. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323–8. Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. IMPACT Investigators (Improving Mood-Promoting Access to Collaborative Treatment): Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836–45. Vassos E, Agerbo E, Mors O, Pedersen CB. Urban–rural differences in incidence rates of psychiatric disorders in Denmark. Br J Psychiatry. 2016;208(5):435–40. Veltman A, La Rose T. Anti-oppressive approach to assessment. In: Hategan A, Bourgeois J, Hirsch C, editors. On-Call geriatric psychiatry. Cham: Springer; 2016. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016;3(2):171–8. Virginia Department of Health. Community-based participatory approaches. 2019. http://www.vdh. virginia.gov/health-equity/community-based-participatory-approaches/. Last accessed 18 Feb 2019. Watters E. Crazy like us: the globalization of the American psyche. San Francisco: Free Press; 2010. Weigel PAM, Ullrich F, Ward MM. Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference? The Journal of rural health, 2018;34(S1):s21–s29. https://doi.org/10.1111/jrh.12220. Weiner, S. Addressing the escalating psychiatrist shortage. AAMC News. 2018. https://news.aamc. org/patient-care/article/addressing-escalating-psychiatrist-shortage/. Last accessed 19 Feb 2019. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unützer J, Miranda J, Carney MF, Rubenstein LV. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20. WHO_World_Mental_Health_Survey_Consortium. Prevalence, severity and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. 2004;291(291):2581–2590. Willging CE, Salvador M, Kano M. Unequal treatment: mental health care for sexual and gender minority groups in a rural state. Psychiatr Serv. 2006;57(6):867–70. Williams JW, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders: effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58–67. Zempleni, A. L’interpretation et la therapie du desordre mental chez les Wolof et Lebou (Senegal). Ph.D. Thesis. Anthropology. Universite de Paris; 1968. Zhang N. Trends in urban/rural inequalities in cardiovascular risk bio-markers among Chinese adolescents in two decades of urbanisation: 1991–2011. Int J Equity Health. 2018;17(1):101. https://doi.org/10.1186/s12939-018-0813-1.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Where, Who, and Why? Distinctive Features of Mental Health Care in Rural and Remote General Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Where? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Who? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recovery-Oriented Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Central Role in Primary Health-Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Whole Person Generalist Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improved Physical Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Doctor as Healer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What and How? Practice Implications for Rural and Remote General Practitioners . . . . . . . . . . Health Promotion and Illness Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identification and Early Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment, Diagnosis, and Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment Planning and Shared Decision-Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Where to Begin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-Care, Supervision, and Sustainable Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

Abstract

This chapter addresses mental health-care provision by general practitioners (GPs) in rural and remote practice. It first considers the contexts in which rural GPs and their patients are located (“where, who, and why?”). This is followed by a consideration of the spectrum of care that is offered in general practice (“what and how?”), including health promotion and illness prevention; identification and early intervention; assessment, diagnosis, and formulation; treatment planning and shared decision-making; prescribing; referral; and collaborative practice. The chapter concludes with a discussion of the necessity and challenges of self-care and supervision/case consultation in rural GP mental health practice. The emphasis is on the pragmatic: where theoretical concepts are introduced, it is because they are relevant to the daily work of GP mental health care. Reference is made to several other chapters where relevant topics are covered in greater depth, and readers are encouraged to follow those links to gain a deeper understanding of complex topics which by necessity are only briefly acknowledged in this chapter.

Introduction GPs are central to the provision of mental health care in the Australian health system and most clearly so in rural and remote areas (in some locations, GPs may be the only providers of mental health care). Furthermore, GPs are not only concerned with the prevention, detection, and treatment of mental illness; they are also concerned with the promotion of social and emotional well-being (“SEWB”) in the communities in which they live and work (Gee et al. 2014). Not all GPs, however, consider themselves to be “mental health professionals,” and mental health teaching and practice experience offered during undergraduate training years have often been undertaken in tertiary facilities under the supervision of specialist psychiatrists and inpatient teams. Postgraduate GP training includes some primary care mental health curriculum yet rural GPs report feeling underequipped for the task which is often much greater and more complex than they had anticipated, particularly in relation to the “high-prevalence disorders” such as depression and anxiety (RACGP 2014). It is, therefore, appropriate to attempt to define what it is that rural GPs are required to do in their mental health practice, including what is unique, and to provide resources and information to help them practice more effectively.

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Where, Who, and Why? Distinctive Features of Mental Health Care in Rural and Remote General Practice Where? Most Australians live in larger centres (71%) apart from Aboriginal and Torres Strait Islander Australians, 65% of whom live in regional, rural, or remote areas. There are significantly fewer GPs per head of population in outer regional, remote, and very remote areas in Australia than in cities (Australian Government Department of Health 2017a). Populations in remote and very remote areas have a higher burden of disease and require more health-care resources. GPs in these areas work longer hours and frequently have a broader scope of practice than GPs in urban centres (National Rural Health Alliance 2015). Many remote and very remote communities have small populations (getmedia>ctg-rs21pdf.aspx. Accessed 5 Sept 2019. Australian Bureau of Statistics. Mortality of people using mental health services and prescription medications. Analysis of data Canberra, ACT; ABS 2017. 2011–2017. https://wwwabsgovau > AUSSTATS > abs@nsf > DetailsPage > OpenDo. Accessed 10 Sept 2019. Australian Institute of Health and Welfare. Rural, Regional and Remote Health: a Study on Mortality. 2nd ed. Canberra: Australian Institute of Health and Welfare 2007; 2007. Report No.: Cat. No. PHE 95 Barraclough F, Longman J, Barclay L. Integration in a nurse practitioner-led mental health services in rural Australia. Aust J Rural Health. 2016;24:144–50. Beks H, Healey C, Schlicht K. ‘When you’re it’: a qualitative study exploring the rural nurse experience of managing acute health presentations. Rural Remote Health. 2018;18(3):4616. Beyenne L, Severinsson E, Hansen B, Rortveit K. Shared decision-making – balancing between power and responsibility as mental health care professionals in a therapeutic milieu. Sage Open Nursing. 2018;4:1–10. Bulbrook K, Carey T, Lenthall S, Byers L, Behan K. Treating mental health in remote communities: what do remote health practitioners need? Rural Remote Health. 2012;12(4):2346. Cosgrave C, Malatzky C, Gillespie J. Social determinants of rural health workforce retention: A scoping review. Int J Environ Res Public Health. 2019;16(3):314. Crane P, Ward S. Self-healing and self-care for nurses. AORN Journal. 2016;104(5):386–400. Crowther A, Ragusa A. Realities of mental health nursing practice in rural Australia. Issues Ment Health Nurs. 2011;32:512–8. Drury V, Francis K, Dulhunty G. The lived experience of rural mental health for rural and remote consumers in South Australia. Health Soc Care Community. 2005;17(2):216–24. Dudgeon P, Wright M, Paradies Y, Garvey D, Walker I. Chapter 3: Aboriginal social, cultural and historical contexts. In: Dudgeon P, Milroy H, Walker R, editors. Working together: aboriginal

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and Torres Strait islander mental health and wellbeing principles and practice. Canberra: Office of Aboriginal and Torres Strait Islander Health, Department of Ageing; 2014. Edwards D, Burnard P, Coyle D, Fothergill A, Hannigan B. Stress and burnout in community mental health nursing: a review of the literature. J Psychiatr Ment Health Nurs. 2000;7(1):7–14. Ellis I, Philip T. Improving the skills of rural and remote generalists to manage mental health emergencies. Rural Remote Health. 2010;10:1503. Gibb H. Rural community mental health nursing: a grounded theory account of sole practice. Int J Ment Health Nurs. 2003;12:243–50. Harris M, Barnett T, Bridgman H. Rural Art Roadshow: a travelling art exhibition to promote mental health in rural and remote communities. Arts and Health. 2016;10(1):57–64. Holland C, Dudgeon P, Milroy H. The mental health and social and Emotional Wellbeing of Aboriginal and Torres Strait Islander Peoples, Families and Communities. Supplementary paper to ‘A Contributing Life: the 2012 National Report Card on Mental Health and Suicide Prevention’ for the National Mental Health Commission. 2013. https://healthinfonet.ecu.edu.au > key-resources > publications. Accessed 5 Sept 2019. Janca A, Bullen C. The Aboriginal concept of time and its mental health implications. Australas Psychiatry. 2003;11:S40–4. Jelinek G, Weiland T, Mackinlay C, Hill N, Gerdtz M. Perceived differences in the management of mental health patients in remote and rural Australia and strategies for improvement: findings from a National Qualitative Study of emergency clinicians. Emerg Med Int. 2011;2011:965027. Kalbfleisch P. Effective health communication in native populations in North America. J Lang Soc Psychol. 2009;28(2):158–73. Kogstad R, Hummelvoll J, Ekeland T. In defence of a humanistic approach to mental health care: recovery processes investigated with the help of clients’ narratives on turning points and processes of gradual change. J Psychiatr Ment Health Nurs. 2016;18(6):479–86. Letvak S. Overview and summary: healthy nurses: perspectives on caring for ourselves. Online J Issues Nurs. 2014;19(3). Linehan M. DBT skills training manual. New York: The Guilford Press; 2014. MacLeod M, Stewart N, Kulig J, Anguish P, et al. Nurses who work in rural and remote communities in Canada: a national survey. Hum Resour Health. 2017;15(34) McIntyre C, Harris M, Baxter A, et al. Assessing service use for mental health by Indigenous populations in Australia, New Zealand and the United States of America: a rapid review of population surveys. Health Res Policy Syst. 2017;15(67) Merrick J, Merrick E. Equal treatment: closing the gap. A formal investigation into physical health inequalities experienced by people with learning disabilities and/or, mental health problems. J Policy Pract Intellect Disabil. 2007;4(73) Mils A, Millsteed J. Retention: an unresolved workforce issues affecting rural occupational therapy services. Aust Occup Ther J. 2002;49:170–81. Morell A, Kiem S, Millsteed M, Pollice A. Attraction, recruitment and distribution of health professionals in rural and remote Australia: early results of the rural health professionals program. Hum Resour Health. 2014;12:15. Nagel T, Thompson C. Aboriginal mental health workers and the improving indigenous health service delivery model in the ‘top end’. Australas Psychiatry. 2006;14(3):291–4. Northern Territory Government, Department of health. Remote area nurse Safety, On-call after hours security. 2016. https://digitallibrary.health.nt.gov.au > prodjspui > handle. Accessed 10 Sept 2019. Nursing and Midwifery Board of Australia. Public consultation paper. Endorsement as a nurse practitioner registration standards and supporting documentation. 2014. www.nursingmidwi feryboard.gov.au > documents. Accessed 10 Sept 2019. O’Brien L, Jackson D. It’s a long way from the office to the creek bed: remote area mental health nursing in Australia. J Transcult Nurs. 2007;18(2):135–41. O’Sullivan J, Ward GJ. Addressing the health and lifestyle issues of people with mental illness: the healthy living programme. Aust Psychiatry. 2006;14:150–5.

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Panazzola P, Leipert B. Exploring mental health issues of rural senior women in southwestern Ontario, Canada: A secondary analysis photovoice study. Rural Remote Health. 2013;13(2): 2320. Procter N, Ferguson M, Backhouse J, Cother I, Jackson A, Murison J, Reilly J. Face to face, person to person: skills and attributes deployed by rural mental health clinicians when engaging with consumers. Aust J Rural Health. 2015;23:352–8. Puckett A. Community mental health. Sydney: W.B. Saunders; 1993. Redvers N, Marianayagam J, Blondin B. Improving access to indigenous medicine for patients in hospital-based settings: a challenge for health systems in northern Canada. Int J Circumpolar Health. 2019;78(2):1589208. Roberts R, Lockett H, Bagnall C, Maylea C, Hopwood M. Improving the physical health of people living with mental illness in Australia and New Zealand. Aust J Rural Health. 2018;26:354–62. Saurman E, Lyle D, Perkins D, Roberts R. Successful provision of emergency mental health care to rural and remote new south wales: an evaluation of the mental health emergency care-rural access program. Aust Health Rev. 2014;38:58–64. Saurman E, Kirby S, Lyle S. No longer ‘flying blind’: how access has changed emergency mental health are in rural and remote emergency departments, a qualitative study. BMC Health Serv Res. 2015;15(156) Serhal E, Crawford A, Cheng J, Kudyak P. Implementation and utilisation of tele psychiatry in Ontario: a population-based study. Can J Psychiatr. 2017;62(10):716–25. Taylor J, Edwards J, Kelly F, Fielke K. Improving transfer of mental health care for rural and remote consumers in South Australia. Health Soc Care Community. 2009;17(2):216–24. Terry D, Le Q, Nguyen U, Hoang H. Workplace health and safety issues among community nurses: a study regarding the impact on providing care to rural consumers. Br Med J. 2015:5e008306. Trueman S. Contextualising mental health nursing encounters in Australian remote aboriginal communities: part I, history and customs. Issues Ment Health Nurs. 2013a;34:715–8. Trueman S. Contextualising mental health nursing encounters in Australian remote aboriginal communities: part II, client encounters and interviews. Issues Ment Health Nurs. 2013b;34:772–5. Vicary D, Andrews H. A model of therapeutic intervention with Indigenous Australians. Aust N Z J Public Health. 2001;25(4):349–51. Ward M. The consequences of service planning in mental health nursing. In: Barker P, Baldwin S, editors. Ethical issues in mental health, vol. 1991. London: Chapman & Hall; 1991. p. 127–47. Westerman T. Engagement of indigenous clients in mental health services: what role do cultural differences play? AeJAMH. 2004;3 Wilson R, Usher K. Rural nurses: a convenient co-location strategy for the rural mental health care of young people. J Clin Nurs. 2015;24:2638–48.

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Contents Optimal Care with Suboptimal Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adapting to Personal Challenges and Professional Struggles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relevant Professional Struggles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Prescriptive Authority Debate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Registration and Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Sociohistorical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Responding to the Rural Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adaptations to Professional Practice Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reaping the Intrinsic Rewards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

A review of the role of the psychologist in rural and remote practice highlights practical considerations and illuminates the varied, rich, challenging, and rewarding aspects of this practice setting. This chapter underscores the need to understand the immediacy and complexity of rural professional practice; these contexts may foster practice conditions that may be more prevalent, complicated, or even less easily resolved than in urban professional practice. The psychologist’s role in this context is one of providing optimal care with suboptimal resources, adapting to personal challenges and professional struggles, and responding to the rural context by adapting professional practice

J. L. Malone (*) PAA Psychologists’ Association of Alberta, Edmonton, AB, Canada e-mail: [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_18

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norms, adopting rural-specific practice guidelines, and finally, reaping the intrinsic rewards of the rural lifestyle.

Optimal Care with Suboptimal Resources As a practicing rural psychologist, and lifelong rural community member, I have often reflected on the needs and characteristics of rural and remote communities. I dedicated much of my academic career to studying the role of psychologists in these settings and the related professional ethical implications for practice. The core to that was my own experience that psychologists succeeding in rural and remote practice are there by choice and share the value of providing optimal psychological health services in settings that differ greatly from those inherent in our often urban-centric training. The available literature on rural mental health paints a bleak picture indicating that rural people are more likely to suffer from stress and mental health concerns like depression, suicide, and substance abuse (Bray et al. 2004; DeLeon et al. 2003; Hoolahan et al. 2006; Thorngren 2003; Harowski et al. 2006; Stamm et al. 2007) and suggests that up to a third of the rural population has moderate to high levels of psychological distress (Campbell et al. 2006a; Gale and Deprez 2003; Kilkkinen et al. 2007). There are some difficulties in taking this at face value. Many such studies do not use consistent definitions of rurality, making it difficult to compare groups in making such statements. Also, researchers have questioned whether some of these results tease out differences between culture and rurality (Judd et al. 2006b). The existence of supportive community factors should also be taken into consideration which impacts perceptions of stress and distress (VellaBrodrick et al. 2006). Research does indicate that rural mental health concerns are more likely to be undetected and untreated (Barbopoulos and Clark 2003; Findlay and Sheehan 2004). It is proposed that rural people tend to underestimate the prevalence of mental health problems and, when they do have concerns, tend to seek assistance from their general medical physician (Bartlett et al. 2006; Gale and Deprez 2003). Rural physicians do not detect mental health concerns as often nor do they provide as much psychotropic treatment or referral to professional mental health services as their urban counterparts (Harowski et al. 2006; Jameson and Blank 2007). If this is the case, it must be difficult to empirically validate mental health needs. There are distinct rural considerations that impact access to health care. Rural people tend to be widely geographically dispersed and culturally diverse (Gale and Deprez 2003; Roufeil and Lipzker 2007). Proposed barriers to service access include the distance to services (DeLeon et al. 2003; Findlay and Sheehan 2004; Gale and Deprez 2003; Perkins et al. 2007) which may be further hampered by lack of supportive services like public transportation (DeLeon et al. 2003; Gale and Deprez 2003; Harowski et al. 2006; Turpin et al. 2007). It has also been proposed that rural people are less likely to access available professional mental health services, and some of the literature has indicated that this may be due to concerns

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about anonymity and confidentiality (DeLeon et al. 2003; Harowski et al. 2006; Jameson and Blank 2007; Schank and Skovholt 2006). This concern, however, does not appear to be empirically supported and is likely conjecture based on what is known about mental health stigma. Other research has demonstrated that rural people are less likely to access available professional mental health services because of a general lack of awareness about mental health (Bartlett et al. 2006; Findlay and Sheehan 2004; Roufeil and Lipzker 2007; Thorngren 2003). I would suggest that inappropriate funding is more likely an issue at play than rural characteristics. Professional mental health services are less accessible in rural areas, particularly psychological services (Barbopoulos and Clark 2003; Bowman and Kulig 2008; Roufeil and Lipzker 2007; Findlay and Sheehan 2004), and are underfunded compared to other health services (Campbell et al. 2006b; Gale and Deprez 2003; O’Kane and Tsey 2004; Turpin et al. 2007). This likely reduces literacy about mental health issues and heightens difficulties in accessing services. Insufficient funding may reflect urban-centric policies which are not responsive to the rural context (Benson 2003; DeLeon et al. 2003; Harowski et al. 2006; Jameson and Blank 2007; Nelson and McPherson 2004). The health and mental health needs of rural and remote community members are most often coupled with less service availability. There are typical rural service issues such as lack of childcare and public transportation, but more significantly, health care tends to be less accessible (McIlwraith and Dyck 2002; Mitura and Bollman 2003; Pong 2007). The population dispersion makes it expensive and difficult to provide healthcare services, and there are also significant shortages of health and mental health providers (Brannen and Johnson-Emberly 2006; Romanow and Marchildon 2003). Many rural and remote community members cannot access psychological treatment. Alternatively, they access less appropriate, but more available, services through medical, legal, or other public services (McIlwraith and Dyck 2002). This is likely due to a combination of negative community attitudes toward mental health treatment combined with the marginalization of psychology within the healthcare systems (CPA 2007; Hunsley and Crabb 2004; McIlwraith and Dyck 2002; Romanow 2006). There is not enough rural mental health practice research to adequately assess these issues. This hampers the ability of psychologists in rural and remote practice to provide empirically validated services, equitable treatment and services, or solutions to complex rural issues (Barbopoulos and Clark 2003). Although mental disorders are more prevalent in rural and remote communities, there is a shortage of mental health professionals in these areas (Barbopoulos and Clark 2003; McIlwraith and Dyck 2002). There are often lower ratios of psychologists to population, and there tend to be significant issues with recruitment and retention in rural areas (Goodwin 2004; McIlwraith and Dyck 2002; McIlwraith et al. 2005). Rural psychologists tend to be less experienced than their urban counterparts (Barbopoulos and Clark 2003), possibly because psychology students receive no formal training or exposure to rural practice considerations (Barbopoulos and Clark 2003; Goodwin 2004; McIlwraith et al. 2005) despite market demands.

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However, barriers can also be opportunities. Acute needs and low provider numbers have fostered several creative programs and ideas for mental health service delivery and adaptation in rural areas (DeLeon et al. 2003; Gale and Deprez 2003; Roufeil and Lipzker 2007; Schopp et al. 2006). Recognizing the need to reduce mental health stigma, rural prevention programs have targeted stoicism and self-reliance to increase mental health literacy (Findlay and Sheehan 2004; Griffiths and Christensen 2007; Judd et al. 2006a; Letvak 2002; Wrigley et al. 2005). Telehealth and the Internet have also created unique opportunities. Using this technology, psychologists may be able to provide services at a distance, lessening some of the barriers of travel and visibility (DeLeon et al. 2003; Jameson and Blank 2007; Schopp et al. 2006; Stamm et al. 2007). An idea considered crucial in rural areas is developing interdisciplinary rural mental health teams to provide services more tailored to the rural area and to reflect the collective dimension of rural life (Boyd et al. 2008; Gale and Deprez 2003). It has been proposed that these teams consist of physicians and allied health professionals (DeLeon et al. 2003; Gale and Deprez 2003; Jameson and Blank 2007). Others suggest that these teams include specialty mental health providers, primary care providers, community agencies, school systems, clergy, consumers, and other key stakeholders (Harowski et al. 2006; Heflinger and Christens 2006). While there have been some favorable pilot projects where such teams have been established (Lewis 2001), these often require outside resources to succeed (Griffiths and Christensen 2007; Hourihan and Kelly 2006). The limited number of all health professions in rural areas, however, begs the question of ease with which these teams might be created. While local teams would be most responsive to the community, effective teams require time for communication and for ongoing training to work collaboratively. Personally, I have experienced frustration in my struggle to work collaboratively with my peers in health and allied health. This is because each person’s workload, including my own, is so high that we rarely get time for any collaborative work. Rather than develop new interdisciplinary teams, another approach is to further develop existing community resources and to increase collaboration between local community helpers. Many studies have shown that this improves psychological treatment outcomes and increases mental health awareness (Dimogiannis 2000; Hodgins et al. 2004; Judd et al. 2004). These kinds of initiatives would likely require substantial funding and time to become established. While the available discourse tends to present a bleak picture of rural health, it also indicates that there are complex and nuanced aspects of rural practice. It is important to balance an understanding of the commonalities of rural people with recognition of the diversity and variation within rural communities and peoples. The health of rural and remote community members involves complex environmental, cultural, social, and psychological factors. There are challenges related to distance, fewer colleagues and allied health professionals, and limited training, research, and professional infrastructure in rural practice. The social networks and values of rural communities position the practicing psychologist within a cultural system that may be vastly different from urban settings.

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Adapting to Personal Challenges and Professional Struggles Those who choose life in rural and remote communities know that familiarity is often an important part of all relationships, personal and professional. In most small communities, providers of psychological services will experience overlapping relationships and difficulties in separating formal and informal community participation (Coakes 2002; Schank and Skovholt 2006). Although the issues identified for small communities are not exclusive to rural and remote communities, this chapter focuses on the needs, practice considerations, and sensitivities specific to rural and remote communities of practice for psychologists. The literature on rural and remote communities shares common themes regardless of the setting – Canada, the United States, and from Australia in particular. One theme is the difficulty inherent in defining what is rural or remote. I reflect on that here only to underscore that any definition provides the general context only. The multidimensional concept of rurality may never be adequately defined to the requirements of all users because of the increasing diversity and ongoing economic and social changes in rural areas (Barbopoulos and Clark 2003; Jameson and Blank 2007; Harowski et al. 2006). Key is that all rural and remote communities share related issues in some of the following areas: less access to health care, services, and amenities (Muula 2007; Stamm et al. 2007; Zapf 2001), a distinct rural lifestyle or culture (Armstrong 2008; du Plessis et al. 2001; Harowski et al. 2006; Letvak 2002), geographic disparity from urban centres (du Plessis et al. 2001; Harowski et al. 2006; Letvak 2002), and distinct socioeconomic concerns (Jackson et al. 2007; Jameson and Blank 2007; Judd et al. 2006a, b; Murray et al. 2004). Overall, one cannot consider the role of psychologists in rural and remote practice without consideration to the population size, isolation, economic activity, and social systems in those communities of practice. There is so much diversity among rural settings and people that characterizing these communities is difficult. This means studying a group with great heterogeneity. That said, distinct concerns and characteristics of rural people have been proposed. Research has shown that the prevailing idea of idyllic stress-free rural life is an urban myth (Barbopoulos and Clark 2003; McCabe and Macnee 2002; Pong 2007; Zapf 2001). In fact, Jameson and Blank (2007) have suggested that rural people be considered a vulnerable group of people. International and national changes in economies, politics, and ecology have created disadvantages for rural people (Cheers 2001; Pong 2007), increasing their needs and decreasing their ability to serve their community members (Jameson and Blank 2007; Heflinger and Christens 2006). Key forces in shaping rural communities have been geographic isolation, social and economic factors, rapid changes to rural areas, and the culture of rural people. Isolation creates significant service disparity for rural communities (Barbopoulos and Clark 2003; Harowski et al. 2006; Philo et al. 2003), yet being isolated does not protect rural communities from the impact of national and world events (Cheers 2001). Rural communities experience more economic hardship and report higher levels of unemployment or underemployment than their urban counterparts (Barbopoulos and Clark 2003; Gale and Deprez 2003; Jameson and Blank 2007;

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Judd et al. 2006b; Philo et al. 2003; Shepard 2004; Stamm et al. 2007). There is more poverty among rural people than inner-city residents, especially for women and children (Harowski et al. 2006; Meyer and Lobao 2003). Poverty has been shown to increase the likelihood of mental distress for rural people (Pong 2007; Stamm et al. 2007; Thorngren 2003). Certainly, this appears to imply that there are distinct concerns for rural people. In considering common characteristics, it has been implied that rural communities and their psychological service needs have been changing (Barbopoulos and Clark 2003; Heflinger and Christens 2006; McCabe and Macnee 2002). In addition to their geographical diversity, rural populations are becoming more diverse. Numbers of aging rural residents are growing, younger rural residents are migrating to urban centres (Barbopoulos and Clark 2003; Gale and Deprez 2003; Jameson and Blank 2007; Harowski et al. 2006), and there are increasing numbers of immigrants and refugees to rural areas (Bonifacio 2007; Hargrove 2007; Harowski et al. 2006). In some areas, community dynamics are being further altered by an influx of employment-mobile urban families seeking rural lifestyles (Hargrove 2007). Given this diversity, the notion of a homogeneous “rural culture” has been questioned. Yet, the literature consistently suggests that psychologists be sensitive to traits considered common in rural populations. These include stoicism, conservativism, interconnection with others, and being from marginalized groups (Barbopoulos and Clark 2003; Gale and Deprez 2003; Harowski et al. 2006; Jameson and Blank 2007; Judd et al. 2006b; Letvak 2002; Roufeil and Lipzker 2007; Shepard 2004; Thorngren 2003). The risk in this “sensitivity” is that rural people are aggregated into one group and defined only by their difference from urban populations. This could foster stereotypes that do not consider variability. One example is the stigma concerning mental disorders. This is presumed to be worse in rural areas due to socially influenced or collective attitudes toward mental illness in rural communities (Boyd et al. 2008; Jackson et al. 2007; Letvak 2002). Some literature has suggested that rural residents report higher levels of pride, independence, and stoic behavior (Griffiths and Christensen 2007; Harowski et al. 2006; Judd et al. 2006a; Sanderson 2004; Stamm et al. 2007; Thorngren 2003). There is little causal empirical evidence to suggest that this translates directly into mental health stigma. However, research has shown that rural people tend to be less aware of mental health issues and seek help less often (Caldwell et al. 2004; Jackson et al. 2007; Stamm et al. 2007; Thorngren 2003). What accounts for this paucity in mental health awareness and help-seeking is not clear. One explanation is the perception that these communities are “closer knit” and therefore are less responsive to labeling mental health issues and see individual concerns as community considerations. If this is true, then perhaps there are social functions to the stigma against help-seeking in rural areas that foster a greater emphasis on family, individualism, and fatalism (Barbopoulos and Clark 2003; Boyd et al. 2008; Harowski et al. 2006; Jackson et al. 2007; Jameson and Blank 2007; Murray et al. 2005; Thorngren 2003). Further, rural communities have a vibrancy that contributes to the safety net of rural people. This helps people to connect and endure in trying times, giving people hope and building successful

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communities (Harowski et al. 2006; Schank and Skovholt 2006; Vella-Brodrick et al. 2006). Perceptions of rural health needs may underestimate the beneficial impact of informal community services, greater community involvement, and the capacity that derives from collective values (Boyd et al. 2008; Sanderson 2004; Thorngren 2003; Vella-Brodrick et al. 2006). There are other features of rural communities that may negatively impact mental health. Enhanced social connectedness may foster a “goldfish bowl phenomenon” as community members expect to know more about each other which decreases privacy and increases community pressure (Barbopoulos and Clark 2003; Harowski et al. 2006; Shepard 2004; Thorngren 2003). There can be a sense of isolation created by limited access to services and resources, social relationships, and increased difficulties in accessing services and necessities (Barbopoulos and Clark 2003; Gale and Deprez 2003; McCabe and Macnee 2002; Shepard 2004). Characteristics are difficult to empirically validate, but two characteristics of rural communities were studied more thoroughly. In a comparative study in Australia, remoteness of communities was associated with increased reports of psychological distress (VellaBrodrick et al. 2006). The second consideration from Canada was that Aboriginal people (who live predominantly in rural areas) have very high rates of serious mental health concerns. Aboriginal Canadians are culturally marginalized and profoundly socially disadvantaged which makes them more sensitive to economic problems and the inadequate and inequitable mental health services in rural areas (Barbopoulos and Clark 2003; Romanow and Marchildon 2003). There are distinct mental health issues in rural areas, but an inconclusive understanding of the characteristics of rural communities and people. Psychology in rural and remote practice is the study and practice of psychology that is primarily concerned with rural communities and people (APS 2004b; Barbopoulos and Clark 2003; Schank and Skovholt 2006). The current state of rural mental health has practical challenges and advantages for psychologists (APS 2004b; Barbopoulos and Clark 2003; Gale and Deprez 2003; Schank and Skovholt 2006; Thorngren 2003). Primary challenges are related to geographic barriers, lifestyle constraints, limited privacy, and higher risks of burnout (Barbopoulos and Clark 2003; Gale and Deprez 2003; Perkins et al. 2007; Stamm et al. 2007). Rural psychologists may find that they serve a larger population, have more disadvantaged clients, and are more likely to work in professional isolation than their colleagues in urban practice (APS 2004b; Fair 2004). Despite these challenges, rural psychological practice can be rewarding. Perkins et al. (2007) found that those who remain in rural practice report high levels of satisfaction with the job, lifestyle, and environment. Enhanced career, professional, and employment opportunities benefit the psychologists and the communities they serve. It has been found that those who work in rural settings do so by choice, and the distinct professional challenges and lifestyle advantages may be strong incentives (Casey 2007; Charlebois 2006; Dimogiannis 2000; Schank and Skovholt 2006). Rural psychologists may experience intrinsic rewards related to impact they can have for rural communities and people (Dollard et al. 2004). These psychologists may also get professional challenge from working as generalists with a variety of client needs, building

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multi-layered relationships and connections, and having a contextual and multifaceted view of their clients (APS 2004b; Casey 2007; Schank and Skovholt 2006). Rural psychologists experience more community involvement and acceptance (Casey 2007; Schank and Skovholt 2006). They are afforded more professional opportunities to be educators, to offer professional development, to assist with community development, and to be involved in evaluation and research (Barbopoulos and Clark 2003).

Relevant Professional Struggles My own research has indicated that there are several professional struggles that impact the experience of professional ethics in rural practice. Key sociohistorical considerations are (a) competition and concern over the delivery of services, (b) the influence of government, (c) the prescriptive authority debate, (d) rural-specific registration and mobility concerns, and (e) insufficient professional advocacy.

Competition The first sociohistorical consideration was a sense of competition. The Canadian Psychological Association defines psychology as a profession that “studies how we think, feel and behave from a scientific viewpoint and applies this knowledge to help people understand, explain and change their behaviour” (Cohen 2009a, para 1). Services that are psychological in nature are not delivered exclusively by psychologists, and there are concerns about non-psychologists offering substandard services and about insufficient public awareness. Competition to provide services may affect rural communities, and their clients, and may also affect the profession of psychology. Literature on the competency of allied health professions is sparse, particularly about their work in rural practice (Lin et al. 2009). The CPA acknowledges that there are a range of mental health practitioners who “claim to treat mental health problems. Not all of them are well trained professionals in the mental health field” (Cohen 2009b, Para 2–3). In public advice, the CPA encourages consumers to seek regulated or licensed professionals to ensure that their psychological services are provided by someone who has met high training and practice standards (Cohen 2009b). A specific area of concern can be the provision of psychological services by general physicians. There is a perceived lack of psychological training for physicians and concerns that general practice physicians create unfair competition. Literature on psychology in Canadian health care reflects these concerns nationally. A recent Royal Commission on national health care noted that psychotherapy is publicly funded if provided by physicians. This commission also noted that psychologists have far more extensive training than physicians in this regard (Romanow and Marchildon 2003). Many Canadians “go to their family physicians for psychological reasons, either forcing family physicians to provide services that they are not

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optimally equipped for, or more often leading family physicians to prescribe medications as a short-term solution to a problem” (Dobson 2002, p. 68). Westra et al. (2006) have warned that this competition may negatively affect psychology as a distinct profession. The literature also speaks to how the profession of psychology may be fostering this competition to deliver psychological services. Rather than promoting general psychologist practitioners, as there are general physicians, psychologists specialize. This leaves general psychological practice to ally health professionals. Albert Bandura warned that: It is feared that as we give away more and more psychology to disciplines lower on the food chain, there will be no core psychological discipline left. . .psychology is the integrative discipline best suited to advance understanding of human adaptation and change. It is the discipline that uniquely encompasses the complex interplay between intrapersonal, biological, interpersonal, and sociostructural determinants of human functioning. (Bandura 2001, p. 12)

Currently, the profession of psychology is not well integrated. Prominent Canadian psychologists have expressed concern that the profession has been lax to integrate new skills and knowledge across the profession of psychology. They advise that the profession needs to create a core discipline based on both research and practice in addition to development on specialties (Latham 2003; Seijts and Lantham 2003; Sternberg 2004). Thomas Hadjistavropoulos, reflecting on his tenure as president of the Canadian Psychological Association, said: “it is important for psychologists across Canada to work together and talk to each other, proud of their traditions in both science and practise” (2009, p. 5). When they do not, or when there are insufficient psychologists, mental health needs will be met by other providers.

Government Another consideration is the influence of government on the provision of professional psychology and ongoing demand to change healthcare funding systems. The literature has provided consistent research demonstrating the efficacy of psychology and the medical cost-offset effect of psychological services. Psychologists, particularly clinical psychologists, have argued that they should be publicly funded within health care (Dobson 2002). Despite this, there is little public funding for psychology, and it is not recognized as an essential part of any of the provincial health systems (Arnett et al. 2004; Dobson 2002; Hunsley 2003; Westra et al. 2006). There is a “continuing marginalization of mental health services and the dominance of political considerations over compelling scientific evidence for the impact of psychological services on health and recovery from illness” (Hunsley and Crabb 2004, p. 233). Special funding can support the delivery of psychological services and improve access, but it does not ensure public awareness. In Canada, the Aboriginal Healing Foundation is a federal initiative that provides specific funding to assist Aboriginal

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Canadians in their healing in relation to trauma experienced because of the residential school system. Psychologists are one of several approved providers of mental health service for this program (Aboriginal Healing Foundation 2009). Aboriginal Canadians tend to live in rural and remote communities (Romanow and Marchildon 2003), and so rural Canadian psychologists are likely to experience the greatest service demands related to this program.

The Prescriptive Authority Debate The third sociohistorical consideration is the prescriptive authority debate for psychologists. Westra et al. (2006) advised that “whether to pursue prescriptive authority is a critically important and controversial issue currently facing psychology” (p. 77). Perhaps therefore rural psychologists have support, opposition, and caution in reviewing prescription drug privileges in their reflections. Some Canadian psychologists have argued for these privileges, spoke of the benefits to consumers and the field of psychology, and argued that this move is necessary (Nussbaum 2001; Westra et al. 2006). Given the shortage of psychiatrists, prescription privileges may be particularly relevant for those who work with underserved populations like “children, the elderly, the chronically mentally ill, and rural areas” (Westra et al. 2006, p. 78). Prescription privileges could be particularly relevant for psychologists in rural practice (Harowski et al. 2006). Research by St. Pierre and Melnyk (2004) indicated support for prescription privileges among clinical psychology interns. They said that “few people felt that prescribing was theoretically or philosophically opposed to the field of psychology or that it would compromise psychological service delivery” (p. 284). The literature on prescription drug privileges reflects tempered optimism. Such a change to the practice of psychology raises a myriad of issues. Prescription privileges could fundamentally alter the course of training and delivery of psychology. In fact, the overhaul to the profession could be so great that “training and regulating prescriptive authority would be more expensive than utilizing currently available medically trained professionals” (Westra et al. 2006, p. 78). Further, given the rising Medicare costs of prescription drugs, applied psychological services have been suggested as an alternative to psychotropic treatments (Romanow and Marchildon 2003; Westra et al. 2006).

Registration and Mobility Professional registration and mobility within a country comprise the fourth sociohistorical consideration. Rural psychologists with PhDs can have concern that master’s-level psychologists represent the profession with substandard qualifications or pose unfair competition in the field. Those with master’s degrees may have concerns that requiring PhD level training will foster a shortage of psychologists in rural practice.

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There is a growing shortage of psychologists in Canada (Bieling 2009). There is also debate in the literature about registration at the PhD versus master’s level of training in professional psychology (Pettifor 2004). Registration as a psychologist is done provincially in Canada and specific processes vary across provinces. My initial search of provincial registration bodies indicated that most required a PhD for registration. I was surprised that half of the participants in this study, all of whom were registered to practice the profession as a “psychologist” in their province, had only a master’s degree. I learned that several provinces allow psychologists to register with a master’s degree despite proposed changes or preferences for PhD-level training. Differences in level of registration are a primary issue impacting mobility of psychologists beyond provincial boundaries. Perhaps nationwide registration, like Australia has, would facilitate better mobility. Another solution is competency-based national credentials. Informed opinion among psychologists on this issue is likely confounded by their own level of registration. As Canadian professional psychology evolves and diversifies, it is experiencing increased professional mobility (Pettifor et al. 2002). As registered health professionals, psychologists are only licensed to practice in the province in which they have secured registration. There has been recognition of the need to facilitate mobility across the country. Despite the suggestion that “a framework now exists for the full mobility and interprovincial recognition of psychologists” (Dobson 2002, p. 68), mobility remains limited.

Advocacy The final sociohistorical consideration is advocacy for psychology. There is a need to advocate for the sake of consumers of psychological services and for the profession itself. Public awareness is crucial to psychology, particularly efforts to reduce the stigma of mental illness. Further, advocacy can strengthen the profession by increasing its accountability and enhancing its reputation. The need for advocacy is frequently articulated in the literature. Some authors have spoken to the marginalization of psychology within the Canadian healthcare system (CPA 2007; Hunsley and Crabb 2004; McIlwraith and Dyck 2002; Romanow 2006). Canada is the only G8 country without a developed national mental health strategy, an urgently required reform (Arnett et al. 2004; CPA 2007; McIlwraith and Dyck 2002; Romanow and Marchildon 2004). There have been calls, in the literature, for “(a) continuing efforts to educate policymakers, the media, and Canadians about the value of psychological services and (b) active involvement from psychologists in efforts to develop new models of primary health care in Canada” (Hunsley and Crabb 2004, p. 233). There is a need to advocate specifically for psychology in rural practice. The available literature indicates that this advocacy may be more difficult because of a significant shortage of rural practitioners. Twenty percent of the Canadian population is rural which should be enough justification for at least an academic focus on rural issues in the profession (Brannen and Johnson-Emberly 2006; Romanow and

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Marchildon 2003). Although I found a wealth of Australian research and literature, I found few academic articles from Canada. When searching databases with the key term “Canadian psychology” and then searching with the key terms “Canadian psychology” with the Boolean “and” for “rural,” the latter search had far fewer hits. The percentage of articles with both search terms was six percent and thirteen percent of the number of searches for “Canadian psychology” alone for Google Scholar and PsycInfo, respectively. There were no hits with the two terms in either Sage or PsycEXTRA.

The Sociohistorical Context All psychological phenomena should be understood and interpreted within their sociohistorical context (Hadjistavropoulos 2009; Sternberg 2004, p. 282). The relevant professional struggles I identify in this chapter are contextual considerations. Competition concerns highlight the potential vulnerability of the field of applied psychology. This concern suggests a need to foster more emphasis on general psychological practice. Another concern was how dependent psychology can be on government funding models and decisions. The prescriptive authority debate for psychologists appears to be controversial as cautious optimism is balanced with opposition to psychopharmacology gaining excessive prominence in the field. The debate about level of registration was seen to affect more than just mobility of psychologists in Canada. Inconsistencies in provincial registration processes may directly affect the availability of rural psychologists. The final key consideration was the need for advocacy to increase public awareness, decrease the stigma of mental illness, and develop Canadian psychology.

Responding to the Rural Context Adaptations to Professional Practice Norms Rural Specific Practice Guidelines There is an often-unacknowledged difference between urban and rural practice in psychology. The professional and social milieus of rural and remote communities position the practicing psychologist within a context that may differ vastly from urban settings. Responding to the often complex and nuanced aspects of rural practice requires adaptations to both professional practice norms and the development of practice guidelines that elucidate the distinct practice considerations, consistent personal and professional characteristics, and the geographic realities of these practice contexts. Situations arise which are quintessentially rural and remote in nature, and awareness of these has implications for the training and development of psychologists. There are practical implications, including necessary adaptations to professional practice norms. How and why such strategies are chosen are important – that element

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of rural practice which makes adaptations necessary could easily be used as a rationale or excuse for idiosyncratic variations to practice that are not justifiable. Such risks are enhanced with insufficient awareness. There are several adaptations of professional practice norms that can assist a psychologist in accommodating geographic barriers and resource limitations in rural and remote practice. Here I will highlight responses to four key considerations: geographic barriers, practice in non-normative settings, tailoring service delivery, and enhanced social justice considerations. Adaptations are often required to mediate geographic barriers. Often this means the provision of services at a distance, by telephone or via online technologies. Use of such tools to mediate distance may mean increased access but may impact the client-psychologist relationship and increase ethical dilemmas. Another way to mediate geographic barriers is travel by the psychologist which is fraught with logistical considerations and highlights concerns in relation to transporting and storing files. Another adaptation related to travel is practice in non-normative practice settings. Travel often means work in borrowed office space. There are benefits of shared office spaces for increasing communication or being more accessible to the community. One example is when psychologists house their practice within a community medical clinic. Such settings lessen the psychologist’s control over confidentiality and the security of storing client files and psychological materials. Another variation to typical professional practice may be to provide services in the client’s home, literally decreasing client barriers by bringing the services to them. This setting has potential risks for both clients and psychologists. Practice within a client’s home can also pose risks for the psychologist or their reputation. However, appropriate service delivery in such settings may reduce risk of client harm by minimizing the chance of exploitation of the client or the same perception for the psychologist. These settings can also increase the ability to provide enhanced assessment and service delivery. A third adaptation to urban-centric practice is tailoring service delivery to the needs of rural consumers. Psychologists require an awareness of the impact of rural norms when conducting assessments and often desire for rurally relevant assessment protocols. Rural and remote practice may translate into practice conditions without established protocols. Funding programs may provide for short-term intensive psychological services for clients with significant geographical barriers to service access. These specific practice scenarios both force and require variations to normative standards for assessment and treatment in rural practice. Consequently, the rural practitioner may need to adopt innovative practices that are not supported by the conservative evidence-based literature. Finally, social justice is important in the provision of psychological service to rural and remote people and communities. There is a need to advocate for socially appropriate services which could, at times, mean systemic interventions to deliver appropriate services. In this practice context, a psychologist’s role may include a responsibility to advocate for rural communities and peoples. Essential is an awareness of systemic processes in rural communities, the impact of poverty, and how our professional role can impact these social conditions.

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There is virtually no literature that reflects the first three of these adaptations of professional practice norms to accommodate rural practice considerations. I lament this lack of discussion in the literature as it creates a certain vulnerability and professional isolation for rural psychologists. My personal bias is that practice accommodations are often required yet may leave rural psychologists vulnerable because of the atypical nature of such practices. In over two decades of practice in rural and remote settings, I have provided psychological services by telephone and travelled to mediate geographic barriers. For years I carried two heavy briefcases during my travels. Not only was this physically challenging, but I often encountered situations where I wished I had brought still other resources. Sharing office space with secured storage helped but this was only in one community. I have also conducted home visits when required to provide optimal conditions for the provision of services. I was initially somewhat naïve when working in clients’ homes but soon developed protocols to ensure protective factors for both the client and me. I have also had to tailor assessments to the needs of rural consumers, particularly as I often work with Aboriginal people. The fourth adaptation or consideration, social justice, is better represented in the literature and is more frequently considered in our profession (Cohen 2009b; Pope and Arthur 2009). Why the social justice focus? Rural and remote communities and people experience poorer socioeconomic conditions and have less favorable health status than their urban counterparts (Pong 2007; Romanow and Marchildon 2003) which speaks to the nature of the practice in these settings. Indeed, “social care is embedded in place, by which we mean the social relations that determine who provides what are closely connected with the physically bounded settings of meaning and interaction in which these activities and relations occur” (Hanlon et al. 2007, p. 466). If this is true, then rural practice itself may foster such views or, alternatively, attract the kind of psychologist who has social advocacy as an area of focus. Research has indicated that rural practitioners are likely to participate in social advocacy for their communities (Boydell et al. 2008; Greenhill et al. 2009; Larson and Jones 2009). There is more need for such advocacy for the economically disadvantaged (Pope and Arthur 2009, p. 62) which, unfortunately, means many rural people. My own practice reflects a bias toward social advocacy. I usually have a long wait list for my private practice that has a standard hourly rate. Despite this, I always ensure that a certain percentage of my caseload is reserved for a heavily subsidized community program. I am also committed to providing services to a local Aboriginal community that has considerable poverty, a 70 percent unemployment rate, and much more difficult working conditions. I am often asked why I continue to accept this challenging contract, but for me it is difficult to begin to even articulate my sense of responsibility in this regard. What then are the responsibilities of our profession? Psychology, as a discipline, can respond to, and benefit from, needs born out of the rural and remote practice context. One consideration is the development of “general practice psychology” to strengthen the profession considering its divisiveness, in response to competition from allied professionals, and for rural practice. Many training programs in psychology are predicated on training generalists, yet few psychologists are fully prepared

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for rural practice, and shortages may mean that rural areas recruit psychologists with less training than in urban areas. Further, even a cursory review of professional registration categories and interest groups indicates that there is no representation or articulation of “general practice” as a subset or specialty area of practice in psychology. Another consideration is involving rural and remote practitioners in the prescriptive authority debate. Communities in rural and remote areas may be more likely to seek psychologists with prescription privileges. Alternatively, this might further the shortage of psychologists in rural practice, particularly when considering the varying levels of training reported by the participants in this study. Finally, training for rural and remote practice should include focus on required adaptations of professional practice norms, community connection, generalist practice, interdisciplinary collaboration, limits to consent, boundary crossings, and ethical dilemmas common to rural practice. The role of psychologists in these practice settings is articulated by their management of overlapping relationships. Inherent in these practice settings are the need to employ caution, consult with peers, and clarify boundaries; however there is little clarity on how rural psychologists put limits on their professional and non-professional relationships. Training that incorporates available models, like those for managing risks in overlapping relationships proposed by Younggren and Gottlieb (2004), might be particularly valuable for those in or training for rural practice. Overall, guidelines for psychological practice in rural and remote settings are essential. At present, what are the tangible ideas for rural and remote psychologists? General considerations are as follows: set clear and reasonable expectations and boundaries; consult regularly with a community of peers that need not be bound by location; develop effective community relationships; use technology to decrease isolation and distance; develop contingency plans for common pressures; seek out creative alternatives for service provision; and engage in self-care. Most importantly, we need to reconceptualize rural and remote practice conditions. There can be benefits from having prior information about clients in rural areas and limitations of trying to artificially control benign overlapping relationships. Visibility can serve to normalize the psychologist, enhance our professional practice, and allow for the privilege of being a participant observer in community development. There is variety and challenge in generalist practice. Finally, well-managed interdisciplinary services can mean more effective services and a more rewarding practice overall.

Reaping the Intrinsic Rewards Despite the challenges, rural psychological practice can be rewarding. Perkins et al. (2007) found that those who remain in rural practice report high levels of satisfaction with the job, lifestyle, and environment. Enhanced career, professional, and employment opportunities benefit the psychologists and the communities they serve. It has been found that those who work in rural settings do so by choice, and the distinct professional challenges and lifestyle advantages may be strong incentives (Casey

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2007; Charlebois 2006; Dimogiannis 2000; Schank and Skovholt 2006). Rural psychologists may experience intrinsic rewards related to impact they can have for rural communities and people (Dollard et al. 2004). These psychologists may also get professional challenge from working as generalists with a variety of client needs, building multi-layered relationships and connections, and having a contextual and multifaceted view of their clients (APS 2004b; Casey 2007; Schank and Skovholt 2006). Rural psychologists experience more community involvement and acceptance (Casey 2007; Schank and Skovholt 2006). They are afforded more professional opportunities to be educators, to offer professional development, to assist with community development, and to be involved in evaluation and research (Barbopoulos and Clark 2003).

Conclusion Jean Pettifor (2004) said that “there are many paths to follow in the creation of knowledge” (p.11). The results of this research created a foundation for further study. This study provides impetus for research to define rural professional practice in psychology. An adequate definition would capture the diverse characteristics of rurality and foster research and program development by providing a shared understanding of what is rural for psychologists. Qualitative studies could gather understanding about the meaning of rurality to develop potential definitions. Quantitative studies could test these theories, comparing definitions and measuring the responsiveness of psychologists to these definitions. There is a need to develop specific protocols. This study highlighted several adaptations to professional practice norms not in the literature. The profession has an obligation to foster research and literature on actual practices. Qualitative studies could explore and understand practices like short-term intensive psychological interventions in response to geographic isolation, assessment and practice in non-typical environments (like clients’ homes), and the implications of travelling to provide services. Quantitative studies could test protocols and best practices for such services. Qualitative studies will be the most appropriate way to begin this process, and similar studies would add to the knowledge field and begin to foster generalizability. Future studies could compare participant responses in consideration of their level of registrations, region, or type of practice. An interesting area would be to have both insider-researchers and outsider-researchers assess for differences and to allow for both emic and etic perspectives given the specific culture and yet diversity of rural communities. I suspect this might highlight any sub-cultural differences between psychologists who originally came from rural communities and those who came from urban settings. Finally, quantitative studies could seek to develop and test theories based on qualitative findings. Such theories include the results of this study and Schank and Skovholt’s (2006) proposed strategies to minimize the risk of ethical dilemmas in rural practice.

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Ongoing research on professional ethics in rural practice has implications for professional practice and training. Further qualitative studies should also consider what citizens of rural communities expect of psychologists specific to ethical standards. This would make the findings of studies like this one more sensitive to community mores and may ground such findings in a more social constructivist perspective. Jones (2008) indicated that “educational institutions within Australia have an ethical obligation to ensure that they train psychology students to be good at what they do” (p. 45). Given the fact that one-fifth of our population is rural, this ethical obligation likely extends to educational institutions in Canada.

Concluding Thoughts This concludes this chapter but not the study of professional ethics in rural practice. I was originally inspired by Schank and Skovholt’s (2006) assertion that “the central dilemma for small community psychologists [is] how to practice at a high ethical level according to ethics codes, and how to also be an engaged member of the small community” (p. 5). The wealth of data shared by the participants in my own research study was another step in accumulating knowledge to facilitate an understanding of this phenomenon which may eventually inform policy, science, or clinical practice. I have had personal and professional benefit as the researcher and trust this study will serve as informative and validating for many in the field. I present no simple picture of the essence of professional ethics in rural psychology. Again, “a single, saturated, and final comprehension of a phenomenon is not possible” (Strong et al. 2008, p. 122). However, this complex phenomenon is now a bit clearer. As the researcher, it has been an honour to share the stories of other practicing rural psychologists. The results of such studies provide a place to begin further exploration and understanding. As with most qualitative research, there is no clear end to the process (Blackstone et al. 2006). The final words on rural research I leave to the wisdom of Denzin and Lincoln (2005) speaking of qualitative research who said, “And so we come to the end, which is only the starting point for a new beginning” (p. 1083). There is a need for rural-specific practice models, training, supports, and ethics guidelines. Canadian psychologists in rural practice may be particularly vulnerable to government and societal structures and to registration and mobility issues. Some of the adaptations of professional practice norms identified in this study, namely, telephone services, travel-related issues, and atypical service settings, were not in the available literature. Also, the benefits of rural practice are rarely explored.

References Armstrong LL. Speaking a common language: a framework for a youth-friendly definition of rurality in Canadian mental health literature. View Here Perspect Northern Rural Psychol. 2008;3:7.

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Arnett JL, Nicholson IR, Breault L. Psychology’s role in health in Canada: reaction to Romanow and Marchildon. Can Psychol. 2004;45:228–31. Australian Psychological Society. Guidelines for psychological practice in rural and remote settings. Melbourne, Victoria; 2004b. Australia: Author. Bandura A. The changing face of psychology at the dawning of a globalization era. Can Psychol. 2001;42:12–24. Barbopoulos A, Clark JM. Practising psychology in rural settings: issues and guidelines. Can Psychol. 2003;44:410–24. Bartlett H, Travers C, Cartwright C, Smith N. Mental health literacy in rural Queensland: results of a community survey. Aust N Z J Psychiatry. 2006;40:783–9. Benson E. Beyond ‘urbancentrism’. Monit Psychol. 2003;34(6):54. Bieling PJ. Preventing a shortage of psychologists. Psynopsis. 2009, Summer;31:4. Blackstone M, Given L, Lévy J, McGinn M, O’Neill P, Palys T, van den Hoonaard W, Griener G, Poff D, Rice K, De Groote T. Qualitative research in the context of the TCPS: A follow-up to the giving voice to the Spectrum report and a discussion paper. Social sciences and humanities research ethics special working committee (SSHWC) (SSHRC). 2006. Retrieved July 15, 2008, from http://www.pre.ethics.gc.ca/english/workgroups/sshwc/consultation07.cfm#Title3 Bonifacio G. Gender and rural migration conference: realities, conflict and change. Call for papers for 08 March 2008 conference. 2007. Alberta, Canada: University of Lethbridge. Bowman RC, Kulig JC. The north American section of rural and remote health: the time has come! Rural Remote Health. 2008;8:1016. Retrieved July 15, 2008 from http://www.rrh.org.au Boyd CP, Hayes L, Sewell J, Caldwell K, Kemp E, Harvie L, Aisbett DL, Nurse S. Mental health problems in rural contexts: a broader perspective. Aust Psychol. 2008;43:2–6. Boydell KM, Stasiulis E, Barwick M, Greenberg N, Pong RW. Challenges of knowledge translation in rural communities: the case of rural children’s mental health. Can J Commun Ment Health. 2008;27:49–63. Brannen C, Johnson-Emberly D. Rural experiences of stress. The View from Here: Perspective on Northern and Rural Psychology. 2006;1(2):4. Bray JH, Enright MF, Easling I. Psychological practice in rural primary care. In: Frank RG, McDaniel SH, Bray JH, Heldring M, editors. Primary care psychology. Washington, DC: American Psychological Association; 2004. p. 243–57. Caldwell TM, Jorm AF, Knox S, Braddock D, Dear KBG, Britt H. General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia. Aus New Zealand J Psychiat. 2004;38:774–80. Campbell A, Manoff T, Caffery J. Rurality and mental health: an Australian primary care study. Rural Remote Health. 2006a;6:595. Campbell CD, Kearns LA, Patchin S. Psychological needs and resources as perceived by rural and urban psychologists. Prof Psychol Res Pract. 2006b;37:45–50. Canadian Psychological Association. Federal budget 2007: Highlights from a psychology perspective. In: Quick links. 2007, March. Retrieved September 02, 2007, from www.cpa.ca/cpasite/ userfiles/Documents/advocacy/Federal%20Budget%20Summary%20-%20March%202007.pdf Casey C. Rural rewards: the career you want and the lifestyle too. InPsych. 2007;29(5):18. Charlebois J. Counsellors’ professional and personal perspectives on working and living in a remote northern community. Unpublished master’s thesis. Wolfville, Nova Scotia: Acadia University; 2006. Cheers B. Globalisation and rural communities. Rural Soc Work. 2001;6(3):28–140. Coakes SJ. Defining the nature of participation in rural Australian communities: a qualitative approach. J Commun Psychol. 2002;30:635–46. Cohen KR. Some who, what, where, when and whys of the stigma of mental disorders. Psynosis. 2009a, Winter;31:4. Cohen KR. Advocacy – A gap and opportunity for the science and practice of psychology. Psynopsis. 2009b, Summer;31:3.

18

Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas

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du Plessis V, Beshiri R, Bollman RD, Clemenson H. Definitions of rural. In: Rural and small town Canada analysis bulletin, 3 (Catalogue No. 21-006-XIE). Ottawa, Ontario: Statistics Canada; 2001. pp. 2–17. DeLeon PH, Wakefield M, Hagglund KJ. The behavioral health care needs of rural communities. In: Stamm BH, editor. Rural behavioral health care: an interdisciplinary guide. Washington, DC: American Psychological Association; 2003. pp. 23–31. Denzin NK, Lincoln YS, editors. The sage handbook of qualitative research. 3rd ed. Thousand Oaks: Sage Publications; 2005. Dimogiannis, T. Comparison of the work of psychologists in rural and urban settings: implications for professional training. Unpublished master’s thesis, Deakin University, Geelong, Victoria, Australia; 2000. Dobson KS. A national imperative: public funding of psychological services. Can Psychol. 2002;43:65–75. Dollard M, Biswas S, Lynch J. Developing and contextualising a knowledge base in rural work psychology: rural development, rural women and entrepreneurship in India and Australia. Int J Rural Psychol. 2004. Fair TD. The practice of psychology in a rural area. J Psychol Christian. 2004;23:54–57. Findlay RA, Sheehan MC. Utilisation of mental health services in rural and remote communities. J Rural Community Psy. 2004;E7(1):463–5. Gale JA, Deprez RD. A public health approach to the challenges of rural mental health service integration. In: Stamm BH, editor. Rural behavioral health care: an interdisciplinary guide. Washington, DC, US: American Psychological Association; 2003. p. 95–108. Goodwin SL. Training rural psychologists. Psynopsis. 2004;26(3):18. Greenhill JA, Mildenhall D, Rosenthal D. Ten ideas for building a strong Australian rural health system. Rural Remote Health. 2009;9:1206. Griffiths KM, Christensen H. Internet-based mental health programs: a powerful tool in the rural medical kit. Aust J Rural Health. 2007;15:81–7. Hadjistavropoulos T. Canadian psychology in a global context. Can Psychol. 2009;50:1–7. Hanlon N, Halseth G, Clasby R, Pow V. The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC. Health Place. 2007;13:466–81. Hargrove DS. Keeping a rural psychology presence alive. Clin Psychol Sc Pract. 2007;14:304–5. Harowski K, Turner AL, LeVine E, Schank JA, Leichter J. From our community to yours: rural best perspectives on psychology practice, training, and advocacy. Prof Psychol Res Pract. 2006;37:158–64. Heflinger CA, Christens B. Rural behavioral health services for children and adolescents: an ecological and community psychology analysis. J Community Psychol. 2006;34:379–400. Hodgins G, Murray G, Donoghue A, Judd F, Petts A. Introducing a professional development programme to a rural area mental health service: the importance of context. Australas Psychiatry. 2004;12:153–60. Hoolahan B, Kelly B, Stain HJ, Killen D. Co-morbid drug and alcohol and mental health issues in a rural New South Wales area health service. Aust J Rural Health. 2006;14:148–53. Hourihan F, Kelly, B. National health policy: what does this mean for rural mental health research? Aus J Rural Health. 2006;14(2):49–50. Hunsley J. Cost-effectiveness and medical cost-offset considerations in psychological service provision. Can Psychol. 2003;44:61–73. Hunsley J, Crabb R. Shaping the future of psychological services in the Canadian health care system: a response to Romanow and Marchildon (2003). Can Psychol. 2004;45:232–5. Jackson H, Judd F, Komiti A, Fraser C, Murray G, Robins G, Pattison P, Wearing A. Mental health problems in rural contexts: what are the barriers to seeking help from professional providers? Aus Psychol. 2007;42:147–60. Jameson JP, Blank MB. Rural services: defining problems and developing solutions. Clin Psychol Sci Pract. 2007;14:283–98.

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Jones CM. From novice to expert: issues of concern in the training of psychologists. Aust Psychol. 2008;43:38–54. Judd FK. Progressing the agenda for rural mental health research. Rural Remote Health. 2006;6:615. Judd F, Davis J, Hodgins G, Scopelliti J, Agin B, Hulbert C. Rural Integrated Primary Care Psychiatry Programme: a systems approach to education, training and service integration. Aus Psychiat. 2004;12:42–7. Judd F, Jackson H, Komiti A, Murray G, Fraser C, Grieve A, Gomez R. Help-seeking by rural residents for mental health problems: the importance of agrarian values. Aust N Z J Psychiatry. 2006a;40:769–76. Judd F, Cooper A, Fraser C, Davis J. Rural suicide–people or place effects? Aust N Z J Psychiatry. 2006b;40:208–16. Kilkkinen A, Kao-Philpot A, O’Neil A, Philpot B, Reddy P, Bunker S, Dunbar J. Prevalence of psychological distress, anxiety and depression in rural communities in Australia. Aust J Rural Health. 2007;15:114–9. Larson A, Jones P. Rural health in a time of cataclysm. Rural Remote Health. 2009;9:1200. Latham GP. Toward a boundaryless psychology. Can Psychol. 2003;44:216–7. Letvak S. The importance of social support for rural mental health. Issues Ment Health Nurs. 2002;23:249–61. Lewis BL. Health psychology specialty practice opportunities in a rural community hospital: practicing local clinical science. Prof Psychol Res Pract. 2001;32:59–64. Lin IB, Beattie N, Spitz S, Ellis A. Developing competencies for remote rural senior allied health professionals in Western Australia. Rural Remote Health. 2009;9:1115. McCabe S, Macnee CL. Weaving a new safety net of mental health care in rural America: a model of integrated practice. Issue Mental Health Nurs. 2002;23:263–78. McIlwraith RD, Dyck KG. Strengthening rural care – the contribution of the science and practice of psychology. (ISBN#: 1-896538797. Ottawa: Canadian Psychological Association; 2002. McIlwraith RD, Dyck KG, Holms VL, Carlson TE, Prober NG. Manitoba’s rural and northern community-based training program for psychology interns and residents. Prof Psychol Res Pract. 2005;36:164–72. Meyer K, Lobao L. Economic hardship, religion and mental health during the Midwestern farm crisis. J Rural Stud. 2003;19:139–55. Mitura V, Bollman RD. The health of rural Canadians: a rural-urban comparison of health indicators. In: Rural and small town Canada analysis bulletin 4. Ottawa: Statistics Canada; 2003. Catalogue no. 21-006-XIE, p. 2–23 Murray G, Judd F, Jackson H, Fraser C, Komiti A, Hodgins G, Pattison P, Humphreys J, Robins G. Rurality and mental health: the role of accessibility. Aus New Zealand J Psychiat. 2004;38:629–34. Murray G, Judd F, Jackson H, Fraser C, Komiti A, Hodgins G, Pattison P, Humphreys J, Robins G. The five factor model and accessibility/remoteness: novel evidence for person-environment interaction. Personal Individ Differen. 2005;39:715–25. Muula AS. How do we define ‘rurality’ in the teaching on medical demography? Rural Remote Health. 2007;7:653. Retrieved 15 July 2008 from http://www.rrh.org.au Nelson C, McPherson D. Contextual fluidity: an emerging practice model for helping. Rural Soc Work. 2004;9:199–208. Nussbaum D. Psychologists should be free to pursue prescription privileges: a reply to Walters. Can Psychol. 2001;42:126–30. O’Kane A, Tsey K. Towards a need based mental health resource allocation and service development in rural and remote Australia. Australas Psychiatry. 2004;12:390–5. Perkins D, Larsen K, Lyle D, Burns P. Securing and retaining a mental health workforce in far Western New South Wales. Aust J Rural Health. 2007;15:94–8. Pettifor J. Personal reflections on 60 years of psychology: many roads to truth. Can Psychol. 2004;45:11–5.

18

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Pettifor J, Estay I, Paquet S. Preferred strategies for learning ethics in the practice of a discipline. Can Psychol. 2002;43:260–9. Philo C, Parr H, Burns N. Rural madness: a geographical reading and critique of the rural mental health literature. J Rural Stud. 2003;19:259–81. Pong RW. Rural Poverty and Health: What do we Know? Presentation to the standing senate committee on agriculture and forestry. Sudbury: Laurentian University Centre for Rural and Northern Health Research; 2007. Pope JF, Arthur N. Socioeconomic status and class: a challenge for the practice of psychology in Canada. Can Psychol. 2009;50:55–65. Romanow RJ. Canada’s medicare – At the crossroads? Can Psychol. 2006;47:1–8. Romanow RJ, Marchildon GP. Psychological services and the future of health care in Canada. Can Psychol. 2003;44:283–95. Romanow RJ, Marchildon GP. History, politics, transformational change in Canadian health care: a rejoinder. Can Psychol. 2004;45:239–43. Roufeil L, Lipzker A. Psychology services in rural and remote Australia. InPsych. 2007;29(5):8–11. Sanderson BJM. Experiencing farming in stressful times: a naturalistic inquiry. Unpublished master’s thesis. 2004. Saskatchewan, Canada: University of Saskatchewan, Saskatoon. Schank JA, Skovholt TM. Ethical practice in small communities: challenges and rewards for psychologists. Washington, DC: American Psychological Association; 2006. Schopp LH, Demiris G, Glueckauf RL. Rural backwaters or front-runners? Rural telehealth in the vanguard of psychology practice. Prof Psychol Res Pract. 2006;37:165–73. Seijts GH, Latham BW. Creativity through applying ideas from fields other then one’s own: transferring knowledge from social psychology to industrial/organizational psychology. Can Psychol. 2003;44:232–9. Shepard B. In search of self: a qualitative study of the life-career development of rural young women. Can J Counsel. 2004;38:75–90. Stamm BH, Lambert D, Piland NF, Speck NC. A rural perspective on health care for the whole person. Prof Psychol Res Pract. 2007;38:298–304. Sternberg RJ. The role of biological and environmental contexts in the integration of psychology: a reply to Posner and Rothbart. Can Psychol. 2004;45:279–83. Strong T, Pyle NR, deVries C, Johnston DN, Foskett AJ. Meaning-making lenses in counselling: discursive, hermeneutic-phenomenological, and autoethnographic perspectives. Can J Couns. 2008;42:117–30. Thorngren JM. Rural mental health: a qualitative inquiry. J Rural Community Psy. 2003;E6 (2):163–8. Turpin M, Bartlett H, Kavanagh D, Gallois C. Mental health issues and resources in rural and regional communities: an exploration of perceptions of service providers. Aust J Rural Health. 2007;15:131–6. Vella-Brodrick DA, Judd FK, Scannett ED, & Burney S. Relative contributions of rurality and community connectedness to subjective Well-being in Victorian coastal regions. Int J Rural Psy. 2006(January);1. Westra HA, Eastwood JD, Bouffard BB, Gerritson CJ. Psychology’s pursuit of prescriptive authority: would it meet the goals of Canadian health care reform? Can Psychol. 2006;47:77–95. Wrigley S, Jackson H, Judd F, Komiti A. Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Aust N Z J Psychiatry. 2005;39:514–21. Younggren JN, Gottlieb MC. Managing risk when contemplating multiple relationships. Prof Psychol Res Pract. 2004;35:255–60.

Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competence to Practice Social Work with Māori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural Aotearoa New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Te Whare Tapa Whā . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Discipline of Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anti-oppressive Practice and Rural Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages for Effective Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter provides an analysis of rural social work in mental health with a particular focus on anti-oppressive practice. The chapter is written within the Aotearoa New Zealand (ANZ) context and as such addresses cultural dimensions essential to practice with Māori (indigenous peoples of New Zealand). The chapter begins by summarizing some key facts about rural ANZ followed by identification of organizational initiatives that have been developed outside of the statutory mental health sector to address health and well-being. Discussion about Te Whare Tapa Wha (Durie, Māori Health Development. Auckland: Oxford University Press, 1994) follows a paradigm for understanding the holistic dimensions of Māori. Next, antecedents for modern-day social work are explained noting the dual functions of social justice imperatives alongside, case management. Mental health social work using Larson’s (J Progress Hum Serv 19:39–54, 2008) seven principles of anti-oppressive practice discussed next to demonstrate the implications for rural social work practice in Aotearoa New Zealand. The relevance and application of J. Maidment (*) School of Language, Social and Political Science, University of Canterbury, Christchurch, New Zealand e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_19

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ecological systems theory to rural social work is alluded to throughout. The chapter concludes with a case study to consider and a list of key points about how to foster effective rural mental health social work in an ongoing way.

Introduction The literature and research related to social work and rural practice in New Zealand is very sparse. To date no material recording social work practice related to rural mental health could be found. This revelation highlights a serious knowledge gap about rural social work practice in general and about rural mental health social work more specifically in New Zealand. As such this chapter has been written with reference to research conducted by a range of entities from outside social work that shed light on rural living and health status in this country. The implications for social work have been considered, particularly with reference to addressing principles of anti-oppressive practice and in relation to working safely within a rural context. Significantly, social work practice in New Zealand must be conducted with reference to bi-cultural understanding and engagement. This principle means that practitioners need to be cognizant of Māori worldviews and prepared to practice in ways that best suit tangata whenua (indigenous peoples of New Zealand). This requirement is reflected in the first competency for social work registration in New Zealand as stated below:

Competence to Practice Social Work with Ma¯ori The social worker demonstrates this competence by: • Demonstrating knowledge of the Treaty of Waitangi, te reo Māori, and tikanga Māori. • Articulating how the wider context of Aotearoa New Zealand both historically and currently can impact on practice. • Te Rangatiratanga: Maintaining relationships that are Mana enhancing, selfdetermining, respectful, mindful of cultural uniqueness, and acknowledge cultural identity. • Te Manaakitanga: Utilizing practice behaviors that ensure mauri ora by ensuring safe space, being mana enhancing and respectful, acknowledge boundaries and meet obligations. • Te Whanaungatanga: Engaging in practice that is culturally sustaining, strengthens relationships, is mutually contributing and connecting and encourages warmth. (Social Workers Registration Board 2016).

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Meeting this competency means that dominant Western models for understanding mental health may not always be the most appropriate or helpful to use when working with Māori service users. In this chapter Te Whare Tapa Wha (Durie 1994), an indigenous model of health is explained. The way in which mental health is conceptualized and understood by the service user, by their family, and by the practitioner will have an impact on how mental health issues are acknowledged and addressed. Notions of self-reliance and resilience abound in rural New Zealand as they do in rural communities elsewhere (Maidment 2012). Within this context, values of individualism and stoicism flourish, where responsibility for well-being is seen as resting with the person, with little reference to the broader social, economic, and structural dimensions that impact on health. In this vein the considerations of the collective health as in health of an iwi (extended kinship group for Māori) are not part of the focus for Western mental health practice. The mental health of a different collective that of rural dwellers is also not addressed aside from individual presentations within traditional mental health practice. Ecological systems theory, an approach frequently used in social work, does however take account of the highly contextualized, changing and interdependent relationship individuals, families, and communities have with their environment (Harvey 2009), recognizing the impact of environmental dimensions (including social, cultural and economic dimensions) on mental health. The use of ecological systems theory is referred to throughout this chapter with reference to social work with people in rural communities.

Rural Aotearoa New Zealand Key information about rural New Zealand gleaned from the 2013 census show that 14% of New Zealand households are located in rural areas, with the majority living in regions with 300 or less in population. While 71% of the exports for ANZ are associated with agriculture, forestry, and seafood, just 30% of the rural workforce are employed in these industries with many in the population working in other sectors or travelling to urban centres for employment (Statistics New Zealand 2016). Retention of young working age people in the 19–39 age bracket in rural ANZ is a key issue, as it is in other countries, creating problems for securing farm labor (Pitt 2010). A significant portion of those living in remote regions have no children, a reflection of the aging rural population in this country (Statistics New Zealand 2016). Since the economic downturn of the 1980’s, rural townships in New Zealand have lost the services of shops, banks, and small hospitals and experienced diminishing school rolls (Smith 2010) resulting in threatened and actual school closures. These changes impact upon the economic sustainability of rural towns with a growing number of rural poor; people moving to rural locations are attracted by the low rents and house prices (Pitt 2010). The link between poverty and compromised health status has been well documented, with Māori being disproportionality impacted (Haultain 2012). Together with the corporatization of the primary industries, these

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changes to the nature of rural living and working have impacted on individual and community welfare and health in rural regions. One of the main frustrations for examining rural mental health in New Zealand is locating up-to-date compiled statistics on the incidence and outcomes of mental health presentations and treatment. Even so a report commissioned by FARMSAFE published in 2012 notes coronial data related to workplace death, indicating a triplefold increase in rural suicides between the years 2008 and 2011, averaging 25 completed rural suicides per year (Walker 2012, 6). Data for the years 2001–2005 presented in the same report showed that occupational status could be a strong predictor of suicide risk with those working in fisheries, farming, forestry, and trades having a higher suicide rate than other occupations (Walker 2012). Further, the Accident Compensation Commission in New Zealand published a review on farmer mental health (Goffin 2014). In it the author noted that uncontrollable events (such as natural disaster and weather events), peak work periods, and mental illness influence suicide rates; and that services accessed by farmers may not be appropriate for their needs (Goffin 2014, 3). Factors operating at the global and national levels such as climate change, commodity markets, high interest rates, weather dependency, and the presence of disease or pests contributed to stress among those dependent on primary industries. Financial stressors also impacted on mental health with irregular and uncertain income and debt servicing in particular, along with and meeting government compliance requirements adding to pressures (Goffin 2014). It was noted in this review that mental illness among farmers was likely to result in an increased risk of injury, accidental death, and suicide (Goffin 2014, 5). Research focused on farming community mental health conducted in New Zealand between the years of 2010 and 2013 included a sample of farm owners, managers, share-milkers, and hired labor. The research recruitment occurred through “health pit stops” set up at major dairying events throughout the country (Botha and White 2013). Data gathered showed a high prevalence of exhaustion among this population, higher than the estimated national average for mood disorders during 2011, 2012, and 2013; with 26% of the sample population (n¼478) suffering from burnout during the 2012–2013 period. Rapid increases in herd size within the dairy farming sector resulted in farmers reporting additional stressors related to issues with staff recruitment, retention, and management (Botha and White 2013). While these figures shed some light on adult farmer mental health, they do not give any indication about the wider family wellness including the health of spouses, children, and adolescents or of adults living rurally who are not involved in the farming sector. Despite difficulty in New Zealand with sourcing accurate statistics about rural mental health, there has been in recent year’s greater recognition of the need to acknowledge and address mental health in rural locations. This focus has seen the emergence of an infrastructure of networks with a desire to both increase mental health literacy and response to mental health presentations. An early initiative in New Zealand has been the development of the nationwide network of Rural Support Trusts, set up to help people and communities deal

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primarily with adverse events, including climatic and natural disasters, personal crisis, and financial issues. Although not specifically focused on mental health, different regional trusts have published awareness raising materials and resources focused on mental health (e.g., Feeling down on the farm 2016a, b). These trusts are not solely focused on working with farmer populations in the rural regions. Other organizations such as Federated Farmers, NZ Young Farmers, Dairy Women’s Network, and Rural Women NZ have between them significant contact with many people living rurally, and they each promote contacts with existing services in local communities that can address mental health. A recent initiative in New Zealand, Farmstrong, is a collaboration between the Mental Health Foundation, FMG (Farmers and Growers insurance and advice), Accident Compensation Commission, Movember (a men’s health initiative), and NZX Agri (the NZ capital markets operator). Farmstrong is a not-for-profit organization dedicated to encouraging farmers to “live well and farm well” (Farmstrong 2016). The organization promotes openness in discussing mental health issues with its website-containing resources and discussion pages for people to use. The appointment of Sam Whitelock, All Black rugby player to be ambassador, has been strategic. Whitelock understands rurality having grown up on a farm in the Manawatu district and holds a certain status due to his sporting prowess. Sporting connection and participation have long been integral to rural identity in New Zealand (Pitt 2010; Smith 2013). The Rural Health Alliance Aotearoa New Zealand (RHANZ) is another key stakeholder in promoting best practice in rural health service delivery, research, and policy development. RHANZ has as its main objective “to bring a ‘united voice’ – from across multiple rural sector organizations – to develop solutions and influence policy affecting the health and well-being of rural communities” (RHANZ 2016). The Alliance has been contracted by the Ministry of Health to make a substantive submission toward the development of a Framework to Improve Mental Health and Addiction Outcomes for rural New Zealanders. At the time of writing this chapter, this submission was not yet available to the public. However, “The Framework to Improve Mental Health & Addiction Outcomes for Rural New Zealanders, commissioned by the Ministry of Health, and led by the Rural Health Alliance Aotearoa New Zealand, has at its core, activities; to empower rural communities to care for themselves and each other; to strengthen linkages between communities and mental health and addiction networks and to increase accountability for District Health Boards and Primary Health Organisations for rural health outcomes. This latter activity includes working toward a nationally agreed definition of ‘rurality’ as it pertains to health in New Zealand and establishing a program to identify information needs and associated capture of data across all funded services. It is hoped the Framework will help reduce the level of mental distress and suicide in rural communities as well as being the catalyst for meaningful rural mental health reporting and analysis” (Michelle Thompson, RHANZ CEO, Personal communication November 2016). It is evident that there are many different organizations working toward strengthening the physical and mental health of rural New Zealand. While significant

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urbanization of the Māori population occurred in New Zealand during the post-World War II period, a migration that resulted in significant cultural disjuncture and fracturing for many, Māori still comprise 16% of the current rural population in New Zealand (Statistics New Zealand 2016). Specific models for working with Māori in health settings have been developed. Of these Te Whare Tapa Wha is the best known

Te Whare Tapa Wha¯ During the last 30 years, there has been growing recognition and use of models from outside of mainstream psychiatry, for working with Māori in mental health (McNeill 2009). Since health is a holistic notion for Māori, these models have been adopted by practitioners to use in work across diverse fields including child protection, youth justice, community corrections, as well as in mental health. A distinguishing feature across a number of the models is the way health is associated with the interconnectedness between the mind, body, and spirit, underscored by relationship with social and natural environments. In this chapter Te Whare Tapa Wha is discussed due to its enduring relevance for shaping responses to both personal mental health presentations as well as application to health policy. Te Whare Tapa Whā was developed by Māori psychiatrist Professor Mason Durie (Rangitane, Ngāti Kauwhata, and Ngāti Raukawa tribal connections). Within this model the balance is sought between the four cornerstones for health. These cornerstones include Taha tinana (physical health), Taha wairua (spiritual health), Taha whānau, (family health), and Taha hinengaro (mental health) (Durie 1994). None of the cornerstones can be considered on their own, as overall health is the outcome of the integration of all. The inclusion of Taha whānau signals that the service user system includes the broader family as part of the direct intervention. As such, conditions of inclusion and confidentiality need to be discussed since the service user might well wish for numbers of her family to be involved in assessment and treatment from the outset. In later work Durie noted that Māori in New Zealand suffered the fate of many indigenous populations in colonized nations including confiscation of land and serious compromise to language, culture and autonomy. He observed a turning point came in 1984 when the new Labour Government formally recognized the need to meet the Crown’s obligations under the Treaty of Waitangi, signed in 1840 (Durie 2011). The resultant application of Treaty principles to social policy quickly saw Māori reinstated as an official language for ANZ as well as a shift in consciousness and practice across health and social service sectors. Acknowledgment and recognition of the unique features for attending to Māori well-being have subsequently grown. Durie contends there are still significant challenges for mental health practice with Māori, including incorporating a deeper appreciation for the social and environmental relationships service users may have; providing greater recognition of the concept of wairua (spirituality) in mental health assessment and intervention; challenging the continued practice of separating out mental and physical domains of

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health which create a barrier to providing holistic care; fostering the development of a Māori health workforce; and tackling through social policy the inequitable socioeconomic circumstances that continue to impact on Māori well-being in ANZ (Durie 2011, 33). An important policy document released by the Ministry of Health in New Zealand (2014) seeks to redress the dominant influence of non-Māori medical models of care in ANZ. Tikanga ā-Rongoā was developed through partnership and collaboration with iwi [tribal grouping] and service providers and establishes a standard for culturally appropriate, quality health service delivery with Māori. Tikanga ā-Rongoā is a voluntary standard that care providers are encouraged to demonstrate for the safe delivery of effective health services for Māori. Resources including professional development toolkits to help organizations and practitioners to meet this standard have been made available. The authors of Tikanga ā-Rongoā explain: Rongoā [Health] Māori is a wellbeing oriented practice. It is a specialty based on a body of knowledge accumulated by tipuna [elders, grandparent] Māori that is applied in totality to bring about wholeness or interconnectedness of body, mind, emotion, spirituality, energy, society, culture, relationships and environment. It is a way of being in the world and sharing the appropriate knowledge to help restore balance. It is not a medical modality in which components can be selected or ignored as one chooses. It is a process that combines healing tradition, environment and mātauranga [knowledge of everything visible and non-visible]. As such it differs significantly from a western medical paradigm which has at its heart the identification and management or treatment of disease. (Ministry of Health 2014, 3)

As noted in the Introduction to this chapter, social work as a discipline has a commitment to achieving the integration of a Māori worldview into practice and a responsibility to demonstrate this cultural competency in meaningful ways. Although social workers play a distinct role in the delivery of mental health services, historically this role has not been well articulated by practitioners themselves or properly understood by other members of multi-disciplinary teams.

The Discipline of Social Work Social work as an occupation dates back to the late 1800s with its antecedents firmly embedded in the work the British Charity Organization Societies (COS) established in the 1860s, the social activist work of American Jane Addams (1860–1935), and pioneering of social work delivery by Mary Richmond (1861–1928). The different approaches that COS, Addams, and Richmond brought to their work with the poor and disenfranchised contributed to the foundation for contemporary social work service delivery. Jane Addams established Hull House a settlement community for mainly immigrant women in Chicago. The focus of her work was to empower in practical ways people who were poor and new migrants to the city. Addressing poverty and child welfare was to the forefront of the work at the settlement house.

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This practice was supported by prominent social workers and reformers of the time (Jane Addams 2016) and involved consciousness raising about matters of power, privilege, and rights. The ethos and practice at Hull House were driven by the needs of the immediate surrounding community and underscored by principles of community development, civil rights, and social justice. In a different yet equally important vein, the charity work of Mary Richmond (1861–1928) created precedent for contemporary social work practice. Richmond’s earliest publication “Social Diagnosis” (1917) documented systems for social work case management. In this publication Richmond emphasized the need for systematic research on issues that prompted individual troubles. Her second publication “What is social casework?” (1922) encouraged practitioners to examine ways to communicate effectively with clients, help clients problem solve independently, and foster client resilience (History of Social Work 2016). Richmond’s documented observations from her case study work provided a strong precursor to ecological systems theory used extensively in contemporary social work (History of Social Work 2016). Ecological systems theory has a focus on the interrelationship between a person (or family group) and their environment. Central to its use is an examination of the nature of relationships between different parts of the family system at the micro (personal, individual level of functioning), meso (connectedness to community resources such as school, church, or workplace), and macro (impact of wider political and societal discourses). Using this model enables a practitioner to gain a greater understanding of a family system and identify key stressors and ways in which an individual or family group are responding to manage these. As such Addam’s approach mainly addressed meso and macro concerns derived from grassroots engagement with the local community and included a politicalized analysis of presenting issues, while Richmond provided the foundational research and documented ideas that led the development of individual casework management systems. Addressing both individual personal concerns and broader political issues remains part of the social work mandate. This dual approach is reflected in the most recent definition of social work offered by the International Federation of Social Workers. IFSW state: The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilizing theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work. (IFSW 2016)

The reference to the “where people interact with their environment” signals the centrality of ecological systems theory for social work assessment and intervention (O’Donoghue and Maidment 2005). This approach guides the practitioner to pay attention to clients’ relationships and the impacts of these at the micro-, meso-, and macro-levels of personal, community, and societal functioning to identify how and where best interventions may be targeted.

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Anti-oppressive Practice and Rural Social Work There is agreement in the literature that rural social workers frequently need to be generalist practitioners to address the diverse scope of presenting client issues (Daley 2010; Locke and Winship 2005; Warren et al. 2014). Practitioners in small towns and rural regions can be the identified key worker in cases that span care and protection matters pertaining to children, older persons, and people with intellectual disabilities; issues related to family violence, offending and juvenile justice; and intervening in cases specific to mental health presentations. In all fields of practice, social workers are likely to encounter clients experiencing mental health issues. Rural practitioners also use generic social work interventions that include individual case management (both online and face to face), facilitating groupwork and fostering community development initiatives. As such rural social workers are both generalist in terms of the fields of practice in which they engage and generic in their mode of intervention (Pugh and Cheers 2010). The degree of responsibility and competence required to practice with this broad mandate necessitates specialist levels of knowledge and skill, particularly in the areas of risk assessment and intervention, safety planning, and ethical decision making. For the rural mental health practitioner, it is crucial to pay respect to the key historical markers that underscore the culture for the region (environment) in which they work, in order to understand the location of the community and individual service users within that particular milieu. Social positioning within small and dispersed communities is scripted by factors such as longevity of residence, contribution to the life of the community, family reputation, and personal and professional credibility. Standing in the community is not necessarily a reflection of economic interests and land ownership. Other features such a sporting prowess, community leadership, and sustained volunteer contribution all hold social capital currency in rural areas. It has been argued that Western ideas about well-being, mental health, and care have dominated psychiatric service delivery, with little recognition or use of more holistic models for understanding and responding to the human condition (Larson 2008). Importantly for working with Māori, the indigenous population of Aotearoa New Zealand, attending to notions of connection with whakapapa [ancestry] and traditional tribal lands with associated mountains, lakes, rivers, and sacred spaces, is integral to facilitating both individual and collective physical and mental well-being. Social workers in hospital and community mental health multi-disciplinary teams (MDT) can typically find themselves being the sole social work practitioner in the team. As such it is critical for the worker to be able to clearly articulate what the discipline specific aspects of their work will entail. On occasions the MDT will not be resident in the town or region where the service is provided and may offer a clinic on a rostered basis. If this is the case, it is especially important for practitioners to make efforts to get to know the community and its people, rather than simply be “drive in drive out” professionals. In cases where the social worker may reside in the local area and taps into the expertise of a mental health service at a distance, it is imperative the worker does not respond to crisis situations without first consulting

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with other mental health team members. Working in isolation is not safe or effective for the practitioner or ultimately the service user system. The social work knowledge base is grounded in fields of sociology and social policy enabling practitioners to contribute a structural analysis of the social conditions frequently experienced by the marginalized populations overrepresented in mental health services. As Byrne and Swords observe “It [the bio-medical model] recognizes biochemical and genetic forms of distress but not necessarily external, systemic and collective distress stemming from family and societal stressors, thus placing responsibility for wellness on the individual” (2015, 73). It is the role of social worker to bring to the attention of a MDT and service user the nature of these types of stressors and address them with the service user and within the wider mesoand macro-systems. This systemic lens gives rise to accessing opportunities for advocacy at meso- and macro-levels for better conditions that impact upon mental well-being such as safe and secure housing, access to employment, and adequate income support. While different disciplines bring diverse contributions to MDT’s, social work is a strongly values based occupation where practitioners have historically worked in partnership with service users and have been particularly influenced by anti-discriminatory and anti-oppressive paradigms for practice (Gould 2016). This values stance harks back to the social justice antecedents of the discipline but does also present particular challenges for practicing in the field of mental health where a bio medical discourse is often dominant, or ‘at best’, a bio-psycho-social model may be used (Larson 2008, 40). To work from an anti-discriminatory or anti-oppressive stance requires social workers to challenge social relations that appear to be detrimental to a service user or the service user system as a whole. At times this may take the form of addressing hierarchical, patriarchal and power differentials within the mental health system or MDT itself; no easy task for a worker who occupies a minority status within that system. From his collaborative inquiry with social work students and practitioners working in mental health, Larson (2008) was able to identify seven principles for actioning anti-oppressive practice in this field. These principles include Inviting service users to be full participants in all aspects of mental health service (2008, 44). This principle appears self-evident in light of the growing recognition of consumer rights and the empowerment experienced by service users as being active participants in their own care and in mental health system development (Scott 2016). The reality however is that service user participation in most aspects of mental health service activity such as staff meetings and governance as well as mental health policy and development remains limited in Aotearoa New Zealand. To more fully embrace this level of service user inclusion, traditional paternalistic values such as “the professionals know best” would need to be revised. However, it is within the scope of current social work practice in mental health to promote opportunities for consumer inclusion where possible. This principle has been evident in part within rural mental health promotion in New Zealand through the inclusion of many service user stories acknowledging engagement with mental health systems and prompting others who may need to do so to do the same (Feeling down on the farm 2016b)

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The second principle is Using language and discourse that is respectful, egalitarian and empowering (Larson 2008, 45). The way dominant cultures (in this context mental health professionals) use particular language to perpetuate and maintain power over service users has been explored in the literature (Alex et al. 2013; Byrne and Swords 2015). Research with a group of adolescent service users identified that both familial and professional discourses encouraged participants to conceal experiences of mental ill-health reinforcing associated stigma. The labelling of “disordered” fostered by consistent reference to the DSM V signals dominant aspects of the culture within mental health services and serves to maintain the demarcation between “them” the service users and “us” the professional staff. It is not hard to see how even small changes in the way language is used both between staff and with service users and their families might create a more egalitarian and less stigmatizing environment for service users. Although the dominant psychiatric discourse has enormous power, the role of social work is to try and negotiate spaces and processes that enable respectful and more emancipatory language and discourses to be used in practice and policy development. While Larson discusses the importance of language within mental health service delivery, for practice in rural communities, it is very important for the practitioner to also be cognizant with the language of rurality, the meaning and appropriate use of key farming terms, and the usage of Māori language for greetings and exchange of mihimihi [basic introduction to let people know of where you come from]. Within a rural environment, the conversation with a new service user generally starts first with acknowledgment of the place a person lives, their length of time in the district, if you have not met before; some dialogue about the weather (this is not small talk, as the weather has a crucial role of play on the land); and discussion about the wider family unit. This is the case for both Māori and non-Māori. This engagement phase is likely to take longer than within an urban setting where initial conversations usually focus directly on the purpose for a referral without too much preamble. The third principle for actioning anti-oppressive social work practice within mental health service delivery is To actively deconstruct the medical model with service users and their families and actively encourage alternative healing perspectives and strategies (Larson 2013, 46). In Aotearoa New Zealand, this principle needs to be considered in relation to obligations Crown entities have to protect Māori interests under the Treaty of Waitangi. These obligations include the delivery of statutory mental health services that recognize and are responsive to Māori rights to be in control of matters that affect their sense of well-being. There have been multiple models for addressing health issues developed by and for work with Māori (McNeill 2009). During the last decade, there has also been a significant increase in Kaupapa Māori organizations established to deliver health services. Even so the fact that internationally Māori in ANZ experience the highest rates of seclusion (McLeod et al. 2013) suggests there is still significant improvement required for effective Kaupapa Māori mental health services to become widely available, and this will be even more so in rural regions where access to specialist mental health services can already be limited.

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While all social work practitioners need to be mindful of these cultural considerations in working with Māori, it is important not to assume that all Māori who are engaged in mental health services will have strong links with their iwi (tribe) or hapu (family group within an iwi). Practitioners who are uncertain of how to work with a Māori service user are advised to consult with a specialist Māori mental health worker or a Kaumatua (elder) in their region. In some district health boards, Pukenga Atawhai (specialist Māori mental health workers) are attached to mental health services. The offering of alternative healing practices for migrant and refugee service users within statutory mental health services in ANZ is limited. Significantly, research conducted across Australasia identified that for refugee service users, effective response rates to a trial of anti-depressants were lower than would normally be expected (Briggs 2011, 342). This finding signals that different forms of treatment and healing are necessary for this population group, an understanding of which would be strengthened by developing greater cultural competence among mental health staff. Within this context social work practitioners can create opportunities for growing cultural awareness and competence within mental health settings and encourage consideration of alternative recovery strategies within team and family meetings. With specific reference to working in rural communities, Pitt reminds social workers that “Practicality is another characteristic of rural clients, who don’t want ‘fluffy’ service delivery but practical down to earth assistance” (Pitt 2010, 42). In this regard while pharmacological interventions to improve mental health are often necessary, planning strategies that address prevailing stressors, like debt servicing, stock management, or addressing isolation are equally important to consider. Here it is important for the rural social work practitioner to have good networks with local banks or people who can provide informed advice and support in managing farm finance; veterinary and stock management advice; and local people or groups who are willing to be a listening ear or support for those feeling isolated. Clearly issues of privacy and confidentiality need to be addressed to ensure that service user and family matters are kept confidential and this is an important discussion to be had if linking a person in with an informal support person or network. The fourth principle Larson (2008) offers for fostering anti-oppressive practice within mental health is Establishing just working relationships (2008, 47). This principle refers back to the social justice imperative of social work practice identified in the IFSW (2016) definition. This principle is demonstrated in practice by not using titles or referring to educational qualifications of staff; encouraging service users to speak up and ask questions; helping demystify service delivery by providing explanations of care options and jargon used; keeping the focus on service user strengths and fostering the inclusion of service user input in all decision making; actively getting service user evaluation of treatment received and ways to improve service delivery; and providing welcoming and friendly meeting environments (Larson 2008). Practitioners need to be self-aware and vigilant to the ways in which the dominance of the psychiatric discourse unfolds and is ever present through daily

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interactions in order to promote the above strategies. In this regard social workers within the system need to be prepared to make visible the small and large moments where disempowerment of service users occurs, to bring about more egalitarian social relations within that system. The cultural values of rural communities are not homogenous and will differ depending upon the geographical location and population makeup of the particular region. Even so, in New Zealand, as elsewhere in other countries, there is a dominant discourse that highlights rural resilience, problem-solving, and a “can do” attitude (Maidment 2012). Within this milieu the demonstration of egalitarian values and competence are important markers of credibility. The rural practitioner can draw upon these values to promote partnership in problem-solving to address mental health difficulties, acknowledging current and past successes during intervention. Part of ensuring just service delivery is to make access to services more equitable. This could mean the practitioner needs to develop a plan for service users to access additional mental health expertise as required, especially when transport options are often limited. E-health service delivery may need to be considered if the service user lives very remotely. The fifth principle to promote anti-oppressive social work practice within mental health is Promoting Education (Larson 2008, 49). Education is necessary at the micro, meso- and macro-levels to address stigma and discrimination most users of mental health services experience (Ben-Zeev et al. 2010). At the micro-level this education agenda is important in work with service users to address both internalized oppression and unhelpful prejudicial assumptions that family and community members may perpetuate about mental illness. Internalized oppression (or self-stigma) refers to the “the incorporation of others’ prejudices and stereotypes about people with mental illnesses into beliefs about oneself” (Lucksted and Drapalski 2015, 99). It is not uncommon for service users to speak about and think of themselves using negative stereotyping labels that reinforce disempowering narratives. Drawing upon the education role social workers can introduce counter narratives of resilience and choice. Educational initiatives at the meso (community and organizational) and macro (national and policy) levels are equally relevant and are within the mandate of social work as a discipline to address. Several of the regional Rural Support Networks have compiled information to address stigma about mental health in their areas (Feeling down on the farm 2016a, b). Part of these efforts have included publishing personal testimonies from rural people who have addressed mental health issues. Social work in a rural community involves discussing with the service user (or whanau, extended family) perceptions of mental health with the view to encourage disclosure to close friends and family about mental health status. The use of normalizing and giving information about the incidence of mental health presentations across the population are an important part of that discussion. This is where having up to date information on the incidence of different types of mental health presentations would be very helpful. Part of a social work role is community education and this can occur in rural communities in a variety of ways including both developing and using online resources with existing networks, engaging with local radio for discussions and presentations at field days.

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The sixth principle for anti-oppressive practice identified by Larson is “Embracing cultural diversity and strengths perspective in practice” (2008, 50). It is evident that different cultures perceive mental well-being in diverse ways and attribute healing and recovery to a wide range of modalities. Treatment seeking behavior, the role of gender and family dynamics, and coping styles are all shaped by culture but also influence what the best process might be for mental health intervention (Gopalkrishnan and Babacan 2015). Through engaging with this principle, practitioners will be open to considering non-Western traditions and approaches to healing that may be more familiar and acceptable to the service user. Rural New Zealand has a significant proportion of migrant workers, predominately from the Philippines and Pasifika nations who are employed in dairying and horticulture. It is imperative the rural practitioner develops a knowledge base about the culture of migrants in the community in which they work. Some language skills such as knowing basic greetings can help to break down initial barriers, with the view to also networking with community leaders (of different ethnic groups) to gain some understanding about how mental health presentations may be interpreted within the service user’s country of origin. The current level of integration of diverse cultural perspectives about wellness within mental health provision in ANZ appears to be low. Recent research notes that young people from Pasifika nations did not engage well with statutory mental health services; experienced a disjuncture between their own traditional and western views about mental health; identified the need to address cultural competency of staff; and advocated for the inclusion of the wider family in the engagement, assessment, and treatment processes (Tiatia-Seath 2014). A second qualitative study with health professionals canvassed views about Chinese population use of mental health services in Canterbury (Zhang et al. 2013). This research also noted cultural dimensions that were potential barriers to use of mental health services for the Chinese population, such as needing information about mental health and how to access services in Chinese language; concerns about acceptance within mainstream services; lack of practitioner knowledge about traditional Chinese medicine practices; and a general reluctance by Chinese people to seek help (Zhang et al. 2013). For a rural social worker taking an anti-oppressive practice approach, these barriers signal areas for intervention including proactive networking with the culturally and linguistically diverse communities in the community to make sustainable and strategic connections; resource development in appropriate languages; and facilitating education initiatives within the multi-disciplinary team. The final principle for anti-oppressive practice within the mental health setting outlined by Larson (2008) is Promoting principles of social justice. This principle has been an enduring tenet within the discipline of social work since the late 1800s. The expectation that the social worker will be proactive in promoting a social justice agenda is set down in the Aotearoa New Zealand Association of Social Work’s practice standards: Standard 9 “The social worker has an awareness of and demonstrates a commitment to social justice, human rights and human dignity” (2014, 6). While promoting social justice is integral to social work, it potentially raises serious questions for the practitioner working in a mental health setting when considering

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issues of self-determination, privacy, use of restraint, and seclusion (Scott 2016). For practitioners in rural regions, the matter of access to services is also a social justice issue. Promoting policy and service development that facilitates better access to mental health resources and professional expertise is integral to practicing in this context. Social work in rural Aotearoa New Zealand remains an “invisible” occupation, yet there is much that practitioners in this work do to help sustain the health and wellbeing of small communities and the people who live there. Every day these practitioners will encounter people who are living with mental illness. Both service users and the people they live with deserve effective mental health service delivery despite their rural address. While most district health boards do have rural outreach, there is still much to be done to counter the stigma and barriers for accessing specialist mental health services. For social work as a discipline in this country, there needs to be systematic research about the discipline reach into rural Aotearoa New Zealand and the extent of mental health service delivery offered by practitioners. This is fertile ground for seeking baseline knowledge regarding rural mental health social work practice in Aotearoa New Zealand.

Case Study Datu is a 30-year-old man from the Philippines who has migrated permanently to New Zealand and was joined by his wife Divina six months ago. Datu works on a dairy farm in South Canterbury and Divina cares for their newborn daughter at home. They live on the farm property in a house provided by their employer. Neither set of grandparents live in New Zealand. Since joining Datu in New Zealand, Divina has not made friends and has no connections with other new mothers. The farm property is 25 kilometers to the nearest town, and Divina does not drive. The midwife was concerned about the couple’s isolation before the birth but has now made a referral to the community mental health team due to her concern for Divina. She notes that Davina does not appear to have bonded with her baby, is listless, cannot sleep, and appears to be depressed. Since arriving home with the baby Davina has not gone outside, rarely changes her clothes, and shows little interest in attending to the newborn. Davina has told the midwife she is scared for her baby but would not elaborate on this statement. Datu does not know what to do. He is seeing to the newborn at night and working on the tractor and using heavy machinery during the day. Davina has told the midwife that only her neighborhood manghihilot [faith healer] back home can help her. 1. Before going to see Davina, what further information do you need? 2. What strategies will you use to engage with Davina and Datu? 3. How will you attend to risk management and safety for all members of this family? 4. What additional resources might you need to work effectively with Davina and her family?

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Take-Home Messages for Effective Practice As a rural social worker: • Always consult with others in the mental health team when responding to situations of crisis, even when other members of the team may be located at a distance • Draw upon Larson’s seven principles for anti-oppressive practice to find strategies and spaces within mental health service delivery to promote service user agency. • Engage with people from other cultures professionally and socially. Read about health perspectives, values, and healing practices from countries where the service users you see come from. Always ask the service user what they think might aid their recovery. • Build a supportive team around you to consult with and access professional supervision on a regular basis. The “team” may not work with you on site but could be made up of individuals from different agencies. • Remain engaged with your Professional Association and use professional development opportunities (either in person or online) for knowledge updates and collegial networking.

References Alex M, Whitty-Rogers J, Panagopoulas W. The language of violence in mental health: shifting the paradigm to the language of peace. Adv Nurs Sci. 2013;36(3):229–42. Aotearoa New Zealand Association of Social Work. Social work practice standards. 2014. [Internet] 2016. [Published November 2014; cited 2016 November 8th]. Accessed from: http://anzasw.nz/ wp-content/uploads/Practice-Standard-Publication-Full-Nov-14.pdf Ben-Zeev D, Young M, Corrigan P. DSM-V and the stigma of mental illness. J Ment Health. 2010;19(4):318–27. Botha N, White T. Distress and burnout among NZ dairy farmers: research findings and policy recommendations. Ext Farming Syst J. 2013;9(1):160–70. Briggs L. Demoralization and psychological distress in refugees: from research to practice. Soc Work Ment Health. 2011;9(5):336–45. Byrne A, Swords L. “Attention Seeker”, “Drama Queen”: the power of talk in constructing identities for young people with mental health difficulties. Ment Health Rev J. 2015;20 (2):65–78. Daley M. A conceptual model for rural social work. Contemp Rural Soc Work. 2010;2:1–7. Durie MW. Māori health development. Auckland: Oxford University Press; 1994. Durie M. Indigenizing mental health services: New Zealand experience. Transcult Psychiatry. 2011;48(1-2):24–36. Farmstrong. 2016. [Internet]. Available from: http://farmstrong.co.nz/ Feeling down on the farm. Mental health in rural Taranaki. 2016a. [Internet]. Available from: http:// www.likemindstaranaki.org.nz/uploads/Current%20resources/(Final)%20Feeling%20Down% 20on%20the%20Farm%202nd%20v2.pdf Feeling down on the farm. Mental health in rural Wairarapa/Taurarua. 2016b. [Internet]. Available from: http://www.rural-support.org.nz/pdf/eFeelingDownontheFarm.pdf

19

Social Work, Mental Health, and Rural Practice: A Perspective from New. . .

433

Goffin A. Farmers’ mental health: a review of the literature: Accident Compensation Commission; 2014. Gopalkrishnan N, Babacan H. Cultural diversity and mental health. Australas Psychiatry. 2015;23 (6):6–8. Gould N. Mental health social work in context. 2nd ed. New York: Routledge; 2016. Harvey D. Conceptualising the mental health if rural women: a social work and health promotion perspective. Rural Soc. 2009;19(4):353–62. Haultain R. Making the links between low pay, poverty and poor health. Kai Tiaki Nurs New Zealand. 2012;18(3):31. History of Social Work. 1917 Mary Ellen Richmond [Internet]. 2016. [Updated 2013 April; cited 2016 November 29th]. Available from: http://www.historyofsocialwork.org/eng/details.php?cps¼6 International Federation of Social Work. Definition of social work [Internet]. 2016. [Updated 2012 March 3; cited 2016 November 29th]. Available from: http://ifsw.org/policies/statement-ofethical-principles/ Jane Addams. American social reformer [Internet]. 2016. [Updated 2012 November 9; cited 2016 November 29th]. Available from: https://www.britannica.com/biography/Jane-Addams Larson G. Anti-oppressive practice in mental health. J Progress Hum Serv. 2008;19(1):39–54. Locke B, Winship J. Social work in rural America: lessons from the past and trends for the future. In: Lohmann N, Lohmann R, editors. Rural social work practice. New York: Columbia University Press; 2005. Lucksted A, Drapalski, A. Self stigma regarding mental illness: definition, impact and relationship to societal stigma. Psychiatr Rehabil J. 2015;38(2):99–102. Maidment J. Developing new approaches to mental health in farm settings. In: Maidment J, Bay U, editors. Social work in rural Australia. Sydney: Allan and Unwin; 2012. McLeod M, King P, Stanley J, Lacey C, Cunningham R, Simmonds S. The use of seclusion for Māori in adult in-patient mental health services in New Zealand. Auckland: Te Pou o te Whakaaro Nui; 2013. McNeill H. Māori models of mental wellness. Te Kaharoa. 2009;2:96–111. Ministry of Health. Tikanga ā-Rongoā [Internet]. 2016. [Published online: May 23rd 2014; cited 2016 December 1st]. Available from: http://www.health.govt.nz/publication/tikanga-rongoa O’Donoghue K, Maidment J. The ecological systems metaphor in Australasia. In: Nash M, Munford R, O’Donoghue K, editors. Social work theories in action. London: Jessica Kingsley Publishers; 2005. Pitt L. Woolsheds, wet weather gear and the West Coast: social work practice in Taranaki. Aotearoa New Zealand Soc Work. 2010;22(3):39–47. Pugh R, Cheers B. Rural Social Work. An international perspective. Bristol: The Policy Press; 2010. Richmond M. Social diagnosis. New York: Russell Sage Foundation; 1917. Richmond M. What is social casework? An introductory description. New York: Russell Sage Foundation; 1922. Scott A. Nothing about us without us. In: Maidment J, Beddoe Christchurch E, editors. Social policy for social work and human services in Aotearoa New Zealand: University of Canterbury Press; 2016. Smith P. Whatever happened in Tuatapere? A study on a small rural community. Aotearoa New Zealand Soc Work. 2010;22(3):27–38. Smith P. Whose culture is it anyway? Social working within a rural community. Aotearoa New Zealand Soc Work. 2013;25(1):14–23. Social Workers Registration Board. Core competence standards. 2016. http://www.swrb.govt.nz/ competence-assessment/core-competence-standards Statistics New Zealand. New Zealand in Profile 2013. [Internet]. [Cited 2016 December 28th]. Available from: http://www.stats.govt.nz/browse_for_stats/snapshots-of-nz/nz-in-profile-2013/ exports.aspx Thompson M. Personal Communication. Rural Health Alliance New Zealand. 6 November 2016. Tiatia-Seath J. Pacific peoples, mental health service engagement and suicide prevention in Aotearoa New Zealand. Ethn Inequal Health Soc Care. 2014;7(3):111–21.

434

J. Maidment

Walker J. Mental health in the rural sector. A review. [Internet] 2016. [Published August 7th 2012; cited 2016 November 8th]. Available from: https://www.mentalhealth.org.nz/assets/ ResourceFinder/Mental-health-in-the-rural-sector-a-review-2012.pdf? Warren J, Ahls C, Asfaw A, Nunez J, Weatherford J, Zakaria N. Ethics issues and training needs of mental health practitioners in a rural setting. J Soc Work Values & Ethics. 2014;11(2):61–75. Zhang Q, Gage J, Barnett P. Health provider perspectives on mental health service provision for Chinese people living in Christchurch, New Zealand. Shanghai Arch Psychiatry. 2013;25 (6):375–83.

Peer Work in Rural and Remote Communities and Mental Health Services

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Fay Jackson, Tim Heffernan, Mark Orr, Robert Butch Young, Cherie Puckett, and Susan Daly

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining Peer Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Local Connection and Dedication: Peer Work in Rural and Remote Communities . . . . . . . . . . . Local Peer Workers Bridge Gaps Between Transient Workers and the Community . . . . . . . . . . Research from Across the Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peer Workers Are Crucial to Multifaceted Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preparing the Workforce Culture to Accept and Value Peer Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historically Slow Uptake of Peer Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Everyone Knows Everyone Here” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Different Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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F. Jackson (*) Vision In Mind, Brunswick Heads, NSW, Australia e-mail: [email protected] T. Heffernan · R. B. Young NSW Consumer Peer Workforce Committee, Woolloomooloo, NSW, Australia e-mail: [email protected]; [email protected] M. Orr Flourish Australia, Sydney Olympic Park, NSW, Australia e-mail: mark.orr@flourishaustralia.org.au C. Puckett Clinical Operations West, Murrumbidgee Local Health District, New South Wales Health, Wagga Wagga, NSW, Australia e-mail: [email protected] S. Daly Health, New South Wales, Sydney, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_21

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Abstract

Peer Workers are the most underutilised, valuable resource available to rural and remote mental health services and communities. Evidence has confirmed the efficacy of peer work, yet their historically slow uptake has robbed communities and individuals of the opportunity to be supported by staff who can provide an added layer of assistance as part of a multidisciplinary team or beneficial alternative to conventional treatments. This chapter seeks to inspire confidence in all stakeholders involved in rural and remote communities to engage with the valuable, fast growing, competent, and readily available Peer Workforce. It discusses the evidence, value, and efficacy of peer work in rural and remote mental health services and communities. The high level of stigma and discrimination surrounding mental health in rural and remote communities and the desperately low level of “homegrown” mental health personnel who know that the local people, customs, languages, and land can be rectified by the employment of Peer Workers from within the community they live. This chapter asserts that the ethical and practical conclusions regarding peer work in rural and remote communities are that supported, respected, and valued Peer Workers are vital to the much needed reform of mental health services. It sets out the main reasons for this by utilising recognised, published research and academic papers, along with case studies utilising peer work in three very different rural and remote areas in Australia which are utilised to demonstrate and authenticate the desperate need for and beneficial effects of Peer Work.

Introduction In rural communities, people see their crops and livestock suffer, the earth crack, dams, rivers and creeks dry up in times of drought. They see fire devastate the bush leaving charred remnants behind with the vile smell of the burnt flesh of domestic animals and wildlife. Their livelihoods and sometimes the people they love perish. The smell of death and loss lay heavily in the air, in their lungs, and in their memories long after the flames have enforced their will in their lives. They see their homes, soil and crops washed away with floods. They know the might of banks as they enact their legal right to take away their farms and homes. They know the devastating effect of this on relationships and on the small businesses and communities. All these things conspire to make it feel impossible to keep going. And yet the country recovers. Rivers flow again after the drought breaks and the grass and trees sprout again with the first rain. People rebuild after flood waters subside (van Kessel et al. 2014) as they did after the 2019 Queensland floods which dumped 1.4 meters of rain in less than 2 weeks – double London’s rainfall in a year (Morton and Smee 2019) The floods destroyed homes and livelihoods, and killed people, domestic and wild animals. In rural parts of the State, the flood killed an estimated 500,000 cattle devastating graziers already struggling with the

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impact of prolonged drought. Yet these graziers and their families continue to farm the land. Rural communities go through these ebbs and flows of nature together. They are devastated and rebuild together. However, it is a cruel fact that some individuals and families will not find the hope to continue. They may have been crushed by the blows once too often. The suicide rate for Australia’s farming people is double the general male population, at 32.2 compared with 16.6 per 10,000 (Bryant 2018). Droughts, floods, unplanned fires and climate change impact heavily on Aboriginal and Torres Strait Islander communities. “Climate change raises distinct challenges for Aboriginal people, cultures, lands and resources. It poses a threat to the health, cultures and livelihoods of Aboriginal peoples in NSW. This occurs in coastal and flood prone areas, salt inundation of freshwater supplies, changes to mangroves and fire regimes, coastal erosion and rising sea levels as well as for those Aboriginal communities affected by long-term drought and desertification, among other impacts” (Manton 2008) The indigenous male suicide rate is 39.6 deaths per 100,000 persons (ABS 2017). Parallels can be drawn between the experiences of living in rural and remote communities and people experiencing trauma and mental health issues. These issues often arise out of devastating experiences. They wreak havoc long after the trauma has passed. The destructive thoughts and feelings can pervade all aspects of a person’s life, often driving them to the point of “breakdown” or thoughts of suicide. Eventually, hope, income, and relationships fall away; and yet most manage, with time and the support of their community, to rebuild their lives (McGowan 2018). The rebuilding of lives devastated by weather changes or mental health issues is always easier with the support of people “who have been there and done that” and who live within the community (Helsloot and Ruitenberg 2004). For people with mental health issues, Peer Workers are the “been there” people (Austin et al. 2014). At a time when people with mental health issues are at their most vulnerable, the person most approachable, most easily able to relate to and bring hope back to people in psychological distress is “someone” who has already passed through similar distress, “someone” who has emerged out the other side and has shown that recovery and healing is achievable (Watson 2019a). Peer Workers are the “someone” that people can turn to. They are wonderful examples of mental health recovery, demonstrating that it is possible to live meaningful, connected and contributing lives in their community (Watson 2019a). This demonstration is vital in the fight against stigma and discrimination which is so often experienced by people with mental illness, their families and carers (Amsalem et al. 2018). Stigma and discrimination can be devastating for people who live in small rural communities. With limited specialist services to support people with mental health issues and without the connection to “someone” who has been through similar experiences, people often feel very alone and experience marginalisation. The benefits of Peer Workers and family and carer workers in these contexts cannot be overstated (Candelaria et al. 2014). ‘All truth passes through three stages. In the first, it is ridiculed. Then it is opposed. And finally, it is accepted as self-evident.’ Attributed to Arthur Schopenhauer (1788–1860)

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Distinctive Features The importance of peer work to effective rural and remote practice and communities is confirmed in this chapter through the establishment of the evidence, value and efficacy of peer work in rural and remote mental health services and communities. It leads to the legitimate conclusion that supported, respected, and valued Peer Workers are vital to the much needed reform in mental health services and to positive change in culture, stigma and discrimination in rural and remote services and communities. It sets out (NSW MH Comm. 2015) how peer work leads to: • Improved outcomes in multiple aspects of service delivery • Much improved attitudes toward mental health by individuals, communities and service personnel • Inclusive, multifaceted teams focused on sustainable recovery, hope and healing alternatives to conventional practice • A decrease in seclusion and restraint • Increased well-being of rural and remote populations Rural and remote services must strive to provide best practice, evidence-based and innovative services if they are to meet the needs of the people. Good, effective services are not governed by outdated, inaccessible, stigmatising and discriminating languages, cultures, and practices. Services responding to the outcry for positive change, for help to be available when and where people need it and utilising the least restrictive practices possible, are embracing Peer Work. This chapter demonstrates and authenticates the desperate need for and beneficial effects of, peer work through utilising recognised, published research and academic papers, along with case studies utilising peer work in three very different rural and remote areas in Australia. The employment of Peer Workers from within the community that they live can greatly reduce the desperately low level of “homegrown” mental health and wellbeing personnel. Local workers know the people, customs, languages, connections and land. They can also rectify the high level of stigma and discrimination surrounding mental health in many rural and remote communities. Voluntary peer support has been recognised as an important part of the lives of people with mental health issues in Australia for more than 30 years. Paid peer work roles, under various names, began in the early 1990s. However, informal peer support and mateship have always been a strong element in mental health and rural and remote communities. In these communities, the support of a person with lived experience of mental illness and recovery by someone else with mental health issues has been essential for reframing experience and developing hope in a better future. Research and personal stories by people who have experienced the support of Peer Workers across Australia have led to the recognition of the importance of this workforce by state and national Mental Health Commissions and by their respective governments. The National Mental Health Commission notes that:

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‘Increasingly, the Australian Government is recognising the importance of the Peer Workforce. . .. Mental Health Peer Work has been an area of focus for the Commission since our establishment in 2012. The development and promotion of the mental health Peer Workforce has been recommended as part of our 2012 and 2013 National Report Cards and the 2014 Contributing Lives, Thriving Communities report.’ (Nat. MH Comm. 2019)

Defining Peer Work Shery Mead, the founder of Intentional Peer Support which is both a philosophy and a way of working with peers, defines peer support as: ‘. . .a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. Peer support is not based on . . . models and diagnostic criteria. It is about understanding another’s situation empathically through the shared experience of emotional and psychological pain. When people find affiliation with others whom they feel are ‘like’ them, they feel a connection. This connection, or affiliation, is a deep, holistic understanding based on mutual experience where people are able to ‘be’ with each other without the constraints of traditional (expert/patient) relationships. Further, as trust in the relationship builds, both people are able to respectfully challenge each other when they find themselves re-enacting old roles.’ (Mead et al. 2019)

While peer work has its roots in voluntary peer support relationships, paid employment of Peer Workers is expanding (Watson 2019a). Those engaged in peer work are called by a variety of names such as Peer Worker, peer specialist, peer support worker, lived experience worker or consumer worker. They undertake a wide range of tasks which is of necessity, like many other roles and may be more varied and flexible in rural and remote communities. This flexibility is important. However, it is essential that Peer Workers are not undervalued by being given menial tasks which are not expected of other staff. They must also not stray into clinical practices or be utilised in coercive practices, even if through good intention (Watson 2019b), (Mead et al. 2013). These practices change the nature of the mutual peer relationship (Craze and Plant 2018). The variety of tasks undertaken in Peer Worker roles was highlighted during a workshop hosted by Flourish Australia, in Sydney in 2018. Leading Peer Workers from across Australia gathered together to discuss the current Peer Workforce across Australia (Ibid). The workshop identified over 75 roles and activity areas, including the major categories shown in in the table below (Fig. 1). Peer Workers are the fastest growing workforce in mental health in Australia (Nat. MH Comm. 2015). Their roles are different to that of other mental health workers (Ockwell and Pearce 2019). Fundamentally, they require a person to openly, thoughtfully and purposefully utilise their lived experience of mental health issues – of services and treatment, psychological distress, trauma and recovery – to support and bring hope to other people with mental illness. The supports they offer people (“consumers,” “patients”), and the relationships they build with the people they support, are based on mutuality, reciprocity, sharing experiences, honesty, hope, and

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Peer support

Promotion of wellness and physical health

Representation

Service navigation

Policy advice and development

Systems advocacy and service reform

Assessment

Change leadership

Veteran support

Care and service coordination

Managing and leading teams

Training and teaching

Working with specific groups

Individual advocacy

Research and evaluation

Peer worker supervision, coaching and mentoring

Staff orientation, induction and professional development

Program administration

Accreditation assessment and quality improvement

Facilitating co-production projects

Lived experience academics and casual/sessional lecturers

Community development and education

Facilitating engagement and participation

Consultant and advisory roles including policy development

Fig. 1 Roles and functions of Peer Workers as identified by workshop participants (Craze and Plant 2018)

a strong belief that each person is able to recover and live a meaningful, connected and contributing life (Repper 2013). The Peer Worker has “a professional role that is distinguished from other forms of peer support by the intentionality, skills, knowledge, training and experience that Peer Workers bring to their role. Peer Workers are employed as professional subject matter experts who can be a key conduit between a consumer, their other support people and the services they use” (Meagher and Naughton (2018). These “role models of recovery” are able to give hope to people with long-term mental health problems (Slade 2012).

Local Connection and Dedication: Peer Work in Rural and Remote Communities In rural and remote communities, clinical services may be sparse or nonexistent; the presence of Peer Workers is all the more urgently needed. The Australian Government Senate Community Affairs Reference Committee, which reported on the accessibility and quality of mental health services in rural and remote Australia in 2018, stated: ‘In many of the communities it visited, the committee heard about the important role played by peer support workers, who provide support to people experiencing mental illness and often fill a gap left by the shortage of mental health professionals in rural and remote communities.

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The committee recommends that peer support workers be given appropriate training to enable them to continue their role in helping people experiencing mental health issues. The committee further considers that peer support workers should be recognised as a valuable support service by being paid to perform this role in rural and remote communities.’ (Aust. Fed. Gov. 2018)

Peer Workers like all service health staff in rural and remote areas may be asked to extend their role to fill gaps in service provision; they may have a need for flexibility around what is required of them compared to their city cousins who are generally part of a large multidisciplinary team. However, Peer Workers must stay true to the peer work ethos and practices, or their unique skills may become diluted. They may be co-opted or willingly fall into performing tasks they are not trained in and that change the nature of the relationships and value the peer work brings to the individual and community. Greg Hunt, Federal Minister for Health noted recently that ‘The types of health services needed in metropolitan communities differ dramatically from those of communities in remote and regional areas’ (Aust. Fed. Gov. 2019). Peer Workers break down barriers and bring stories of acceptance, hope, recovery and living meaningful and contributing lives to their rural communities. The openness of rural Peer Workers leads to an acceptance and valuing of lived experiences, which changes community attitudes toward mental illness. Contributing lives is essential in rural and remote communities where everyone is expected to “pull their own weight.” Peer Workers are a great example for individuals and communities experiencing adversity that there is hope for a better tomorrow (Repper and Carter 2011) and that “things can and will improve” (Brown 2019). For the majority of people living in rural communities, becoming “unwell” with severe psychological distress is rarely private. Once services have been sought, one way or another, the news spreads that a person has been “unwell” (Komiti et al. 2006). Stigma and discrimination are frequently cited by people in rural and remote communities as reasons for not seeking help. The very act of becoming a Peer Worker in a rural or remote community defies and overcomes this discrimination. It demonstrates that with the right support, mental health recovery is possible and people who have had mental health issues are valuable members of the community. This impacts positively on the well-being of small communities. Peer work can also provide a different and affirming experience of mental health services. It builds on, strengthens and makes accessible the informal mental health support that has always been experienced in many rural and remote communities, where: ‘Generally, these (peer) support services are provided by people who have had their own lived experience with mental illness but have received no formal training in mental health support and are not employed or paid for the support services they provide. Many rural and remote communities rely on these outstanding members of the community.’ (Senate Community Affairs Reference Committee)

It must be noted that the report refers to people with mental health issues and traumatic experiences, who use what has happened to them in the service of

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others as “outstanding members of the community” rather than “the mentally ill” as so often referred to in the language of services, media and government agencies. These outstanding community members deserve to be paid for their work, supported and trained to manage the emotionally vulnerable positions they may find themselves in when identifying their lived experience to others in their rural communities.

Local Peer Workers Bridge Gaps Between Transient Workers and the Community In rural and remote Australia, a significant proportion of the mental health workforce is transient. In addition to a small number of long-term local staff, it is not uncommon for a rural mental health team to consist of people working anywhere from 3 months to 3 years before they move on (Humphreys et al. 2010). The ready availability of Peer Workers, like other dedicated mental health and well-being staff who are drawn from the community they live in, know the community, its history, people, languages, connections, beliefs and land. This local connection and knowledge are a priority if early intervention, suicide prevention, healing and sustained recovery are to be commonplace. Peer Workers can be a bridge between the mental health team and the community. They are the right people, in the right place, at the right time. The shortage of mental health personnel in rural and remote communities has led to an increasing number of “blow-ins” filling the small number of roles in country areas. These “new comers” may be agency staff, new graduates from other areas or may have immigrated to Australia. They may stay for only a few months or a few years as they progress their careers. Some do become “locals”; however as many of us moving to a new area have experienced, becoming a local can take quite a few years. It takes time for rural and remote people to trust “new people.” Local Peer Workers are a strong link for the local community to the new staff. Peer Workers are very adept at quickly determining if the staff members are people who can be trusted. The Peer Workers will actively break down the barriers, welcome the new staff and introduce them to their new community if they feel the new staff member will be good for their service and community (Gordon 2014). Obviously in rural and remote areas, knowing the local community is a great asset. Knowing the Aboriginal Elders, the coach of the footy club, vet, church ministers, the publican, the school principal, and the Royal Flying Doctor Service can be very helpful. Good knowledge of the land can be helpful if needed to attend an urgent situation. Knowing what services are available is of great assistance. Peer Workers engaged with these services and relationships can break down the stigma and discrimination about mental health issues and can connect the service and individuals to the community (NSW Health 2017).

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Research from Across the Globe There is growing research into the efficacy and impact of peer work in mental health services. Increasing evidence showing that peer work is not only effective and valuable to the people who access support, other staff, the Peer Workers themselves, families, and communities, it also delivers a good return on investment. Peer support has been shown to bring about significant reductions in hospital bed days, leading to financial savings well in excess of peer employment costs (Trachtenberg et al. 2013). Chinman determined that “the effectiveness of peers added to traditional services and of peers delivering structured curricula was positive” (Chinman et al. 2014). This research found the beneficial effects for people receiving services included reduced inpatient service use, improved relationships with service providers, better engagement with care, higher levels of empowerment, higher levels of patient activation and higher levels of hopefulness for recovery. The beneficial supports people report receiving from peers have driven research into trying to identify what those supports are and the mechanisms through which they are accessed or provided and how they deliver such positive results (Vayshenker et al. 2016). Peer support is a rapidly growing feature of mental health services across the world including in the USA (Chinman et al. 2001), Canada (Rebeiro Gruhl et al. 2015), in the UK (Gillard et al. 2013), Australia (Lawn et al. 2008), and Asia (Fan et al. 2018; Tse et al. 2013). The research has been so convincing that peer support is beneficial that in 2013 the World Health Organization (WHO) commented that peer support was essential to any comprehensive mental health system (WHO 2013) and technical training resources were developed, with support from across the World (Funk and Drew 2017). Notable elements of peer support have been reported to include social support, emotional support, support with treatment, support with connecting to community resources, goal planning, teaching skills, sharing experience and inspiring hope (Gidugu et al. 2015; Lawn et al. 2008; Scanlan et al. 2017). There is also evidence that consumers involved in peer support initiatives have higher levels of community integration (Repper and Carter 2011). The benefits of peer work may best be demonstrated through the use of case studies. Case Study 1 Far West Local Health District Mental Health Service

Far West Local Health District (LHD) Mental Health Service in remote New South Wales (NSW) covers a geographical area of 194,949 square kilometers and includes the traditional lands of the Barkandji/Paakantji, Wilyakali, Muthi, and Nyampa. It uniquely shares borders with three states (South Australia, Victoria and Queensland) and is closer to Melbourne and Adelaide than Sydney (1100 km away). (continued)

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Far West NSW is the most sparsely populated region in NSW with 62% of its over 30,000 inhabitants living in the regional city of Broken Hill. The remainder of the population lives in agricultural towns and villages along the Murray River, on stations or in isolated communities of 80–800 people. Of the total population, 91.1% are from an English speaking background. The region has the highest proportion of Aboriginal residents (12.7%) in NSW and many experience significant disadvantage. This population is relatively young, which reflects the lower life expectancy of Aboriginal people. Director of Mental Health and Drug and Alcohol, Susan Daly: The Connections Project Partnerships are particularly important in rural areas where services are few, so the LHD’s first major peer work project, Connections, was with our partners, Mission Australia and GROW. GROW is a community-based organisation run by and for people with lived experience of mental illness. “Growers” share wisdom and knowledge to help each other overcome life’s challenges and recover from mental ill health. Connections is an out-of-hours social connection program, aimed at reducing loneliness, wholly staffed by Peer Workers employed by Mission Australia and supported by all three organisations. It runs each Thursday, Friday and Saturday evening plus every second Sunday. People who attend Connections develop a monthly program of social activities with the Peer Workers; this includes local community activities like the movies, gym, art gallery openings and cafes. In a rural area, attendance at community activities can be quite low (e.g., the local table tennis club consists of two people) and there’s a risk they will simply stop running. By boosting attendance, Connections has a benefit for the community itself, as well as for participants. We looked at the first 6 months’ data for the five people who attended the most frequently. We found that, in the 6–7 months before Connections opened, these 5 people had used 549 acute mental health bed days and presented to the Emergency Department (ED) 16 times. In the 6 months after Connections opened, their bed days had reduced to 195 and there were only 3 ED presentations. This is equivalent to approximately $760,000 in efficiency savings. This data supported our hopes that reducing loneliness through increasing social connection, using the remarkable and unique engagement skills of Peer Workers would reduce their need for health services. But the data is just a part of it; the outcomes for some people have been life changing. For example, before Connections opened, one participant had spent almost 18 months continually in the hospital, rarely saw his family, used drugs and alcohol and was essentially homeless because he was very uncomfortable in his own home. (continued)

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Within 6 months of attending Connections, he was settled at home, ran a poetry workshop for 14 people, became a Zumba regular, and started going to the gym (both with Connections and on his own). He stopped using drugs and alcohol and is now reconnected to his previously estranged daughter and grandchild. He doesn’t come to Connections so often now, because he’s too busy being a dad, a grandfather, writing poetry and going to the gym. This true connection with community, not reliance on a service, was a major aim of the project. Peer Workers in the Far West are similar to Peer Workers everywhere despite their different backgrounds. Stuart Leyh (Peer Worker) said, “I wanted to work in a people orientated field where I’m working with others, communicating with others as opposed to mining where I was previously.” Peter Daley (Peer Worker) captured the joy of peer work when he said, “I became a Peer Worker because it seemed a natural thing to do. I am motivated to help people be happier than what they are.” Those people that responded to me as a human being and that provided me with care, support and the inclination to feel safe, gave me the belief that I could do the same for others. Now, I would be diminishing my sense of selfworth if I wasn’t a Peer Worker. It’s not about saving the world or saving other people; it’s about making possible the minor changes and improvements in life that people can make for themselves. When I heard about this job, I thought “I’m the bloke to do it.” I wouldn’t be doing anything else; as some said, “If you find the right job, you’ll never work again.” Sam Jessett, Consumer Engagement Coordinator said, “All the good will and work in the world will not tell you more about the needs of the people we support than the voices of the people being supported. Ensuring these voices are heard on an organisational level and empowering Consumers to be a force in improvement and change organisationally is largely what I do, easy right! There are so few people who are lucky enough to combine their work and their passion.”

Like other specialised professions, Peer Workers need professional supervision by seasoned, expert Peer Supervisors who have worked in similar services. While it may be necessary for their day-to-day support and supervision to be provided by a clinical supervisor, until a lived experience, Peer work manager is appointed, it is essential that they have professional external Peer supervision. This protects the role of peer work from colonisation by clinical practices, outlooks and language. It also helps Peer Workers keep up with latest research, retain a vision of the big picture and gain new skills. An independent ear to hear the Peer Worker’s concerns and help them find the right direction is invaluable.

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Peer Workers need to be supported in rural and remote communities, just as they do in metropolitan areas. Regular connections to networks of Peer Workers and emerging Peer Worker peak bodies are perhaps even more important when the Peer Worker is from a rural or remote community. In rural areas, travel costs can be prohibitive, so face-to-face meetings and gatherings with peers are not always easy to maintain. Telephone and video conferencing, online peer work communities of practice and already existing and emerging social media groups help fill this gap. As peer work becomes more common, networks of Peer Workers from a number of different local organisations in rural communities are another method of supporting this growing workforce. Work has begun on establishing a National Peek Body for the Lived Experience Workforce. Peer work can enable people to be less reliant on clinical interventions. Louise Byrne, a Lived Experience Academic from Townsville and Yale Fulbright Scholar, commented that there are many critical areas of peer work that are increasingly understood and represented in the literature, including the benefits of peer work. Yet, while research has proven the positive outcomes of peer work, there is still a need to define how the shared experiences, mutuality and reciprocity are making such remarkable differences in the lives of all stakeholders with lived experience. As Louise notes, “not all that encompasses good practice is contained in published research” (Byrne 2018).

Peer Workers Are Crucial to Multifaceted Services Across a range of human service sectors, it is acknowledged that peer work is a means of individualised interaction that can prevent the escalation of distress and marginalisation. It promotes recovery, adjustment and inclusion by enhancing the participant’s emotional, physical and spiritual well-being (Meagher and Naughton 2018). Many services in the Community Managed Organisation (CMO) and public sectors in mental health have come to recognise that peer work and other lived experience positions are crucial elements to delivering high-quality multifaceted services which meet the needs of individuals, their families and the communities they serve. Private mental health services, however, are yet to realise the value of paid peer support (Priv. MH CCN 2014). Some visionary services, like Flourish Australia and Southern New South Wales, Local Health District, Far West Local Health District, Mental Health and South Eastern NSW Primary Health Network which commissions services to employ Peer Workers, have recognised that Peer Workers strongly influence positive cultural change (Byrne et al. 2019). They have utilised designated lived experience roles to lead changes in design, culture, practice, research and reporting. Services which have employed Peer Workers and other designated lived experience roles at all levels place people with lived experience at the front of services rather than only in the centre. The paid Peer Workers and staff in other designated lived experience roles leading service change do so both from their own lived experience and that of the collective lived experience community.

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Peer-Operated Services such as the Victorian Mental Illness Awareness Council (VMIAC) in Victoria, Brook RED in Queensland and the Flourish Australia PeerOperated Service in Hervey Bay, Queensland are proof that services whose entire personnel are Peer Workers or people with lived experience, are the proof that PeerOperated Services can be services of high quality and longevity. Case Study 2 The Southern New South Wales Local Health District

The Southern New South Wales Local Health District (SNSWLHD) is part of the Public Health system in NSW and encompasses the Local Government Areas of Bega Valley, Bombala, Cooma-Monaro, Eurobodalla, Goulburn Mulwaree, Palerang, Queanbeyan, Snowy River, Upper Lachlan and Yass Valley. It covers an area of 44,534 sq./km with a population density of 4.5 residents per square km. The travel distances between towns within SNSWLHD can be significant. Traveling from Bega to Goulburn, for example, is a nearly 4-hour trip via road one way, making return trips a 10+ hour expedition. Journeys throughout the LHD can be further lengthened by the Great Dividing Range which effectively divides the region in two. Areas within the region are prone to closure in winter due to frost and snow. Senior Peer Worker/Consumer Advocate Robert (Butch) Young: ‘Working as a Peer Worker in an acute mental health inpatient setting which services rural and remote areas has been a journey that has come with its challenges. However, the challenges are outweighed by the opportunity to influence my colleagues without lived experience and promote a journey of wellness for people with mental illness. Being in a position to be able to influence positive cultural changes in the inpatient unit can change the outcomes of care for people with lived experience and their families and carers. This cultural change develops through being inquisitive and questioning staff at all levels about why they have been doing things in a certain way, and if it isn’t working well for the consumers, then why not change work practices. Peer Workers challenge the status quo. That is part of our job. When challenging status quo, it is important as a Peer Worker, to understand not only lived experience but the Mental Health Act and other legislations. Knowing these legislations enables Peer Workers to challenge practices, staff behaviors and situations with confidence and respect. An example of the advocacy role I undertook in the Goulburn Inpatient Mental Health Unit is as a member of the Seclusion and Restraint Committee. As the peer work member of the multidisciplinary team, I review all seclusions and restraints within the unit. I work with staff to build their understanding of opportunities to provide early support and intervention for consumers, how to de-escalate vulnerable situations and to prevent incidents of seclusion and restraint. (continued)

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Also, as a Peer Worker and member of the team in the Goulburn inpatient services, I form part of the Violence Prevention and Management Training Team. This supports clinical staff to understand the impact of performing a restraint or seclusion on a person that has been admitted. We talk about the trauma this causes and the long-term impact this can have on people and the way it negatively changes relationships with the staff, treatment, services, families and carers. We discuss how to talk with people and how to provide options for noncontact interventions. This work has led to a major reduction in our seclusion and restraint figures and the subsequent reduction in trauma on all people involved including the workforce. Our unit now has some of the lowest seclusion rates in NSW public facilities. We aim to end seclusion and restraint in our service. The impact of seclusion and restraint is a heavier burden in rural and remote areas because there are no other services to access. There is no choice, and so people become very afraid of having to return to the same service they were traumatised in previously. They often don’t access the service until they are forced to because they are so afraid of being secluded and restrained again. It is a catch 22 situation. They feel damned if they do and damned if they don’t. Supporting a culture of understanding, the experience of an inpatient unit, especially a rural service, is part of the Peer Worker role. Being able to support staff to understand what it feels like to live with mental illness in a rural or remote community, the fear of being restrained, being isolated from contact with the outside world and the experience of going back into the community where “everyone knows everything” has made a big difference to the culture of our service. Another major project we have been able to introduce is the ability for people in the inpatient unit to have access to their mobile devices. Through listening and supporting the voice of people in the inpatient setting, enabling clinical staff to be reassured about the possible risks, supporting and empowering people admitted to do the right thing within a shared environment, “rules” were worked out with and by the consumers as to what was acceptable and appropriate use of phones. These rules and the culture of respect and care for each other and all concerned have negated the risks. People having access to their phones have helped them stay connected with their loved ones when they are a long way from home. Without this there would be little to no contact with their families and friends as the distances can be impossible for many people to negotiate because there is no public transport between many rural communities. Their phones enable them to meet their responsibilities such as paying bills and reassuring children back home that things will get better. (continued)

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All of this has also contributed to the decrease in seclusion and restraint, but more than this, it is humane. Director of Mental Health Drug and Alcohol, Cancer, Renal, Palliative Care, and Breast Screen, Cherie Puckett: As the Director Mental Health Drug and Alcohol, leading and supporting the introduction of peer work and peer advocacy roles within Mental Health facilities is important. It is imperative to have a clear understanding of the how the positions will work as part of the team, how to support each individual, and recognizing the importance within the team. There is also advocacy responsibilities within the health care organization to ensure that the role is understood and the work that is done is recognized, acknowledged, and valued. When analysing seclusion and restraint data and reviewing trends, a major factor discovered in this analysis was the difference the support of the Peer Worker made in the inpatient setting. ‘When I looked back over our seclusion and restraint incidents to see if there was any common denominators supporting our low incidence of seclusion and restraint it became obvious, we had not had an occasion of seclusion and restraint when Butch, our senior Peer Worker was on duty.’ While lived experience is an imperative of the Peer Worker role, it is not the only requirement in successfully recruiting to a Peer Worker position. Recruiting and retaining Peer Workers within the acute setting is often difficult as the experience of the persons lived experience can influence their desire to remain in the role. It is particularly difficult in rural areas, as the person’s experience is often within the unit they are expected to work and their colleagues may be people that provided their care when an inpatient. Ensuring that there are appropriate supports in place for a person through both leadership and supervision support is imperative. In rural areas the demographic spread is significant, putting distances of hours between Peer Workers, within the peer work network. Due to this distance, it is important to support catch-ups, peer supervision, support and orientation through other Peer Workers and networking opportunities on a regular basis. As a Director, building relationships and being accessible are important for Peer Workers just as it is for all staff. Peer Workers with lived experience articulate frequently their difficulty in trusting and have confidence within the system, associated with the long-term psychological impact of the system. This often restricts the Peer Worker’s capacity to disclose issues with confidence when they arise. Delivering care to people with mental illness across a large demographic region in rural areas of NSW has many challenges, but these challenges can be lessened by a clear and collaborative approach to care through the voices of those who use the services and the voices of the Peer Workers; ‘however service leaders and directors need to listen.’

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Practice Implications Peer Workers are increasingly important members of mental health service teams. Employing Peer Workers involves overcoming the existing workforce’s low expectations and myths about Peer Workers and their abilities but opens up a whole new set of skills and talents in rural and remote communities that can be accessed to engage with and support people who feel isolated, distressed and hopeless. Whatever the specific requirements, the basic ingredients of peer work is the same. When two minds and two hearts come together, as they do when a Peer Worker sits and deeply listens to a person’s past traumas, current fears, despair, shame and lack of self-worth, it resonates deeply with both parties. When the moment is right and the Peer Worker carefully and purposefully shares their own, similar experiences, similar traumas, abuse and feelings with the person, they connect. They sit with the acknowledgement of each other’s pain. The burden is shared. Hope for healing often begins at this time. The burden of “facing things alone” begins to diminish. It is rare for people to experience such honesty. To share vulnerabilities like this in a professional relationship leads to a strong and binding connection, one that can become the foundation of a new future. In the reciprocal sharing of mutual thoughts, feelings and experiences, new reason, meaning, wisdom and purpose can be explored. Through unpacking and reprocessing harmful thoughts, feelings and inner dialogue that is often preempted by trauma, a new narrative can begin. The close connection and reciprocity felt between the two peers build a healing relationship in an almost unbelievably short space of time. The Peer Worker is adept at not being an expert over the people they are supporting. They encourage the person to find their own ways forward and to reframe the past. The Peer Worker gently champions the people to advocate for themselves; to find their voice; to talk with clinical staff, family and friends; to connect them with services; to support them in tribunal hearings; to explain how the service works; and to connect them with the community in which they live. The peer relationship is one in which the Peer Worker slowly invites the person to become inquisitive about life again, to wonder at possibilities. Authentic peer work is not about the Peer Worker, it is about the person they support. It utilises lived experience purposefully, so it can be a healing bridge between the people supported and those around them. The focus should be sharing, encouragement and experience rather than giving advice (Meagher and Naughton 2018). However, both the Peer Worker and the person being supported can benefit from their conversation and professional relationship, as each learns a new way of thinking about the self, their experiences and their humanity. Peer Workers do benefit greatly from having meaningful employment, finding that their suffering was not in vain and being able to see that what happened to

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them, how they relate to their experience, and purposefully share it with others is valuable, unique and healing for a multitude of people. Although Peer Workers themselves can experience personal growth in the course of their work, the primary purpose of this important role must always be for the benefit of the people they support. Peer work is not sympathetic; rather it is empathic. Experienced Peer Workers also know that what is left out of the conversation about their own lived experience can be as important as what is included. It is important that in sharing experiences, the Peer Worker deliberately includes information that will help and not hinder the person’s recovery. They avoid causing vicarious trauma or making their own experience seem more challenging than that of the person they are supporting. Importantly, while reciprocity of experiences is the basis of the relationship, Peer Workers must not engage in reciprocal victimhood. It is their job to encourage people to acknowledge what has happened to them but also to look to their future with hope and healing.

Preparing the Workforce Culture to Accept and Value Peer Work Workforce shortages in rural and remote communities challenge us to find new solutions to delivering supports for people with mental health issues, their families and carers. Peer Workers and other designated lived experience staff are a mostly untapped and underdeveloped resource waiting to be utilised to serve their local communities. This resource is not only beneficial to mental health services; it is beneficial across all human services. Mental Health services in Australia are leading the way in the paid Peer Workforce. It is important for an organisation to value lived experience at all levels when developing an effective Peer Workforce. Flourish Australia a leading employer of Peer Workers in Australia does just that. As well as their strategy of “Why Not A Peer Worker?” in which they use affirmative action to employ Peer Workers, they also demonstrate their appreciation of the lived experience perspective by employing people with lived experience throughout the service, in advocacy, governance, executive roles and other senior management positions. In addition, every policy, program, and significant decision are made in consultation with people with a mental health issue (Jackson and Fong 2017). This embracing of lived experience of a mental health issue as a valuable organisational resource creates an atmosphere in which discussions can readily turn to increasing and improving the lived experience workforce. This philosophical position translates into practical outcomes in rural and remote areas where Peer Workers and lived experience managers work in local communities delivering both centre-based services and one on one support.

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Case Study 3 Flourish Australia, Hervey Bay Peer-Operated Service

Chief Executive Officer, Mark Orr: ‘Flourish Australia is a large not-forprofit, community managed organisation with expanding services spread over vast distances across New South Wales, Queensland and Victoria. Flourish Australia utilises affirmative action policies to employ people with a personal lived experience of mental health issues. Over 50% of our almost 900 staff identify as having lived experience. Added to this are a large number of colleagues who are family members or carers of loved ones with a mental health issue. In 2014, Flourish Australia instituted a strategy called “Why Not A Peer Worker?” (Jackson and Fong 2014). This strategy was driven by our General Manager of Inclusion, Fay Jackson and Tim Fong, our General Manager of Human Resources. It ensured that, for every new support role made available, it would be advertised as a Peer Worker role unless there was strong reason not to. It also enabled mental health workers who had a lived experience and the ability to be good Peer Workers to transition into a Peer Worker role. Flourish Australia entered into peer work when the growing evidence base for the efficacy and value of peer work for people with mental health became evident. The “Why Not A Peer Worker?” strategy has seen our peer work numbers grow from 20 to over 180 Peer Workers. The rate of this increase is tracked in the graph below’ (Fig. 2). ‘Flourish Australia is now seen as a leader in mental health peer work across Australia and internationally. Achieving these excellent results involved many robust conversations and years of effort which encompassed the development of our Embracing Inclusion Policy, other supporting policies, cultural change, affirmative action and organisational leadership across all levels including the Flourish Australia Board of Directors, executive members, managers and staff. Flourish Australia believes valuing lived experience as a rich source of knowledge and capability is key to developing an effective Peer Workforce that supports people to achieve positive outcomes, recover and lead the lives they choose, connected to their communities and enjoying a sense of belonging, meaning and purpose. While we utilise Peer Workers across all of our services, we have two PeerOperated Services. One of these is in a small coastal town in Queensland. In order to have a true picture of the value of the Peer-Operated Service (POS) and peer work over all, Flourish Australia (previously known as RichmondPRA) commissioned Social Ventures Australia to gain understanding, measure and value the social and economic changes generated by the POS by undertaking a Social Return on Investment analysis. This analysis was called Queensland Social Return on Investment (SROI) analysis of Flourish (continued)

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Fig. 2 Strategic goal – 50% of frontline workforce (Orr 2017)

Australia’s Peer-Operated Service in Hervey Bay (SVA 2014). The information below pertains to this service and is the focus of this case study. Flourish Australia’s Peer-Operated Service (POS) provides recovery-oriented support to adults with severe and persistent mental health issues in the Hervey Bay area, Queensland. It is run entirely by Peer Workers and a Peer Manager who identify as having a lived experience of mental health issues and who purposefully use this lived experience to support the people accessing the service and each other. Individuals who attend the POS are referred to as “Peers.” The POS is made up of three services: (1) Resource Center, the “hub” of the POS where peers can attend one on one support sessions and group sessions and can socialise with other peers; (2) Warmline, a dedicated, non-crisis phone support service for peers who need support with their mental health recovery; and (3) Rest and Recovery House, short-term accommodation available for peers to take time-out from their current living arrangement. Peers voluntarily attend any or all of the services. SROI is an internationally recognised methodology used to understand, measure and value the impact of a program or organisation. It places a monetary value on the impact (the benefit) of an activity and compares this with the cost, or investment required, to create that benefit. The SROI methodology was used to assess the outcomes created in 1 year (2014) and the investment made to generate those outcomes. The analysis involved 24 consultations with stakeholders of the POS, including 11 peers, as well as a review of the program’s historical data and past evaluations. (continued)

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Key Findings When the total investment in the POS in 2014 is compared to the total social and economic value created, the SROI ratio is 3.27:1. This means that for every $1 invested into the POS, approximately $3.27 of value was created. In 2014, 141 peers engaged with the POS, with 40% of those engaging intensely (at least once a week). In total, activities generated approximately $2.1 M in present value for its stakeholders across a range of outcomes (using a discount rate of 7%). An investment of $0.7 M (88% cash and 12% in-kind) was required during this period to fund the program. This equates to approximately $5 k for each peer who participated. The largest portion of value created by the POS accrued to the peers ($1.6 M). 69% of this is attributable to social recovery (developing a larger and more diverse social network) and personal recovery (development of hope, self-determination, and identity). The majority of the remaining value, $0.6 M, accrued to WB MH who experienced reduced pressure on their services due to lower peer admissions/ readmissions and shorter lengths of stay at their health services. Dr. Glen Adamson, the Wide Bay Mental Health Intervention Coordinator said, “I believe that these [peer support] services are the new evolution of psychiatry and although they are a new concept to mainstream treatment, they will be the ‘norm’ in the future.” The POS has had far reaching influence in other rural and metropolitan settings. It has influenced the Community Care Unit (CCU) in Bundaberg (Queensland) to include a model of Intentional Peer Support, and Flourish Australia was invited by Queensland Health to step in to support a service which had suddenly and dramatically closed because of another not-for-profit services financial predicament. This invitation was due to the respect that Flourish Australia, the POS and our large Peer Workforce have earned and enjoy.’ To be effective, peer work and lived experience roles cannot be “tacked onto the end” of service personnel and delivery in rural and remote communities. The people being employed into these positions need to be selected carefully and engaged in all aspects of service design, delivery and review, and they need to be valued. They are important roles through which to engage people who utilise services, families and careers, along with other staff and stakeholders. They ensure a richer, more wholistic, visionary mental health services that meet the needs of the people accessing them. This can be more important in rural and remote communities where, due to resource and workforce constraints, new and innovative ways of delivering services need to be developed. This facilitates the required reform of traditional mental health supports, policies, procedures and work practices that must adapt if an organisation is to develop and grow a high-quality Peer Workforce.

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Historically Slow Uptake of Peer Work Ashamedly, there has been an historically slow uptake of Peer Workers and other designated lived experience roles in mental health services throughout Australia. However, this slow uptake is more prevalent in rural and remote areas. There may be many “reasons” for this some of which include (Byrne et al. 2017): • The continuing dominance of the Biomedical model and its associated research base • Stigmatising and discriminatory attitudes toward people with mental health issues • Not valuing the wisdom of lived experience used deliberately to improve services and heal lives • The “once a patient, always a patient” attitude and the subsequent positioning of Peer Workers as “lesser” • Historically low number of published research papers about the efficacy and value of peer work that were “recognised” by the clinical community • The relatively new emergence of lived experience research • Perceived threat to nursing, other clinical positions and the power of their industrial bodies • Lack of appropriate levels of designated funding for the Peer Workforce • Lack of resources to support the employment and development of quality peer work • Lack of career pathways The reasons given above can no longer be justified. People with mental health issues have the same human, legal and moral rights to be accepted in their communities and to engage in employment as any person. Peer Workers have proven their capability to fulfill the inherent duties in their position descriptions. They can work independently and as a part of a multidisciplinary team. If designated funding is not available, conversion of unfilled positions into Peer Worker positions can solve under staffed services.

“Everyone Knows Everyone Here” Unlike their city cousins, Peer Workers in rural and remote communities tend to “know everyone” and may well be related to many in the community. Lack of confidentiality is an important issue that can lead to people not seeking help when they need it. Boundaries are needed to support the Peer Worker when their friends and families need their support (Byrne et al. 2018). Another reason services give for not employing Peer Workers pertains to the ‘Peer Worker as patient’ concern. This can be used as an excuse for not employing Peer Workers by managers who have been influenced by discriminating attitudes or who have not yet recognised the value of Lived Experience staff However, this can

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be a legitimate concern for both the service and the Peer Worker. Questions and statements such as “But what happens when they become unwell? What about their confidentiality?” and “They can’t come into hospital and be a patient alongside the people they have been supporting!” are sometimes voiced. These concerns can be overcome in a number of ways: The person can be supported in another service; they can receive services at home which may include face-to-face, tele or video health; they can have remote support from other Peer Workers; some rural Peer Workers who are appreciated and valued in their service have no issues with being supported in the service in which they work. This is usually the case when a plan is in place that clearly spells out the boundaries between being a patient and being a worker. It is important to recognise the hopeful and real possibility that the Peer Worker may not need to be hospitialised or use local mental health services again. Evidence has shown that Peer Workers have better mental health and less relapses after their employment (Moran et al. 2011) (MH.org.UK) and particularly so in supportive environments. Acceptance, understanding the value of lived experience to self, the value of using this in service of others, the benefits to local communities and the pride which comes from this experience can be difficult to imagine if you have been on the receiving end of stigma and discrimination in your community; however peer work acts as the bridge to achieve these positive attributes. Ironically, destigmatising mental health and addressing discrimination in rural communities can be a process led by Peer Workers, and it can be some of the most valuable work they do. Peer Workers break down the barriers and help start conversations in all human and health services, schools, churches, the Country Women’s Association, Men’s sheds, Sale yards, Aboriginal health centres, Lands councils, pubs, clubs, the Stock and Station Agency, the GPs, the service clubs such as Rotary, Lions, Probus and others (Nat. Academies of Sc. 2016). Ending discrimination and stigma is a whole of community endeavor. Research by Professor Patrick Corrigan et al. has shown that the best way to address these challenges is by featuring people who are open about their experiences of mental health issues and recovery and are leading contributing lives in local communities. This introduces to the community an alternative view of mental health and wellbeing (Corrigan et al. 2013).

Different Perspectives Notably, while Flourish Australia believe that peer support provided by carers and family members to carers and family members is important, Flourish Australia’s Peer Workforce does not include carers or family members who have had experience of caring for people with lived experience of mental health issues or unpaid volunteers. Nor does it include employees who hold a different position in the organisation who have a lived experience. An employee engaged as a “Peer Worker” with Flourish

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Australia is paid at an award rate just like any other employee and fulfills an important role integrated into mental health service teams (Jackson and Fong 2018). Peer Workers are very capable of supporting family and carers if what they want is in keeping with what the person receiving treatment wants. However, if there is a difference of opinions between what the “patient” wants and what the family and carer wants, the most suitable supports for the patient is a Peer Worker and a family and Carer Worker for the families in crisis (NCCF 2010). The contradictory points of view between a person receiving treatment and their family can be more acute in rural and remote areas where public “shame” runs deep. The person may be vehemently passionately about not taking strong psychotropic medications to “slow them down” because of the unwanted side effects; however, the family may feel desperate for this to happen. The different standpoints are best served by staff who empathise with the respective party. A Peer Worker who has experienced being hospitalised against their will and treated with medications that have caused distressing long-term negative impacts to their bodies is unlikely to be able to 100% support a family wanting this for their family member who is rejecting such treatments. This places all parties in compromised positions. It is unwise and potentially dangerous to all stakeholder’s well-being to be compromised in these or similar conflicting circumstances. It is better to employ Peer Workers for the people accessing the services and family and carers workers for their families (ARAFMI 2011).

Concluding Comments and Recommendations Rural and remote communities desperately need to decrease suicides and improve the services they offer to people at all stages. In order to do this, we must employ and value the Peer and lived experience workforce. This valuable workforce is an almost untapped resource waiting to be utilised in rural and remote communities. When Peer Workers are supported to liaise with the Peer Worker community and receive external professional supervision, they adhere to the principals and value of Peer support. If these principles and values, and the views and experiences of the lived experience workforce are respected, reformed services can be guaranteed. Metaphorically speaking, Peer Workers are a seam of gold running through rural communities. Unlike mining, services just need to scratch the surface to find the gold which will bring the much needed resources to individuals, services and communities. Research has shown the value of peer work in personal recovery for people receiving support, in saved bed days, costs to services and communities. Denying the research and employment of Peer Workers at appropriate numbers and levels equates to rural and remote services which cannot claim that “least restrictive” or “best practices” are being offered and utilised services in these areas. It is time for rural and remote communities and mental health services to recognise and employ peer work for the valuable resource it is. When Peer Workers are listened to about the changes needed in their service, where the problems lie and

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the possible solutions they pose are considered, respected and adopted, immense changes can take place in both the culture and outcomes of services. Mental health reform in rural and remote communities is achievable by utilising the wisdom and experience of local Peer Workers. They are dedicated to their community. These “outstanding members of the community” know the land and its people. They use their lived experience to break down stigma and discrimination and connect services with the individual people, families and broader communities in their region. They form relationships which promote hope, healing, recovery, belonging, worth and contributing citizens. Their knowledge, transparency and pride contribute strongly toward developing thriving, healthy, rural and remote communities. The positive effects Peer Worker and other designated lived experience roles have on services and communities cannot be understated. The openness, undisguised experiences, identities and values held by these roles must be nourished, supported and utilised to permeate the whole mental health system. When services open themselves up to this in rural and remote communities, deep healing of individuals, families and communities takes place, attitudes and cultures are reformed and everyone is a winner. ‘All truth passes through three stages. In the first, it is ridiculed. Then it is opposed. And finally, it is accepted as self-evident.’ Attributed to Arthur Schopenhauer (1788–1860)

Take Home Messages 1. The efficacy and value of peer work has been established via research from across the globe. 2. Services need to employ and value considerable numbers of Peer Workers who are trained and supported. 3. Peer Workers are necessary to produce the best multifaceted services possible. 4. Services that do not offer readily available Peer Workers cannot rightfully claim they are offering recovery focused, best practice, least restrictive services. 5. Peer Workers positively change the culture of services and communities. They contribute greatly to services being more engaging for people who need support.

References 3303.0 – Causes of Death, Australia. 2017. Australian Bureau of Statistics. Retrieved from ABS Website. https://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/3303. 0~2017~Main%20Features~Intentional%20self-harm%20in%20Aboriginal%20and%20Torres %20Strait%20Islander%20people~10. 5 Aug 2019. Amsalem D, Hasson-Ohayon I, Gothelf D, Roe D. Subtle ways of stigmatization among professionals: the subjective experience of consumers and their family members. Psychiatr Rehabil J. 2018;41(3):163–8.

20

Peer Work in Rural and Remote Communities and Mental Health Services

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ARAFMI WA. Best models for carer workforce development: carer peer support workers, carer consultants, carer advocates and carer advisors. 2011. https://helpingminds.org.au/wp-content/ uploads/2018/07/Best-Models-for-Carer-Peer-Workforce-Nov-2011.pdf Austin E, Ramakrishnan A, Hopper K. Embodying recovery: a qualitative study of peer work in a consumer-run service setting. Community Ment Health J. 2014;50:879–85. Brown J. What no one tells you about life after mental illness, www.vice.com. Retrieved from the Internet https://www.vice.com/en_au/article/kwxvwm/life-after-mental-illness-jessica-brown. 5 Feb 2019. Bryant K. Farmers and mental distress: ‘I’m still a bit ashamed about my story’. The Guardian, Dec. 23rd, 2018. Extracted from in online Guardian. https://www.theguardian.com/society/2018/dec/ 23/farmers-and-mental-distress-im-still-a-bit-ashamed-about-my-story?CMP¼share_btn_ link. 5 Aug 2019. Byrne L. Research promoting and supporting the Peer Workforce: how to use it, how to create it, Peer Work in Australia. In: Meagher J, Stratford A, Jackson F, Jayakody E, Fong T, editors. A new future for mental health. Sydney: Flourish Australia and Mind Australia; 2018. Byrne L, Roennfeldt H, O’Shea P. Identifying barriers to change: the lived experience worker as a valued member of the mental health team: final report. Brisbane: Queensland Government; 2017. Byrne L, Roennfeldt H, O’Shea P, Macdonald P. Taking a gamble for high rewards? Management perspectives on the value of mental health peer workers. Int J Environ Res Public Health. 2018;15:746. Byrne L, Roennfeldt H, Wang Y, O’Shea P. ‘You don’t know what you don’t know’: the essential role of management exposure, understanding and commitment in peer workforce development. Int J Ment Health Nurs. 2019;28:572–81. Candelaria M, Ute K, Thomas B. Peer support in mental health services. 2014. Opinion www.CoPsychiatry.com. Retrieved from the Internet https://s3.amazonaws.com/academia.edu.docu ments/34402017/Mahlke_Kraemer_PeerSupportMHservices_COP_2014.pdf?response-con tent-disposition¼inline%3B%20filename%3DPeer_support_in_mental_health_services Chinman MJ, Weingarten R, Stayner D, Davidson L. Chronicity reconsidered: improving personenvironment fit through a consumer-run service. Community Ment Health J. 2001;37(3):215–29. PubMed.gov. US National Library of Medicine National Institute of Health. Chinman M, George P, Dougherty RH, Daniels AS, Shoma Ghose S, Swift A, Delphin-Rittmon ME. Peer support services for individuals with serious mental illness: assessing the evidence. Psychiatr Serv. 2014;65:429–41. Corrigan PW, Kosyluk KA, Rusch N. Reducing self-stigma by coming out proud. Am J Public Health. 2013;103(5):794–800. https://doi.org/10.2105/AJPH.2012.301037. Epub 2013 Mar 14. Review. PMID: 23488488 Craze L, Plant D. Collated from the proceedings of a workshop held in April 2018, Figure 1, published in Peer Work in Australia. In: Meagher J, Stratford A, Jackson F, Jayakody E, Fong T, editors. A new future for mental health. Sydney: Flourish Australia and Mind Australia; 2018. Fan Y, Ma N, Liang M, Xu W, Lamberti S, Caine ED. A community-led peer support service for persons with severe mental illness in China. BMC Psychiatry. 2018;18:170. Funk M, Drew N. Providing individualized peer support in mental health and related areas. Geneva: World Health Organization; 2017. Gidugu V, Rogers ES, Harrington S, Maru M, Johnson G, Cohee J, Hinkel J. Individual peer support: a qualitative study of mechanisms of its effectiveness. Community Ment Health J. 2015;51:445–52. Gillard SG, Edwards C, Gibson SL, Owen K, Wright C. Introducing peer worker roles into UK mental health service teams: a qualitative analysis of the organisational benefits and challenges. BMC Health Serv Res. 2013;13:188. Gordon J. What are decision makers’ barriers, facilitators and evidence needs regarding peer support working? Scottish Recovery Network; 2014.

460

F. Jackson et al.

Greg Hunt. Federal Minister for Health noted recently that ‘The types of health services needed in metropolitan communities differ dramatically from those of communities in remote and regional areas.’ (Government of Australia website, 16 Jan 2019). Helsloot I, Ruitenberg A. Citizen response to disasters: a survey of literature and some practical implications. J Conting Crisis Manage. 2004;12(3):98–111. Humphreys J, Chisholm M, Russell D. Rural allied health workforce retention in Victoria: modelling the benefits of increased length of stay and reduced staff turnover. Monash University School of Rural Health; 2010. Jackson F, Fong T. Flourish Australia, ‘Why Not A Peer Worker?’. Strategy. 2014;21:176–83. Jackson F, Fong T. Why not a peer worker. Ment Health Soc Incl. 2017. Emerald Publishing, United Kingdom. Jackson F, Fong T. Changing culture and growing peer work. In: Meagher J, Stratford A, Jackson F, Jayakody E, Fong T, editors. Peer work in Australia: a new future for mental health. Sydney: Flourish Australia and Mind Australia; 2018. Komiti A, Judd F, Jackson H. The influence of stigma and attitudes on seeking help- from a GP for mental health problems. Soc Psychiatry Psychiatr Epidemiol. 2006;41:738–45. Lawn S, Smith A, Hunter K. Mental health peer support for hospital avoidance and early discharge: an Australian example of consumer driven and operated service. J Ment Health. 2008;17:498–508. McGowan M. Australia’s drought crisis and farmers’ stories of anxiety, fear and resilience. The Guardian. Retrieved from the Internet https://www.theguardian.com/australia-news/2018/aug/ 04/australias-drought-crisis-and-farmers-stories-of-anxiety-fear-and-resilience. 4 Aug 2018. Mead S, Kuno E, Knutson S. Intentional peer support. Retrieved from the Internet https://www. ncbi.nlm.nih.gov/pubmed/24511559. Nov 2013. Mead S, Hilton D, Curtis L. Peer Support: a theoretical perspective, date of publication unknown. Retrieved from the Internet http://www.intentionalpeersupport.org/wp-content/uploads/2014/ 02/Peer-Support_A-Theoretical-Perspective.pdf. Jan 2019. Meagher J, Naughton G. Scope, role and contribution of peer work: derived, synthesis and analysed from selected Peer work literature. In: Meagher J, Stratford A, Jackson F, Jayakody E, Fong T, editors. Peer Work in Australia, A new future for mental health. Sydney: Flourish Australia and Mind Australia; 2018. Mental Health Peer Work Development and Promotion. https://www.mentalhealthcommission.gov. au/our-work/mental-health-peer-work-development-and-promotion.aspx. Cited Feb 2019. Moran GS, Russinova Z, Gidugu V, Yim JY, Sprague C. Benefits and mechanisms of recovery among peer providers with psychiatric illnesses. Qual Health Res. 2011;22:304–19. Morton A, Smee B. Floods, fire and drought: Australia, a country in the grip of extreme weather bingo. The Guardian Newspaper, Feb. 10th, 2019. Retrieved from Guardian Online. https:// www.theguardian.com/australia-news/2019/feb/10/floods-fire-and-drought-australia-a-countryin-the-grip-of-extreme-weather-bingo?CMP¼share_btn_link. 5 Aug 2019. Ms Bev Manton. Chairperson of the NSW Aboriginal Land Council, spoke on behalf of the Australian Aboriginal and Torres Strait Islander Caucus at the UN Permanent Forum on Indigenous Issues (UNPFII) in April 2008. Submission Number: 235 Public Submission received by Email to Drought Policy Review 08/08/08. Retrieved from Internet https://www. lgnsw.org.au/files/imce-uploads/39/Social_Impacts_of_Drought_Submission.pdf National Academies Press. Ending discrimination against people with mental and substance use disorders: the evidence for stigma change. Committee on the Science of Changing Behavioral Health Social Norms; Board on Behavioral, Cognitive, and Sensory Sciences; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press (US); 2016. National Consumer and Carer Forum. Supporting and developing the mental health consumer and carer identified workforce – a strategic approach to recovery. 2010. https://nmhccf.org.au/sites/ default/files/docs/mhca_carewf_layout_16-9_0.pdf National Menta Health Commissions. Retrieved from the Internet https://www.mentalhealth commission.gov.au/media-centre/news/peerworkmaterials.aspx. 12 Mar 2015.

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NSW Health. More peer workers to help mental health consumers back into the community. Retrieved from the Internet https://www.health.nsw.gov.au/news/Pages/20171124_00.aspx. Nov 2017. Ockwell C, Pearce H. Employing and supporting people with lived experience in peer support and other roles. In: Watson E, Meddings S, editors. Peer support in mental health. London: Red Glove Press; 2019. Orr M. Figure 2. Slide, Number of Peer Workers. Flourish Australia. 30 June 2017. Peer Support. https://www.mentalhealth.org.uk/a-to-z/p/peer-support. Retrieved from the Internet https://www.mentalhealth.org.uk/a-to-z/p/peer-support Peer Work Hub, Mental Health Commission NSW. 2015. Retrieved from the Internet http:// peerworkhub.com.au/the-case-for-peer-work/peer-work-globally/ Private Mental Health Consumer and Carer Network. Peer Support workers and the private sector. Retrieved from the Internet http://pmhccn.com.au/Portals/2/PublicDocuments/ DiscussionPapers/DP%203%20Peer%20Support%20Workers%202.14.pdf. Apr 2014. Rebeiro Gruhl KL, LaCarte S, Calixte S. Authentic peer Support work: challenges and opportunities for an evolving occupation. J Ment Health. 2015. Routledge Taylor & Francis Group. Retrieved from the Internet https://www.researchgate.net/profile/Karen_Rebeiro_Gruhl/publica tion/282129052_Authentic_peer_support_work_challenges_and_opportunities_for_an_evolv ing_occupation/links/5745ba5808ae298602f9d31f.pdf. 18 Sept 2016. Repper J. PSWs: theory and practice. London: ImROC and Sainsbury Centre for Mental Health; 2013. Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment Health. 2011;20(4):392–411. Scanlan JN, Hancock N, Honey A. Evaluation of a peer-delivered, transitional and post discharge support program following psychiatric hospitalisation. BMC Psychiatry. 2017;17:307. Schopenhauer A. All truth passes through three stages, science, pseudoscience, and the three stages of truth. Jeffrey Shallit, Department of Computer Science, University of Waterloo Waterloo, Ontario, Canada N2L 3G1 [email protected]. 28 Mar 2005. Slade M. 2012. Retrieved from theguardian.com. Why ‘putting lunatics in charge of the asylum’ can work, 27-01-2019. SVA, RichmondPRA. Peer operated Service in Hervey bay, social return on investment (SROI) analysis. 2014. www.socialventures.com.au The Australian Federal Government, Senate Community Affairs Reference Committee. Accessibility and quality of mental health services in rural and remote Australia 2018. Trachtenberg M, Parsonage M, Shepherd G, Boardman J. Peer support in mental health care: is it good value for money? London: Centre for Mental Health; 2013. Retrieved from http://eprints. lse.ac.uk/60793/1/Trachtenberg_etal_Report-Peer-support-in-mental-health-care-is-it-goodvalue-for-money_2013.pdf Tse S, Wing See Tsoi E, Wong S, Kan A, Kwok CF. Training of mental health seer support workers in a non-western high-income city: preliminary evaluation and experience. Int J Soc Psychol. 2013;60:211–8. Van Kessel G, Gibbs L, MacDougallm C. Strategies to enhance resilience post-natural disaster: a qualitative study of experience with Australian floods and fires. J Public Health. 2014;37 (2):328–36. Vayshenker B, Mulay AL, Gonzales L, West ML, Brown I, Yanos PT. Participation in peer support services and outcomes related to recovery. Psychiatr Rehabil J. 2016;39:274–81. Watson E. What is peer support? History, evidence and values. In: Watson E, Meddings S, editors. Peer support in mental health. London: Red Glove Press; 2019a. Watson E. The politics of peer support? In: Watson E, Meddings S, editors. Peer support in mental health. London: Red Glove Press; 2019b. World Health Organization (WHO). Mental health action plan 2013–2020. Geneva: World Health Organization; 2013.

Critique of Psychiatry in Rural and Remote Communities

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Lewis Mehl-Madrona, Patrick McFarlane, and Kate Mulrenin

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Context for the Criticism of Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Political Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overemphasis of Psychiatric Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychiatry’s Lack of Cross-Cultural Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research on Psychiatry in Rural and Remote Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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L. Mehl-Madrona (*) Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Department of Psychiatry, University of Vermont, College of Medicine, Burlington, VT, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA Coyote Institute, Orono, ME, USA P. McFarlane Family Medicine Residency, Eastern Maine Medical Center, Bangor, ME, USA Department of Family Medicine, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Medical Arts and Humanities Program, Department of Intermedia, University of Maine, Orono, ME, USA K. Mulrenin Private Practice, Bar Harbor, ME, USA © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_44

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Abstract

We criticize the collapse of psychiatry in most settings to a purely biomedical model in which strict rationalist standards are applied to thoughts and behavior leading to diagnosis and treatment with medication. The effect of this on local cultures has been to undermine acceptance of unusual behavior by community members and participation of extrafamilial agents in the recovery process of people with emotional suffering. The arrival of a biomedical model has resulted in greater stigmatization and less compassionate treatment of people with what biomedicine calls mental illness. We criticize the chief response of psychiatry being to diagnose and medicate with relative insensitivity to the social determinants of health and the specific circumstances of peoples’ lives that make them suffer. A profit-driven mental health system which exists in the United States complicates this further by its preference for short visits and medication as more profitable than longer visits and psychotherapy. Even in countries with universal coverage, however, the impetus exists to see more people in shorter time since this reduces short-term costs though arguably increasing longer-term costs. We describe the modern history of the critical psychiatry movement which has arisen in parallel with psychiatry’s increasing emphasis on mental illness arising from defective brains and its almost exclusive reliance on medication as the primary treatment model. We trace this movement from R.D. Laing and Joseph Berke, through Loren Mosher, and to Marius Romme and the Hearing Voices Movement, which is now Intervoice. We discuss Fernando’s analysis of biomedical psychiatry’s coming to Sri Lanka after their devastating tsunami and how its model of trauma undermined centuries-old ways of coping and conceptualizing loss that were grounded in the spiritualities of the region. We review Julie McGruder’s description of American psychiatry’s coming to Zanzibar and how it undermined the quality of life for those suffering from what psychiatry called schizophrenia. We conclude with a call to psychiatry to return to a more balanced biopsychosocial-spiritual model and to balance biomedical treatment with social and spiritual approaches, relying upon local community experts to be collaborative partners in a participatory democratic manner to determine what defines mental health and illness and how it should be addressed.

Introduction We three co-authors work in psychiatric (LMM, PSM) and psychotherapeutic (all) contexts in rural Maine. In serving some remote communities in northern Maine, KM’s initial surprise was that the first offer made by general practitioners and psychiatrists was virtually uniformly medication relatively devoid of a full diagnostic formulation and without psychotherapy. Their histories were checkbox driven, aimed at matching the diagnostic criteria. Their histories lacked a narrative component and lacked a consideration of the social situations in which their symptoms arose and made sense. The lack of referrals to address the psychosocial issues

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became a missed opportunity for the patient who didn’t know better or didn’t know that psychotherapy could be helpful. Psychosocial support services were focused primarily on making sure patients took medication and not resolving crises of family relationship, housing, food insecurity, unemployment, violence, and the lack. Northern Maine had completely adopted a biomedical model of psychiatry. Something was wrong with the patients’ brains that could by fixed by the “right” medication. Patients had incorporated this model, too, leading to prolonged searches for the “right” medication. The providers’ goals were to calm the symptoms. However, the medications being prescribed were not addressing the actual stress of the patient’s life. More importantly, the treatment model did not acknowledge that anyone should do that, since the treatments were biomedical and biopsychosocial. General practitioners and psychiatric providers (physicians or nurses) were too hurried to get the whole story. The requirements of documentation for billing and maximizing RVUs (relative value units, a measure of how much money the visit would generate) prevented them from providing adequate psychosocial care, for the fastest way to get to the most RVUs is to listen briefly and then write a prescription. However, in an integrated care model, the general practitioner could make a warm handoff to the psychotherapist and the clinic could still bill for both. KM’s experience was that she made more time to hear the whole story than did the medical or psychiatric providers. The patients appreciated that time, and more importantly they appreciated telling their whole story to an attentive listener. This is a function of a system of billing that encourages providers to spend the least amount of time with patients so as to maximize income. At least, in the United States, six 10-minute visits generate substantially more income than 1-hour visits, even though health wise, the hour visit might be enough to reduce distress, while the 10-minute visits do not. Other countries have similar needs, but instead of maximizing profit, their goal is to minimize cost. Innovation is more possible in these latter systems for innovation often does minimize cost. Providers working within a biomedical model can forget that everyone is a person first, not a diagnosis, not a 20-minute slot, and not a level 4 appointment (there are five billing levels in the United States). The rush to diagnose and treat quickly leads to dramatic mistakes like diagnosing a 50-year-old woman as having schizophrenia who had never previously had any psychotic symptoms, hadn’t slept regularly in 2 months, and was triggered by daily phone calls from her emotionally abusive mother and a coworker who acted and sounded like her mother. Because the patient had one delusional thought (not hallucinations), the clinician jumped to “schizophrenia.” Rarely does one become schizophrenic after age 50. She was prescribed a high dose of olanzapine and developed extrapyramidal symptoms, but her delusional symptoms dissolved with psychotherapy that addressed her post-traumatic stress disorder. Likewise, another patient was sent for a full neurological workup for Parkinson’s disease because he developed a significant hand tremor. When asked about the timing of the onset of the tremor, he clearly replied, “after they started me on an antipsychotic medication.” While the medication was discontinued, unfortunately, these extrapyramidal symptoms continued. The consulting psychiatrist did not consider that the tremor to be a long-standing side effect from the medication but

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jumped to another medical interpretation. The hurry in medicine is all about RVUs and productivity, and for rural medicine, this can be even more pronounced. When the psychiatrists’ time involvement is limited and brief (either by telemedicine or through quick drive or fly-in visits) to these rural and remote communities, the onus on them is to generate revenue to justify their trip and to see as many patients as possible. We write this not to say that psychiatry is evil or that medication is bad, but that an exclusive reliance upon a biomedical model can make matters worse in rural and remote communities and that this model is being “sold” to these communities as the most modern and effective way to manage their suffering members. Integrated biopsychosocial-spiritual care is not occurring in the rural and remote areas with which we are familiar in the United States and Canada, but rather the wholesale delivery and acceptance of a biomedical model in which defective brains are primary and not the social determinants of health.

Context for the Criticism of Psychiatry In our focus on rural and remote psychiatry, we must acknowledge that a worldwide criticism of psychiatry exists regardless of setting. Within the United Kingdom, the critical psychiatry group is an actual part of the British Psychiatric Association. They are expected to poke at mainstream psychiatry in order to find its shortcomings and ultimately improve it. This movement was called “anti-psychiatry” at one time, but many objected to this term, for they were not opposed to psychiatry but rather were critical of certain practices and philosophies as applied. LMM first encountered this movement when he read Joseph Berke’s and Mary Barnes’ writings about her recovery from psychosis while he was at University. What Berke and Barnes presented was refreshingly original at the time. Berke was assisting Barnes to recover from psychosis without medication in a supportive facility designed for that purpose. Berke was working hard to understand Mary and her stories as making sense within the context and history of her life and was struggling to see her without the lenses of his theories and his prejudices. He was engaged in clinical phenomenology in which he was actually trying to see how Mary thought about herself. He was trying to give Mary her own voice, as hard as it was for him given his training. This work was admirable and time-consuming. During this same time, R.D. Laing was another inspiration in presenting an existential and phenomenological alternative to the stodgy psychoanalysis of the times. He, also, was trying to understand the lived experience of being psychotic. He was looking at psychosis as a rip in the fabric of the connective tissue of one’s existence, the message of his book, The Divided Self. For the times, it was sheer genius. As successful as this timeconsuming approach was for psychosis, it lost ground to the biological model which promised quicker results for lower costs, despite studies by Loren Mosher to the contrary. Mosher’s early research into identical twins and schizophrenia convinced him that genes alone could not explain schizophrenia. By ignoring environmental and

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psychosocial factors, the psychiatric establishment was guilty, he said, of reducing schizophrenia to a “mechanistic” brain disease model. The result, he said, is that, “We’re so busy with drugs that you can’t find a nickel being spent on [non-drug] research.” While doing research training at the Tavistock Clinic in London from 1966 to 1967, he developed an interest in alternative treatments for schizophrenia. He visited Anna Freud and R. D. Laing and was influenced by Laing’s view that schizophrenia was a reaction to an unbearable situation (Lenzer 2004). In the early 1970s, Mosher founded an innovative homelike treatment environment for patients with newly diagnosed schizophrenia, which he called the Soteria (Greek for deliverance) Project. Staff members at the house were encouraged to treat residents as peers and to share household chores with them. The program was meant to foster “an environment that respected and tolerated individual differences and autonomy.” The Soteria Project closed in 1983 when funding ended. Overall, 58% of Soteria patients received antipsychotic drugs at some point, but only 19% remained continuously on the drugs, compared with 94% of patients who received treatment as usual. A 2003 report on outcomes among patients who were randomized to usual care or to the Soteria treatment, written by Mosher and J.R. Bola, concluded that overall the Soteria patients did as well as better than patients assigned to treatment as usual. Surveys of patients treated at Soteria showed that they simply felt better. They liked how they were treated better than in hospital. Mosher had a far more nuanced view of the use of drugs than most psychiatrists. While he emphasized the importance of environmental factors, he believed in a delicate interplay between inherent “vulnerability” and environmental challenges. Adverse life events could tip a patient into schizophrenia or what Mosher preferred to call “disturbed and disturbing” behavior. Data exist now to show that the incidence of adverse childhood events and other traumas are far higher among people who come to be diagnosed as schizophrenia than among others. Projects exist to prevent schizophrenia through earlier psychological intervention such as a wellknown project at Yale University. Mosher believed that medications should be used as a last resort and then in the lowest possible doses, quite differently from what is currently being practiced. Data also exist to show that low dose is as effective as high dose for over 80% of the patients. Residents at the Soteria Project experienced a quiet, calm environment. Medications were used only when people became violent or suicidal, or if they made no progress after 6 weeks and consented to drug treatment. Mosher was ostracized by American psychiatry for his views. In a 2003 interview with the San Diego Weekly Reader, he said, “I am completely marginalized in American psychiatry. I am never invited to give grand rounds. I am never invited to give presentations. . . in the United States.” The anti-psychiatry movement of the 1970s moved in two separate directions – the critical psychiatry movement that became part of the British Psychiatric Association and the Hearing Voices Movement that arose in Maastricht, in the Netherlands. The fate of experiments like Laing’s and Berke’s lay with the National Health Service, which chose to put its resources into biological psychiatry’s promise to cure mental illness with psychopharmacology.

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David Double (2006) has edited a book about the emergence of the critical psychiatry movement from the anti-psychiatry movement, a term which Laing himself ultimately rejected. Double (2009) writes: Critical psychiatry covers a broad range of opinion. A fundamental debate within critical psychiatry is about how much can be achieved within psychiatry. . .. Holloway . . . suggests that [it] is ‘strikingly similar to the anti-psychiatry movement of the 1970s,’ but does not explain in what way. Indeed, there are links between anti-psychiatry and critical psychiatry, which critical psychiatry has not been afraid to hide. However, it should be remembered that both R.D. Laing and Thomas Szasz, perhaps the two psychiatrists most commonly associated with the term, disowned the use of it of themselves. . ..Essentially ‘anti-psychiatry’ has been used by the mainstream to disparage any opposition [to mainstream psychiatry].

There is much more to say about critical psychiatry which is far from languishing and disappearing. Gray [ref] is calling this movement “democratic psychiatry,” which Peter Lehmann [ref] says, aims to create a balance of perspectives between psychiatry and the diverse experiences of people with mental illness with an aim toward consensus and collaboration rather than hierarchical, enforced, top-down treatment. This movement is represented by such organizations as the Hearing Voices Network (http://www.hearing-voices.org/ and http://www.hvn-usa.org/), Intervoice (http://www.intervoiceonline.org/), Asylum (http://www.asylumonline. net/ and http://studymore.org.uk/mpuzasy.htm), and MindFreedom (http://www. mindfreedom.org/). LMM has interviewed people who have attended Laingian-like facilities (Soteria, Diabasis, and others) and have recovered from psychotic diagnoses. I have not met many people who have collaborated with contemporary psychiatry and have recovered. Regardless of what they do, not everyone recovers, but, at least, outside contemporary psychiatry, some people have a chance.

Political Considerations All medical specialties and professions are political, and psychiatry is no exception. Benjamin Rusk, the founder of American Psychiatry, signed the Declaration of Independence. Sigmund Freud famously changed his narrative from one of child sexual abuse within families to children’s having fantasy of sexual abuse to avoid the ire of his peers and the politics of the day in Vienna (Gay 1988). Modern psychiatry arose with the birth of asylums in the eighteenth century to theoretically shelter the poor who were “insane and enfeebled” with no one to care for them, but with a burgeoning underside of women being committed for disobeying their husbands or wanting a divorce or failing to embody Victorian ideals (Trowbridge 2015). Even the illustrious Charles Dickens illustrated this trend when he sought to commit his wife of 20 years and mother of his ten children to an asylum while he pursued his mistress. To the credit of the psychiatry of the times, Dickens was rebuffed by Dr. Thomas Harrington Tuke. Dickens called Dr. Tuke a “wretched being” and a

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“medical donkey (Karasz 2019).” Recently one of us was faced with a “Tukian moment” in being asked to decide if a 6-year-old boy, abandoned by his mother at the emergency room for being “manipulative and violent because he doesn’t like my boyfriend,” met the criteria for a psychiatric hospital admission. This was more of a custody issue than a question of the boy’s mental status. After a refusal to characterize the boy’s behavior as a psychiatric illness, rather than a response to his stressful environment, the issue returned to one of custody. However, that does not happen often, and custody and psychiatry are often conflated. Any professional psychiatric decision is also political, as it lies at a crossroad of conflict among systems with their own agendas, hopefully informed by ethics, but always contending with and responding to harsh, sometimes stark, and often unobjective realities. This can be all the more perilous in rural and remote environments. Politics is a word whose etymology comes from the Greek polis (city) and polites (citizen) and in late Middle English came to describe how groups of citizens share and vie for power in government and organizations, including eventually the professions. One can quickly list examples of how sociocultural politics have impacted psychiatry over the past century from its role in the United States Central Intelligence Agency’s “black prisons,” interrogation methods including waterboarding, the Chinese government’s treatment of ethnic minorities and religion members such as the Uyghurs and Tibetan, and psychiatry’s role in persecuting the Falun Gong practitioners of qigong. Historically outpatient psychiatry began as the “talking cure,” aimed at resolving forms of neurosis and nervous conditions and conscious and unconscious inner conflicts of an individual, and as psychology and psychiatry vied for status among the medical specialties, it began to name and frame its diseases and disorders, at times inventing and at times retiring various constructs and diagnoses. The hallmark of any profession is its jargon and capacity to name and frame its boundaries with exclusive and manufactured language. Psychiatry defines its criteria for diagnostics in the form of the Diagnostic and Statistical Manual, though not without controversy. One remembers the various psychopolitical characterizations of populations including women, for example, as hysterical, which led to benzodiazepines being among the most prescribed medications to this day. The evidence is clear, antagonizing GABA (gamma-aminobutyric acid, a major inhibitory neurotransmitter) can help someone cope with anxiety and stress. This may be important to the one in three women who are battered by their partners (Abate et al. 2016) or historically weren’t allowed to hold property or vote in many countries and thus struggled for a sense of security, or it might have been important to continued oppression. Consider the diagnoses drapetomania and dysaesthesia aethiopica, respectively. The former was applied to slaves who wanted to run away in a “madness frenzy” from his/her accommodating surroundings and the second to the laziness of a slave, both of which were proposed by American physician Samuel Cartwright in what is now considered “scientific racism,” or the efforts of the oppressor to explain the oppressed. Van der Steen, Ho, and Karmelk (2003) referred to “one-sidedness” as the interpretation of signs and symptoms in an arbitrary fashion. They discuss several

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medical philosophy discussions of the problems of defining a disease and offer that medical definitionality struggles to characterize the multifactorial internal and external factors that define any disease, so that we settle on a “thing,” a definition that may upon revisiting reveals more about its creators than those it characterizes. Examples include the constructs of homosexuality as a disorder and the limitations of Asperger’s in the Diagnostic and Statistical Manual’s autism spectrum disorders, both of which have disappeared in DSM-5. For another example, sexual addiction is a construct that can sell beds in specialized treatment for the middle class, versus the use of the term paraphilias among other peoples; psychopathy versus antisocial personality disorder; and schizoaffective disorder versus bipolar depression versus unipolar depression with psychosis, versus post-traumatic stress, versus problems with attention, versus Axis II borderline personality disorder. These categories are constructed in such a way as to render them terribly difficult to distinguish. In our many years of practice, many of our most abused and vulnerable patients have had all of these diagnoses and at times have had all of the medications that “treat” each of these “disorders.” The question of what’s the “real” diagnosis or issue is a real one, often bound to the internal and external characteristics of the patient that usually do not fit into the neat research categories of the DSM or ICD motifs. Indeed, the National Institute of Mental Health has stopped funding DSM-based research as it is considered too unscientific to be useful to our more biological psychiatry with a focus on genetics, biomarkers, and the development of better medical psychiatric interventions. Their current requirement is what is called Research Domain Criteria. It matters who keeps the borders of a place and/or the doors of the asylum. Ken Kesey’s novel, One Flew Over the Cuckoo’s Nest, became part of the art and movement to close the asylums, also called state hospitals in the United States, from the 1960s to the 1980s. It is generally accepted that politically we chose to reduce services without an adequate community mental health structure. One consequence is that the United States developed the world’s biggest prison system to incarcerate more of our citizens than any other western country. [T]he incarceration system holds the largest concentration of people with psychiatric illnesses; thus, de facto it is also how the United States came to address behavioral issues and mental illness in what has become characterized as the school to prison pipeline. Stephen Stahl, an independent and sought consultant to the pharmaceutical industry and chief of psychiatry in the California Prison system, described his work in the prison system at the 2015 Harvard Psychopharmacology master class as approaching violent and/or seriously mentally ill prisoners with off label and high dosage prescribing as his right after having so many years of authorship and practice as a psychiatrist (Stahl 2015). We want prisons to be controlled places. We want certain people to be controlled. Many prisoners are violent and have serious mental illness. But Stahl’s presentation that day made us wonder about the concepts oulined above. We did not then have words for one-sidedness and capacity for examining the internal and external factors necessary for a broad evaluation and consideration marked by being scientifically skeptical. Is it okay to proverbially nuke a prisoner with neuroleptic medications at great risk. . . because they are mentally ill and/or violent in prison? And what does it mean when other western countries’ prisons

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design prisons so differently and humanistically that they have far less violence and serious mental illness in prison? None of this is to say that battered women might not benefit from short-term benzodiazepine use, or that a violent prisoner might not benefit from an antipsychotic, but ethical practice begs that one consider the internal and external factors which may contribute to any “problem” and, thus, consider the context in which the medication is being used to address signs and symptoms. Like our 6-year-old in the emergency room, we could characterize his problems as psychiatric-medico-social, requiring assessment and intervention. But are his problems psychiatric, or environmental, and parenting in a context of poverty and lack of resources? Is this a false distinction? Mainstream consensus is not necessarily equitable to truth or goodness. Mainstream physicians of the day were complicit in the holocaust/Shoah (Annas 2018). Psychologists participated in intelligence operations for the military and gave rise to psychological operations, even playing a role in the Chinese and Russian political social media operations that utilized cultural and population prejudice and reactions to manipulate populations (Dyer 2016). Psychologists also assist the marketing efforts for the latest and greatest thing that people absolutely need.

Overemphasis of Psychiatric Medications Psychiatric medications are by definition controversial. They fundamentally change the architecture and physiology of the brain and thus the mind. When black box warnings were added to the antidepressant class of selective serotonin reuptake inhibitors (SSRIs) and physicians began to take adolescents and children off the medications, pre- and post-insurance data analytics found that there were statistically significant increases in suicide, the very thing the warnings were trying to prevent, which describes the prescriber’s dilemma (Martínez-Aguayo et al. 2016). Action in either direction can increase the risk of suicide. An atypical antipsychotic can help a behaviorally challenged young man be less violent and improve social functioning in his environment and cause him to gain weight and become diabetic (Krill and Kumra 2014). On average the psychiatric population dies 25 years earlier than the rest of the population (Kitchen-Andren et al. 2017). As a prescriber it can be “damned if you do, and damned if you don’t,” each medication decision requiring Abrahamic trust in the patient and the pharmaceutical manufacturer while looking for outcomes with the patience of Job.

Psychiatry’s Lack of Cross-Cultural Awareness Ginn (2011) highlights the difference in perspective between indigenous people, often represented in the academic world by anthropologists, and, more recently, scholars of native studies and indigenous knowledge, from contemporary psychiatry. Indigenous perspectives teach that we learn how to see the world by the stories that are told before we arrived and surrounding us after our arrival. Mind is constructed

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from outside inward. Disturbances in our relationships with others and with the world are embedded in cultural contexts. Biomedical psychiatry dismisses this perspective and assumes that brains function the same in all cultures. Cultural psychiatry is a sideshow curiosity at the major psychiatric conferences and mostly considers how to convince people from other cultures to take their medications. This difference lies at the heart of the critique of psychiatry in rural and remote environments – the perspective of explanatory pluralism in which multiple equally valid explanations and approaches can coexist versus the positivist scientific perspective in which only one truth exists and one correct solution. Fernando (Fernando and Wilkins 2015) studied the effects of implementing biomedical and psychological models of PTSD into Sri Lanka after the 2004 tsunami, noting that the top-down, hierarchical, “we know best and we are right because we are evidence-based” attitudes of American and British mental health professionals created more barriers to recovery than improved recovery (I am grateful to Ethan Watters’ book, Crazy Like Us, for introducing me to these examples after which I went to the source material to read for myself what the authors had written Watters, E. (2010). Crazy Like Us: The Globalization of the American Psyche. New York, NY, Free Press. However, Watters does an excellent job of summarizing the studies and presenting them in lay language accessible to anyone.). Prior to the tsunami, she had been studying the remarkable psychological resilience of Sri Lankans in the face of a long and horrendous civil war. The British and American exports could not imagine that the Sri Lankans had evolved a culture better able to interpret and give meaning to terrible events because of their intimate familiarity with poverty, hardship, and war. The tsunami was just another event, quite different from the perceptions of the British and Americans (Fernando 2005). While the Euro-Americans turned to medications, the Sri Lankans turned to spirituality – Buddhism for the Sinhalese, Hinduism for the Tamils, Islam for the Moors, and Christianity for the rest (Fernando and Berger 2017). All shared the notion of karma and a belief in spirits and close proximity of the spirit world. Fernando had found that Buddhist and Hindu children were more resilient to the trauma of war than Christian children. Sri Lankans were more likely to experience physical symptoms such as joint pain, muscle pain, or chest pain, rather than emotional symptoms as a response to horrible events. They reacted to disasters as if they had a physical blow to the body. Sri Lankans did not match the DSM checklist for PTSD. Rather, they experienced traumatic events as disruptive to their social relationships. Sri Lankans conceived of the damage caused by the tsunami as occurring in their social world rather than their individual brains as the Euro-Americans assumed. Social disruption was seen as the primary cause of distress and not individual brain disruption. More recently, Kidron and Kirmayer (2019) have written about similar phenomena in Cambodia. They compared the Cambodian idiom of baksbat (translated as broken courage) with the DSM diagnosis of post-traumatic stress disorder. They interviewed trauma survivors who were distressed and disagreed with PTSD as it was being translated into the Cambodian context along with the treatments that accompanied that translation. They used the term “idioms of distress” to refer to culturally specific ways of expressing distress. They drew attention to how

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psychiatry pathologizes non-pathological ways of talking about distress and everyday ways of coping with that distress. Cambodians and Euro-American psychiatrists have different ways of conceptualizing normal emotional responses. Cambodian idioms of distress become pathological when translated into Euro-American models of trauma. They acknowledged the difficulties this makes for global mental health. Juli McGruder’s now classic studies of schizophrenia in Zanzibar illustrate the difficulties of Euro-American psychiatry’s dropping a biomedical model onto people suffering distress in other cultures (McGruder 1999, 2004). She concisely summarized the Euro-American psychiatric model that is applied to indigenous people in rural and remote areas in the same manner as dominant cultural populations in major urban centres: The patient has a permanent brain disease: schizophrenia. The brain disease causes a biochemical imbalance, most notably in overactive or over-sensitive dopaminergic cell systems. Traces of this brain disease can also be seen in physical findings like enlarged cerebral ventricles and hypoactivity of the frontal lobes. The chemical imbalance accounts for all of the patient’s unusual ideas and behaviours, which are to be viewed as symptoms. Antipsychotic medications go a long way in righting the chemical imbalance and, thereby, will control the patient’s disease much in the way that insulin controls diabetes, although they will not cure it. These medications have certain risks and may make the patient uncomfortable, but the risk of recurring mental illness is far worse than these side effects. The doctor can prescribe more medications to counteract the difficult side effects of the antipsychotic medications. Therefore, virtually all patients with schizophrenia should remain on these medications for life. The doctor’s job is to find the right combination of antipsychotic and antidyskinetic medications for each patient. Families can assist by helping to convince the patient that he has a brain disease and encouraging him to take medication, by being understanding and tolerant and by being vigilant in watching for relapse. The treatment is not perfect yet, but medical science will eventually solve this problem and cure this disease (McGregor 2004, p. 310).

In another publication, she writes: The medical model is sometimes used in a way that strips away the meaning of the illness experience. Analogies drawn to diseases do not help the understanding of mental illness. Psychiatry is a social practice embedded in a social milieu and that renders it less than objective. It is useful to recognize that the experiences called symptoms have meaning and may have positive and pleasurable aspects. (McGruder 2002, p. 58)

The conventional psychiatric thinking and the way psychiatry is practiced in rural and remote environments assumes that schizophrenia is the same everywhere and has a universal prevalence rate of 1% (Szöke et al. 2014). However, the subjects of hallucinations and delusions differ depending upon where one lives (Bauer et al. 2011), and the prevalence rates also vary more than conventional thinking allows (Youssef et al. 1999; Moreno et al. 2008). In the United States and Europe, people living in urban settings suffer more from the disease than those living in the country or the suburbs (Phillips et al. 2004; Vassos et al. 2016). Even within urban areas, the rates of schizophrenia can vary widely by neighborhood (Kirkbride et al. 2008). If schizophrenia were the same everywhere, why would people in developing countries

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do better over time than people living in first-world countries (Hopper and Wanderling 2000)? In studies sponsored by the World Health Organization, people diagnosed with schizophrenia in India, Nigeria, and Colombia, on average, experienced a less severe form of the disease with longer periods of remission and higher levels of social functioning than people living in the United States, Denmark, or Taiwan. Over 40% of patients in the latter three countries were considered “severely impaired” compared to 24% in the former three countries. Psychiatrists have either ignored or debated the meaning of these results. Some have suggested that more opportunities for feeling productive by engaging in meaningful work with one’s family exist in poorer countries (Iannelli and Wilding 2007). Others have argued that the expectations for appropriate behavior are simpler in poorer countries, which is, in itself, a prejudicial view of people in less developed countries as somehow having simpler social relationships than people in developed countries, when the data suggests just the opposite (Hill et al. 2014). A review of this debate reveals that culture, spirituality, and kinship does matter for the outcome of schizophrenia and that it is not an entirely biological disorder, rendering the imposition of biomedical psychiatry onto rural and remote communities counter-therapeutic. LMM observed this phenomenon in Northern Saskatchewan. He worked in closed communities only accessible by air. He observed people having psychotic episodes and being surrounded by family and friends. They were not stigmatized. Explanations for their troubles were usually found in spiritual realms or from too much contact with people from the South or from eating food from the South (not enough caribou). The people who suffered were not blamed for their suffering, and everyone expected that they would get over it and come back to normal which they slowly did over the course of 6 to 12 months. McGruder’s 1999 dissertation is full of nuanced understandings of how people care for each other in the Zanzibar community and could be required reading for psychiatrists who are planning to work in rural and remote settings. Her findings emphasized the extended nature of the family and the acceptance of all family members even into spaces that were too small to contain them. This paralleled my observations in indigenous communities from Australia to Arizona to South Dakota to Saskatchewan. People take care of each other regardless of the difficulties. In one of the families she studied, the breakdowns of the husband, who was diagnosed in the hospital as schizophrenic, clearly occurred during times of political strife or family stress. Following a stroke, he eventually stabilized at which time his daughter was diagnosed as schizophrenic. McGruder writes about the family’s amazing tolerance for these two individuals, which is what I have also observed in indigenous communities. The family took a remarkably relaxed stance toward the symptoms of these identified patients. They lacked judgment or frustration about the delusions of their relatives. McGruder’s observations clearly discounted the idea that life was simpler and less stressful for people living in more traditional cultures. Family members did not pressure the two patients to act normally, nor did family members pressure the two patients to perform chores, though they showed gratitude when they did. The waxing and waning of symptoms were allowed to occur without much monitoring or comment by the family. Troubled times were not greeted with concern

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or alarm, and wellness was not celebrated. The patients were not pressured to selfidentify as having permanent mental illnesses. To explain the benefits of the family’s radical acceptance of their members, McGruder turned to the research begun by George Brown on the emotional reactions of family members that were highly correlated with relapse of patients and return to hospital. These reactions included criticism, hostility, and emotional overinvolvement, which Brown called “high expressed emotion (Ayilara et al. 2017).” The Zanzibar families had low expressed emotion, which she believed was culturally inculcated. This has also been my observation in indigenous communities. She traced her families’ behaviors to their understanding of the Quran and the collected stories of Al-Bukhari about the life of the Prophet Mohammed. Challenges are seen as part of life together with the idea that Allah would not give a person more than he or she could bear. In that culture, managing hardships provided a way to pay debts of sinfulness. Illness or bad luck was not seen as arbitrary or punishing. God’s grace awaited those who endured suffering and were grateful for the opportunity to prove their ability to endure it. In addition, McGruder also encountered local beliefs about spirit possession, which were radically different from the beliefs occurring in the United States. In Zanzibar spirit possession was not uncommon or unpleasant or extreme. One informer told McGruder everyone has creatures in their heads. The spirits that inhabit living individuals weren’t necessarily good or bad but required proper handling lest they caused problems. Spirits handed down from ancestors protect and only cause problems if ignored or insulted. Spirits could come by accident or be sent through witchcraft. Because almost everyone on the island believed in spirit possession and had personal experiences with it, abnormal behavior could easily be relegated to spirit possession which had the effect of lessening the stigma associated with such behavior. It made bizarre, disruptive, and sometimes even violent behavior more understandable and forgivable. Spirits were not removed through exorcisms, but rather they were coaxed with food and celebrated with song and dance. They were placated, settled, and convinced to be less evil in their activities. McGruder wrote about how these spirit possession activities kept the identified patient in the social group. McGruder then continues to describe how the biomedical psychiatrists attempted to undermine these pervasive beliefs in spirits and witchcraft, which became quite destructive in some families. Psychiatrists from the United States wanted to replace “primitive” native beliefs in spirits and witchcraft with clear and unemotional biomedical stories. They believed that the local beliefs brought stigma to the mentally ill, even though it was the opposite. This conversion was attractive to some of the population who wanted to see themselves as modern and educated. These people came to believe in the story about broken minds that could be fixed through medication. McGruder documented the shift in one family toward high emotional expression, including overemotional involvement. One patient’s brother who had adapted the biomedical view began to express intense frustration at what he believed to be his sister’s stubborn refusal to get better. Her lack of recovery despite his efforts and those of the doctors and the best drugs began to embarrass and infuriate him. McGruder shows how the biomedical beliefs promoted by the

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psychiatrists allowed patients’ family members to dehumanize them, humiliate them, and exercise harsh control over their relatives’ lives. Ethan Watters (2010) provides shorter, more readable, and more entertaining accounts of both Fernando and McGruder’s work. However, what he writes about that exists nowhere else (“Depression Comes to Japan”) is a fascinating interview with McGill University transcultural psychiatrist Laurence Kirmayer about an elite conference sponsored in 2000 by GlaxoSmithKline, in which the company invited experts on culture and illness to tell them how cultures shape the illness experience. He tells how Eli Lilly had decided not to market SSRIs in Japan in the 1990s despite their huge profitability elsewhere due to the very different beliefs about depression held by the Japanese people. Watters (p. 191) quotes a spokeswoman for Eli Lilly who told The Wall Street Journal that “the people’s attitude toward depression was very negative.” They didn’t believe Japanese people would take a drug for depression. Watters writes that Japanese psychiatrists of that era focused almost exclusively on the severely mentally ill and not people who remained somewhat functional. GlaxoSmithKline’s objective “was to influence, at the most fundamental level, the Japanese understanding of sadness and depression” so as to create a market for Paxil. Kirmayer told Watters that he had presented at the conference the idea that the “feelings and symptoms that an American doctor might categorize as depression are often viewed in other cultures as something of a ‘moral compass,’ prompting both the individual and the group to look for the source of the social, spiritual, or moral discord (p. 195).” Watters further quotes Kirmayer as saying, “Indeed, around the world, it is the Western conception of depression, in particular the American version of the disease, that is the most culturally distinctive. . ..Americans are unique both in being willing to openly express distressful emotions and feelings to strangers and in our penchant for viewing psychological suffering as a health-care issue. Because people in other cultures find social and moral meaning in such internal distress, they often seek relief exclusively from family members or community elders or local spiritual leaders. The idea of seeking help from a doctor or mental health professional outside one’s social circle has traditionally made little sense (pp. 195–196).” In the paper he published summarizing his talk at the Kyoto Conference, Kirmayer (Kirmayer 2001) wrote: [P]sychiatry itself is a cultural institution. Medical anthropology has shown how many aspects of psychiatric theory and practice are based on specific cultural concepts of the person. . ..“[C]ulture” is not simply a characteristic of patients. The perspective of clinicians is also a function of their own ethnocultural background, their professional training, and the context in which they work. Hence, it is best to frame issues of cultural difference not simply in terms of the characteristics of patients or communities, but in terms of differences in the perspectives of patient and clinician in what is always, to some degree, an intercultural encounter. . ..Conventional psychiatric research is ill-suited to explore the cultural meaning of distress because it tends to reduce the complexity of illness narratives to a checklist of symptoms and signs of disorder (p. 22).

The conclusions at the Kyoto Conference emphasized applying Euro-American biomedical psychiatry to Japan (Ballenger et al. 2001):

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The consensus statement underlines the prevalence of depression and anxiety disorders across all cultures and nations while recognizing that cultural differences exist in symptom presentation and prevalence estimates. In all countries, the recognition of depression by clinicians in the primary care setting is low (generally less than 50%), and the consensus group recommends a 2-step process to aid the recognition and diagnosis of depression. In line with the low recognition of depression and anxiety disorders is the finding that only a small proportion of patients with depression or anxiety are receiving appropriate treatments for their condition.

Appropriate treatment for depression and anxiety is defined as medication, hence the medicalization of depression in Japan. This conference and its recommendations formed the basis for GlaxoSmithKline’s marketing of Paxil into Japan and resulted in billions of dollars of income to the company. What has not been demonstrated is whether or not people’s overall suffering changed as a result of biomedicalization. Diagnosis of depression became not a matter of talking to people about the quality of their lives but asking two screening questions (e.g., the PHQ-2) followed by nine questions if the screen is positive (PHQ-9). A positive screen leads to a prescription for an SSRI, now also in Japan, as it does in the United States. Our criticism of psychiatry in rural and remote environments rests upon this unexamined worldview that suffering is biomedical, emotional suffering is inherently the result of brain disease, and the proper treatment is medication. Psychiatry, as it currently is conceptualized by its professional associations, by most medical schools, and by the public, is decidedly reductionist and positivist, even arrogant in its insistence upon its being right regardless of other perspectives. Western notions of mental health do not translate easily into concepts that are meaningful for indigenous people (Carey 2013). The term “social and emotional well-being” is being used to capture the holistic sense of health and connectedness that matters to indigenous Australians (Kelly et al. 2009). Indigenous well-being is also firmly culturally based (Yu et al. 2020). Campbell et al. (2007) and Carey (2013) have stressed the importance of social and emotional well-being programs being developed within individual communities in collaboration with those who are to be served and the local practitioners who will help deliver the service. However, due to its emphasis on the biomedical, psychiatry does not do that, but assumes that its concepts and treatments are universal and therefore appropriate and meaningful for any cultural group. Medications are not always the best or most useful interventions for problems whose roots lie in the social determinants of health.

Research on Psychiatry in Rural and Remote Locations Carey (2013) conducted a qualitative study of a social and emotional well-being service (the preferred term among aboriginal Australians to mental health service) that had been organized with the aim of being responsive to aboriginal needs. Even among a service that was seen as effective in responding to the needs of the community, criticisms remained about appropriate staffing, not enough local decision-making, external identification of priorities instead of within the

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community, differences in views of how the service should be evaluated, and rigidity from external systems about job descriptions and qualifications. Similarly, Souraya et al. (2018) conducted a qualitative study in rural Ethiopia of community-based rehabilitation workers, people with schizophrenia, caregivers, health officers, and supervisors. They found limited involvement of patients in decision-making about their care and essentially coercive practices being used. People with schizophrenia tended to be consulted about their care only when they were considered clinically “recovered.” Caregivers had a more prominent role in decision-making but acquiesced to the views of the health-care professionals. People with schizophrenia and their caregivers were often unable to choose their desired treatment due to its being inaccessible and unaffordable. The authors pointed to the need for greater empowerment of service users, wider availability of treatment choices, and policies that would facilitate a recovery perspective.

Practice Implications 1. Exclusive reliance on a biomedical model of psychiatry fails in rural communities, for emotional suffering is inextricably linked to the social determinants of health. People cannot improve with medication alone. Attention must be paid to relationships, community, housing, employment, transportation, and building a sense of meaning and purpose. 2. A psychobiosocial and spiritual model for mental wellness is more appropriate for rural and remote communities. 3. Psychiatrists working in rural settings need training in more than the biomedical model and need to collaborate in multi-disciplinary teams with input from the communities which they serve.

Conclusions We are not disputing the reality that medications can reduce suffering for some individuals. What we are disputing is their acceptance as first-line treatment for emotional and social suffering and often the only treatment. We are opposing the wholesale adoption of a biomedical model and its exportation to rural and remote communities. Psychiatrists exist who still attempt to function within Engel’s biopsychosocial model (Adler 2009), and this serves as a much, improved basis for psychiatry, especially when the spiritual dimension is added as is so important in indigenous communities. We have shown examples in which the biomedical model added to the suffering of those with emotional difficulties. For working in rural and remote environments, psychiatry needs to become genuinely interdisciplinary and collaborative and allow for explanatory pluralism in which local illness narratives are not upended by the biomedical.

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Take-Home Messages 1. Other ways of conceptualizing mental illness and mental health exist besides the biomedical model. These approaches are not necessarily inferior to the biomedical and in some studies have superior or at least equivalent outcomes. 2. Psychiatrists entering rural and remote areas would do well to have extensive conversations with local knowledge holders about their views of mind, mental health, mental illness, and treatment. Collaborative, participatory democratic approaches that arrive bottom-up and include the views of all stakeholders can enrich all participants and can be more effective. 3. Psychiatrists do well to remember that their most well-meaning efforts can backfire in cultures other than their own and worsen the lives of their patients. One should proceed with caution in other peoples’ cultures. 4. Growing alternate movements for how to conceptualize mental illness and mental health exist and are worthy of consideration, including the views of traditional cultural elders; the movements exemplified by MindFreedom, Asylum, and Mad in America; the methods of treatment exemplified by Open Dialogue and Soterialike environments; and the views and activities of the Hearing Voices Network and Intervoice. 5. As psychiatrists, we do well to recognize the despite our convictions that we are absolutely correct in our views and methods; we may be wrong. Case Studies

Benjamin Gray Benjamin Gray is an academic and researcher in the field of mental health who was diagnosed as having schizophrenia in 2003, spending 12 consecutive months in a psychiatric hospital (Gray 2009). He uses his personal experience to argue against conventional biomedical psychiatry and compulsory medical treatment. He was kept in an acute psychiatric unit in the United Kingdom under Sect. 3 of their Mental Health Act and forced to take antipsychotic medication against his will. Importantly for our purposes here, he also describes the experiences of his fellow patients, similar to his, some of whom were transferred to the hospital from rural and remote locations across the United Kingdom. While acknowledging that his strange religious beliefs were perhaps quite rightly delusions, he makes the point that the way his views were ignored or discounted left him feeling that no one was trying to make him feel deeply and humanly understood, that how he felt was completely unimportant and uninteresting, and that he was no one and mattered little. He wrote about how he and his fellow patients shared experiences of feelings of loss, isolation, pain, sorrow, self-pity, confusion, and helplessness. What his voices said mirrored his experience of being on the unit: “You’re alone. You’re going to get what’s coming to you. You’re going down there? (continued)

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You wait until you see what I’m going to do to you (p. 661).” He realized that any appearance or admission of hearing voices would go on his medical case notes as further proof of his insanity at case reviews and would keep him locked away from family, friends, and what seemed like a long-distant normal life. He writes about he and his fellow patients learned some important lessons: never admit to hearing voices, never talk back to the voices, do exactly as told lest one be seen as ill, never question one’s diagnosis, never disagree with the psychiatrist, and be compliant and admit one’s mental illness, or one will never be discharged. He links this to the assumptions and epistemology of psychiatry. Gray describes how the responses of hundreds of patients whom he has interviewed learn to suppress and hide their voices in order to be considered well, stable, and healthy by their psychiatrists. He considers this not only a suppression of symptoms but also a suppression of people’s personhood. He argues that conventional psychiatry is an instrument of social control and oppression and a system of scientific beliefs that crushes people’s subjectivity, choices, human rights, and free will. He describes how people fear meeting with their psychiatrist because any unusual thoughts or behavior can be taken out of context and construed as abnormal. This hiding of symptoms, beliefs, and voices leads to people being ostracized and to a lack of dialogue between mental health providers and people with mental health problems. Psychiatrists do not get the full picture because much of it is concealed from them. He writes: Psychiatry has taken a biomedical approach, with the prescription of powerful antipsychotic medication, including drugs such as olanzapine, risperidone, and Clozaril, all of which I have been prescribed. These powerful antipsychotics have serious and debilitating side effects, are toxic, and have also been suggested to be harmful to those taking them in the long term. These antipsychotic medications have often been described as “chemical cosh,” leaving people who take them passive, debilitated, and zombie like. This could be suggested to lead to the tranquillization of people’s personal beliefs, however irrational, and their thoughts, subjectivity, and feelings. Such an approach could certainly be argued to crush diversity and discount the diversity of people’s experience of life and the world, in the name of normalization and keeping a stable social and medical order. Put very crudely, popping a pill is far less burden on a health service that has limited resources, a lack of money, severe pressures on beds, and a lack of inpatient provision, which often depends on family carers who lack the knowledge and expertise of dealing with people with mental health problems who may be in distress and where care in the community is limited in scope and often means no care in the community, leaving people with mental health problems with the feeling that they are alone, invisible, and ostracized.

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All this means that there is little study of what schizophrenics’ voices say to them, which would make people’s experiences more valid and meaningful and also lend itself to a more human account of mental illness. People’s experiences of hearing voices are silenced, which can only augment ignorance and fear, both in society and in the mental health-care system. Little attention has been given to what people with mental health problems think and feel and what treatments they would prefer. Psychiatry over-relies on powerful antipsychotic medications, and there are long waiting lists for less invasive treatments such as counseling and cognitive behavioral therapy. To complicate and make matters worse, it is almost impossible to talk with other people and relate the pain that voices inflict when they are raging inside you and shouting you down. It is even harder to face the voices and achieve what psychiatrists and mental health professionals call “insight. . ..” The main point to reiterate is that these voices are silenced and dismissed as delusions and that they are managed mostly by medical treatment and thus not addressed in human and sympathetic terms that might begin to tackle the root cause of the problem, which in turn might help people cope more profoundly and insightfully with their voices.

Gray’s articulate writing about his experiences parallels my observations of working in psychiatry. As I (LMM) have gotten to know patients and they have come to trust me as not planning to humiliate or dismiss or overdiagnose or overmedicate them, I have heard the same stories. People referred from rural and remote areas for psychiatric hospitalization are even more vulnerable for they are more alone and out of context than their fellow patients from the area who have family and friends closer at hand. Gray’s example illustrates how the insistence that one has the truth and that other perspectives are delusional or, at best, out of touch with reality can be damaging and does not actually facilitate genuine recovery.

Case Study 2

When LMM started visiting remote First Nations in Northern Saskatchewan, he was confronted by the psychiatry that had been there before him. Patients in these fly-in communities without highway access to the principle population centres of the province had been well educated in the “drugs are the firstchoice solution for emotional problems” approach, and their favored drugs were benzodiazepines, stimulants, and opiates. While these drugs can quickly reduce emotional distress, their long-term consequences are grave, and LMM encountered a population who expected to continue receiving these medications, sometimes with limited justification. Mental health care was provided primarily in small clinics in each of these communities. For two of the communities, only a nursing station existed with a doctor visiting the (continued)

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communities in an even smaller plane that reached the largest community once weekly. On one of the planes flying between communities, he could see the ground between the wooden slats that formed the floor of the plane. The primary caregivers were nurses, community workers (most of whom directed their attention to the classical addictions), and family physicians. The largest community had a 20-bed hospital with X-ray equipment and a minor surgery suite. A psychiatrist came to each community monthly. Most of the physicians came from India or Pakistan and were forced to work in these rural and remote locations for a period of time before they became eligible for landed immigrant status. They were not happy to be there. Nurses came from the southern half of the province and worked shifts of 1 to 4 weeks in community and then the same amount of time back in their homes. Similar to what Kirmayer et al. (1997) found in Northern Quebec, the staff had no special preparation for cross-cultural work and little time or opportunity for learning more about the people they were serving. Most had no specific mental health or psychotherapy experience. The community workers had some training in social work (though not necessarily a degree) or had training in drug and alcohol counseling or both. Each community had a Native Drug and Alcohol program. The context differed for the community members who frequently had to deal with the social and addiction problems of their relatives or friends. An ambivalence existed about this reality in that the pre-conquest values were to share everything within the community and for people to take responsibility to help each other, but European values of privacy and individualism were encroaching upon that, leaving an uneasiness among community members about sharing information or talking about problems. The value of knowing everyone else’s business was in process of being undermined. Most community members belonged to the Roman Catholic Church, and the priest and deacons provided a parallel mental health system for their parishioners. However, they also brought European notions about the privacy of the confessional and methods for the absolution of sins that were decidedly nonlocal. For those who could work under the assumptions of the Roman Catholic faith, LMM observed that the priest was the community’s best psychotherapist. Two of the five communities had priests. For the other three, priests traveled in and out of the communities from the largest two. Priests periodically went south for rest and recreation, though during LMM’s time in these communities, the priests stopped staffing the church and only occasionally did a priest come. For the rest of the time, laypeople (deacons) ran the services. The Roman Catholic Church, however, introduced a new level of stigmatization and criticism of each for the other that also had not existed in the same way before Catholicism. Besides benzodiazepines, psychostimulants, and opiates, patients typically rejected other psychiatric medications, arguing that the medications worked (continued)

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differently on them than they did for people in the South because of their diet of caribou. As in Kirmayer’s study where seal was the curative food, in Northern Saskatchewan, caribou was what people were directed to eat when they felt poorly. Too little fish or caribou and a person could become susceptible to illness, especially the illness that was carried North from the South, though it was difficult for people to articulate what that disease might be. Also similar to what Kirmayer described for the Inuktituk of Northern Quebec, when people felt seriously disturbed, the solution was to go out on the trapline for 1 to 4 months. LMM was completely amazed at the skill of the people for living outdoors months at a time throughout the winter. During the coldest months of the year, he saw a substantial number of patients outdoors for they were afraid to come inside lest they should lose their resistance to the cold. Being inside in the warm could make them sick, they argued. LMM became tough enough to sit in the back of a pickup truck with them or on a skidoo or even just an outdoor bench with temperatures regularly below 40 and sometimes below 50. Mostly what these patients, who were young (between ages 20 and 50) and male, wanted was disability for 1 to 4 months so they could go into the wild. They had memorized lists of severe psychiatric symptoms which they dutifully recited until LMM told them that he would sign their disability papers, but could they please tell him what was really going on. Most were working in the mines, which were the major employers in Northern Saskatchewan. They described a sickness brought on by too much time underground, too much contact with people from the South, bad food, and lack of contact with nature. Their symptoms were variable and unique to each person, but often combined elements of depersonalization, derealization, emotional numbing, feelings that life was meaningless and hopeless and that nothing would ever change, apathy, and abulia. Sometimes these symptoms were associated with externalizing behaviors such as starting random fights, driving too fast in vehicles or skidoos, courting hypothermia, demonstrating excessive bravado walking on ice, and the like. Their symptoms did not match any of the classic DSM psychiatric diagnoses. Their solution was to eat caribou, fish, and wild game for a block of time during which they would live on their traplines and hunt and fish or trap all day. This would rejuvenate and replenish them, and then they would be well and could go back to the mines until the cycle repeated itself. Previous psychiatrists before me had given them a variety of diagnoses to fit the symptoms that they had dutifully repeated, which were not actually what they were experiencing at all. They had been given a variety of psychiatry medication prescriptions, had filled the prescriptions for fear of looking noncompliant, and had promptly thrown the medications in the dump. The visiting psychiatrists had not been able to determine that they did not actually have the symptoms they claimed to have, and they did not take the medications they were theoretically taking. A (continued)

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more narrative approach of curiosity and interest (which requires substantially longer interviews, a feat given the temperature) elicited their actual story. A female version of the above story also existed, though women were less likely to be working in the mines and more likely to be engaged in service occupations, such as cleaning rooms for the local fishing resorts (catering to fly-in Americans and mostly owned by non-indigenous people from the South who paid local indigenous people to be hunting and fishing guides or support staff), working at the town’s one restaurant, working in support roles at the local hospital and clinic, or working in support roles for the variety of government agencies and mining concerns located in town. They, too, retreated to the trapline and the caribou diet and blamed their illnesses on food from the South. The women’s illnesses were similar to the men except for more internalizing tendencies (withdrawal, isolation, excess sadness, and the like). They also had received a variety of psychiatric diagnosis and medications, like the men, which they also did not take, except when they could get benzodiazepines or psychostimulants. LMM witnessed eight psychotic breaks during his time working in this community in which the community surrounded the person and kept them safe until the psychosis resolved. As Kirmayer and McGruder both noted for Northern Quebec and Zanzibar, respectively, people in these small communities were more tolerant and understanding of odd and erratic behavior. Even nonfamily members took responsibility for keeping the person safe, keeping them from wandering into the bush, keeping them off the ice, protecting them from hypothermia, and making sure they didn’t get lost. They were allowed to wander, and the town’s restaurant fed them and sent a bill to the band office for payment. Their safety was truly a community affair. Family members remained with them 24 hours per day, 7 days per week. LMM observed their progressive improvement each time he visits, and none accepted drugs. By 8 to 12 months, all were back to baseline. Watching this process inspired LMM to revise his conceptions of psychosis. Again, he was consulted not for his mental health or psychopharmacological expertise, but more for his power to sign disability forms and other formal paperwork that made more resources available. Psychiatry had been relatively ineffective in these small northern communities except for contributing to the desire for benzodiazepines, psychostimulants, and opiates through promoting the pharmaceutical solution as the first choice for life’s miseries and through minimizing the contribution of life itself to our feelings arising from living it. Psychiatrists had forced DSM diagnoses on people who had learned to present those same symptoms in order to gain desired disability, but no real communication had occurred, and the psychiatrists did not know that actuality of their patients’ lives, symptoms (and lack of certain expressed symptoms). The patients were adapting to the (continued)

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presence of psychiatry in ways that showed creative optimization strategies for getting what they believed they needed. In this community, the dropping of biomedical beliefs and values onto the community like a parachute had taught community members diagnostic savvy and understanding of what to say to get what they wanted, an interest in finding controlled substances, and a misunderstanding of what was actually occurring in people’s lives. Psychiatry may have also done some good, but these other aspects were more noticeable to LMM.

Case Study 3

(Authored by PM) Just put it in the water; and other myths of medication management in rural areas – The story of Lynn.

Lynn first came to my attention when I joined a rural practice. In fact, she was the very first patient I met on day one, and there were whispers about her being schizophrenic, which is a diagnosis that often inspires cliché, stigma, and stereotype. The nurses told me she was very fragile, and I should not ask direct questions about her mom’s death because she would cry. The primary care physicians told me they were concerned about her mediation management since she’d been on her antipsychotic medication for some 50 years, and they suspected that the medication was impacting her liver function and diabetes, which of course it was. They mentioned that her original psychiatric provider had died almost a decade earlier, and everyone had been anxious about changing her medications because, “God forbid,” her psychosis might return. Lynn, as I have alluded, was 73. She was a character. She used her demure personality to avoid challenge and elicit help as many people with developmental differences so effectively use to negotiate safety in the world that may not be kind to differences. She was delightful, and kind, and when I asked directly if she would mind me asking about her life and what makes her sad, scared, or happy, she immediately retorted, “I’ve been waiting a long time to talk about things, dear. I think most people here are afraid of me, that I might come apart.” I learned that Lynn was in special education programs starting in elementary school and that her family vacillated between having her in school and keeping her home with the children that were too mean. Her measured academic intelligence scores indicated that she was in the mild cognitive impairment category, which meant that in Lynn’s experience, “They don’t (continued)

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really ask me questions, they tell me things.” She had this way of telling me pithy truths from her experience that I came to very much value in our interactions. I asked her why she thought people didn’t ask her questions, and she said this sentence I’ll never forget: “Once people think you’re broken they don’t see you, they see what they wrote down about you.” So, I started asking questions, and she answered in a rich and distilled manner. When she was in her late 20s, her mother died. Up to that point, she had lived with her mother, and her mother as when she had been in school ran interference and organization in her life, and she was upended when her mother died. She described “When my mom died, I kind of died, and it broke me down,” which she described many of the hallmarks of psychosis, seeing and hearing things, word salads, paranoia, and olfactory and taste hallucinations. She described being hospitalized, and that’s when her antipsychotic was started. I asked if it helped, and she said, “Yes, dear, like magic. And it helped too when I got back into my own house and when I knew I had good people to check on me. They were all so nice, like my mom.” I wrote down these quotes in her chart, because if I was going to change her medications, I had to have a firm rationale to help alleviate everyone’s anxiety about “messing with the meds” and to paint a developmental picture that wasn’t that of a schizophrenic in need of medications to prevent decompensation. The history seemed to be that she had a psychotic break secondary to grief and stress and that roughly 3 months after it presented, it was resolved, and she had been ever after on her antipsychotic medication, which had been started at a hospital by a psychiatrist who specialized in working people who had developmental and cognitive differences. No one had changed the medication ever after. Not when she became diabetic. Not when she developed minor liver dysfunction. Not when her kidney function was impacted. And despite that fact, she had not exhibited psychosis for an ever increasingly long time, and she could, in fact, cogently discuss stressors and had a plethora of approaches to positive coping. So, I decided to stop the medication over a period of time, and Lynn was delighted. She asked, “Does this mean I am not crazy anymore?” I told her psychosis is sometimes how the brain responds to very stressful times and that if my mom who I lived and who helped organize my life died when I was 28, I might also experience some psychosis for a while. Lynn’s case illustrates many issues related to psychiatric prescribing in rural and remote areas where specialty tertiary care is far away and where the prescribing psychiatrist is viewed as having some kind of special power through time, as opposed to a particular point in time. A forensic psychologist colleague who worked with violence and violent offenders once offered that it (continued)

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was imperative to write into reports that any evaluation is temporal and thus should always be considered in different circumstances and over time as while some data is static, most data is dynamic reflecting the human beings from which our data is derived. Another issue is when a specialty physician makes a diagnosis and decision about medication and there isn’t a consultative mechanism treating that diagnosis and decision-making as sacrosanct is highly problematic and who will own the prescribing over time. Most physicians will provide a refill for a colleague, but similarly most physicians are reticent to change someone else’s diagnosis or treatment regimen. Stigma in this case is also clearly an issue. The entire staff felt anxious about this patient, and though they were all professional and nice, everyone avoided the central question of whether or not this patient was still psychotic with evident signs and symptoms warranting continued medication therapy, That anxiety about her psychosis returning combined with stigma kept this patient on an antipsychotic treatment even when it appeared unlikely that it was needed for the past 30 years.

References Abate BA, Wossen BA, Degfie TT. Determinants of intimate partner violence during pregnancy among married women in Abay Chomen district, Western Ethiopia: a community based cross sectional study. BMC Women’s Health. 2016;16(1):16. Adler RH. Engel’s biopsychosocial model is still relevant today. J Psychosom Res. 2009;67:607–11. Annas GJ. Beyond Nazi war crimes experiments: the voluntary consent requirement of the Nuremberg code at 70. Am J Public Health. 2018;108(1):42–6. Ayilara O, Ogunwale A, Babalola E. Perceived expressed emotions in relatives of patients with severe mental illness: a comparative study. Psychiatry Res. 2017;257:137–43. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Kirmayer LJ, Lépine JP, Ono Y. Consensus statement on transcultural issues in depression and anxiety from the international consensus group on depression and anxiety. J Clin Psychiatry. 2001;62:47–52. Bauer SM, Schanda H, Karakula H, Olajossy-Hilkesberger L, Rudaleviciene P, Okribelashvili N, Stompe T. Culture and the prevalence of hallucinations in schizophrenia. Compr Psychiatry. 2011;52(3):319–25. Campbell D, Pyett P, McCarthy L, Whiteside M, Tsey K. Community development and empowerment – a review of interventions to improve aboriginal health. In: Anderson I, Baum F, Bentley M, editors. Beyond bandaids: exploring the underlying social determinants of aboriginal health. Casuarina: Cooperative Research Centre for Aboriginal Health; 2007. p. 165–80. Carey TA. A qualitative study of a social and emotional well-being service for a remote indigenous Australian community: implications for access, effectiveness, and sustainability. BMC Health Serv Res. 2013;13(1):80–6. Double D, editor. Critical psychiatry: the limits of madness. Geneva, Switzerland: Springer; 2006. Double DB. Critical psychiatry seeks to avoid the polarisation engendered by anti-psychiatry. Psychiatr Bull. 2009;33(10):395–6. https://doi.org/10.1192/pb.33.10.395a.

488

L. Mehl-Madrona et al.

Dyer O. Prosecution of US psychologists who ran CIA torture program moves a step closer. BMJ. 2016;353:i2454. Fernando GA. Interventions for survivors of the tsunami disaster: report from Sri Lanka. J Trauma Stress. 2005;18(3):267–8. Fernando GA, Berger DE. The role of religion in youth exposed to disasters in Sri Lanka. J Prev Interv Community. 2017;45(4):238–49. Fernando GA, Wilkins A. Barriers to recovery in communities exposed to disasters: Sri Lankan voices speak. Int Rev Psychiatry. 2015;27(3):218–32. Gay P. Freud: a life for our time. New York: Norton; 1988. Ginn S. Crazy like us by Ethan Watters. Simon & Schuster. 2010. US$12.99 (pb). 320pp. ISBN: 9781416587194. Br J Psychiatry. 2011;198(1):76–7. Gray B. Psychiatry and oppression: a personal account of compulsory admission and medical treatment. Schizophr Bull. 2009;35(4):661–3. Hill KR, Wood BM, Baggio J, Hurtado AM, Boyd RT. Hunter-gatherer inter-band interaction rates: implications for cumulative culture. PloS One. 2014;9(7):e102806. Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. Schizophr Bull. 2000;26(4):835–46. Iannelli S, Wilding C. Health-enhancing effects of engaging in productive occupation: experiences of young people with mental illness. Aust Occup Ther J. 2007;54(4):285–93. Karasz P. Charles dickens tried to banish his wife to an asylum, letters show. New York: New York Times Company. Online. 2019. Kelly K, Dudgeon P, Gee G, Glaskin B. Living on the edge: social and emotional wellbeing and risk and protective factors for serious psychological distress among Aboriginal and Torres Strait Islander people. Cooperative Research Centre for Aboriginal Health Discussion Paper Series. Casuarina, Cooperative Research Centre for Aboriginal Health; 2009. Kidron CA, Kirmayer LJ. Global mental health and idioms of distress: the paradox of culturesensitive pathologization of distress in Cambodia. Cult Med Psychiatry. 2019;43(2):211–235. Kirkbride J, Boydell J, Ploubidis G, Morgan C, Dazzan P, McKenzie K, Jones P. Testing the association between the incidence of schizophrenia and social capital in an urban area. Psychol Med. 2008;38(8):1083–94. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62:22–8. Kirmayer LJ, Fletcher C, Corin E, Boothroyd L. Inuit concepts of mental health and illness: an ethnographic study. Montreal: McGill University Culture and Mental Health Research Unit; 1997. Kitchen-Andren KA, Gabel NM, Stelmokas J, Rich AM, Bieliauskas LA. Population base rates and disease course of common psychiatric and neurodegenerative disorders. Neuropsychol Rev. 2017;27:284–283, 280. Krill RA, Kumra S. Metabolic consequences of second-generation antipsychotics in youth: appropriate monitoring and clinical management. Adolesc Health Med Ther. 2014;5:171–82. Lenzer J. Loren Mosher. BMJ. 2004;329(7463):463. Martínez-Aguayo JC, Arancibia M, Concha S, Madrid E. Ten years after the FDA black box warning for antidepressant drugs: a critical narrative review. Arch Clin Psychiatry (São Paulo). 2016;43(3):60–6. McGruder JH. Madness in Zanzibar: “schizophrenia” in three families in the “developing” world. Ph.D., University of Washington; 1999. McGruder J. Life experience is not a disease or why medicalizing madness is counterproductive to recovery. Occup Ther Ment Health. 2002;17(3):59–80. McGruder J. Disease models of mental illness and aftercare patient education: critical observations from meta-analyses, cross-cultural practice and anthropological study. Br J Occup Ther. 2004;67 (7):310–8. Moreno B, García-Alonso CR, Negrín Hernández MA, Torres-González F, Salvador-Carulla L. Spatial analysis to identify hotspots of prevalence of schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2008;43(10):782–91.

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Phillips MR, Yang G, Li S, Li Y. Suicide and the unique prevalence pattern of schizophrenia in mainland China: a retrospective observational study. Lancet (London, England). 2004;364 (9439):1062–8. Souraya S, Hanlon C, Asher L. Involvement of people with schizophrenia in decision-making in rural Ethiopia: a qualitative study. Glob Health. 2018;14(85):1–13. https://doi.org/10.1186/ s12992-018-0403-4. Stahl SM. Stahl’s Essential psychopharmacology: prescriber’s guide. J Clin Psychiatry. 2015;76(5): e667. Szöke A, Kirkbride JB, Schürhoff F. Universal prevention of schizophrenia and surrogate endpoints at population level. Soc Psychiatry Psychiatr Epidemiol. 2014;49(9):1347–51. Trowbridge S. Insanity and the lunatic asylum in the nineteenth century. New York, NY: Routledge; 2015. van der Steen WJ, Ho VKY, Karmelk FJ. Beyond boundaries of biomedicine: Pragmatic perspectives on health and disease. Vol. 4. Rodopi; 2003. Vassos EA, Agerbo E, Mors O, Pedersen CB. Urban-rural differences in incidence rates of psychiatric disorders in Denmark. Br J Psychiatry J Ment Sci. 2016;208(5):434–40. Watters E. Crazy like us: the globalization of the American psyche. New York: Free Press; 2010. Youssef HA, Scully PJ, Kinsella A, Waddington JL. Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset. Schizophr Res. 1999;37(3):233–43. Yu Z, Steenbeek A, Biderman M, Macdonald M, Carrier L, MacDonald C. Characteristics of Indigenous healing strategies in Canada: a scoping review. JBI Evidence Synthesis. 2020.

Maintaining Control: The Importance of Self-Care to Effective and Enduring RRvR Mental Health Service Provision

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Timothy A. Carey and Judith Gullifer

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features of Self-Care in RRvR Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The demands of providing mental health services in RRvR locations make effective self-care practices paramount. In RRvR contexts, it can be much harder to separate personal and professional domains. Furthermore, events that disrupt psychological and social functioning, such as trauma and natural disasters, can impact on mental health service providers as well as the people to whom they are providing services. Mental health and other health professionals in RRvR places can also be promoted to positions for which they might not have adequate training and experience nor receive appropriate supervision and support. While there is a plethora of suggestions and resources related to stress, burnout, resilience, and so on, many of these approaches are not based on robust theoretical models. They may not apply across contexts and changing circumstances. A model of biopsychosocial control, however, is particularly relevant to the topic of selfT. A. Carey (*) Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda e-mail: [email protected] J. Gullifer Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia School of Psychology, Charles Sturt University, Bathurst, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_23

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care. Maintaining effective functioning as a RRvR mental health practitioner means being able to control important biological, psychological, and social variables in often challenging environments. Conflict between valued goals can be a significant source of stress, distress, and burnout. Understanding goals, how they function, and their hierarchical organization can be helpful in achieving clarity about that which is important to individuals with regard to the life they wish to live. In this chapter, we describe the process of control and its relevance to health. We also outline goal conflict and identify some of the ways in which this conflict can occur as well as the problems that can arise when it is not easily resolved. A case study of the way in which these ideas were used to build an innovative and effective self-care program highlights their usefulness for RRvR mental health practitioners. Approaching self-care from the perspective of personal control could lead to a more resilient mental health workforce who are able to provide effective services on an ongoing basis, while maintaining a sense of balance, contentment, and satisfaction in both their professional and personal lives.

Introduction The establishment and maintenance of a sustained, high-functioning mental health workforce is essential to the provision of effective and efficient mental health services in RRvR locations. The demands on mental health service providers in RRvR locations, however, can be intense. Developing resources and strategies for service providers to attend to their own self-care is paramount in addressing burnout and other effects of negative workplace practices. An attitude of putting one’s self first is especially important to highlight and promote because it is often the antithesis of a “care-forothers” philosophy held by many mental health workers. A philosophy of putting others first, however, can become problematic when combined with many of the features of working in RRvR settings and, in particular, the often stoic RRvR culture. We have no quarrel with caring for others. In fact, becoming more effective at caring for others for longer periods of time, and across changing environmental circumstances, is the primary motivation for our emphasis on the importance of selfcare. Our stance is that, in order to function most effectively in providing care to others, one must first care for oneself. People everywhere, but especially in RRvR areas where choices are so limited, need mental health professionals to be performing at their best. To do that, these professionals must ensure they are attending to their own physical and psychological requirements. This stipulation is far from being a nonobligatory personal preference. It is actually specified in the professional and ethical codes of different professions. In the Code of Ethics of the Australian Psychological Society (APS 2007), for example, it is clearly stated that psychologists must only provide services within the bounds of their professional competence, which includes but is not limited to, among other things “ensuring that their emotional, mental, and physical state does not impair their ability to provide a competent psychological service.” (p. 19).

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It is important to note that we are writing this chapter as the world continues to come to grips with the COVID-19 pandemic. One of the consequences of this calamity has been an absolute “pandemic of information” about mental health, and in particular, what people can do to safeguard their own mental health. A steadfast, dependable way of understanding mental health and how it can be maintained would help to establish a sense of order and coherence to this deluge of information. After considering some of the peculiarities of mental health service provision in RRvR locations, we propose a perspective which may provide a very useful way of considering your own and other’s mental health. The ideas and concepts contained within this perspective have been used to build an engaging, refreshingly innovative, and effective professional development workshop designed to promote better self-care practices. That workshop is described in the “Case Study” section.

Distinctive Features of Self-Care in RRvR Areas Health professionals generally are at risk of burnout and much more serious problems such as suicide. Rothenburger (2017), p. 567), for example, reports that “Physician burnout in the United States has reached epidemic proportions and is rising rapidly.” Health professionals in RRvR locations, however, face some additional unique challenges (O’Connor et al. 2018). For instance, rural physicians describe “incredible exhaustion” (Rothenburger 2017, p. 567) due to the requirement of extended periods of being on call. Moreover, these challenges can be compounded for mental health professionals in RRvR contexts by factors such as the nature of the work and the blurring of boundaries (Asante et al. 2019). Limited Options There are often far fewer options in RRvR locations to engage in the self-care activities that mental health service providers from cities might be used to. Mental health professionals may be located a long way from family and friends, and might have to rely on technologies such as Zoom, Skype, or WhatsApp which can be of highly variable quality depending on the local internet service (Paulson et al. 2015). There might also be limited options for social activities such as going to the cinema, visiting a café for your favorite style of coffee, dining out in restaurants, going to the gym, engaging in sporting activities, etc. Conversely, there are options that are available in RRvR localities, that are not as easily accessible in cities such as: hiking and bushwalking; camping; events of local significance such as local horse races, rodeos, and fairs; and visiting places of natural beauty. There is no doubt, however, that options can be limited, and the options that are available are not always to the tastes of people who are newcomers to the region. The limited options can sometimes provide an opportunity for creative solutions with regard to self-care practices. It might be possible, for example, to learn new skills or acquire new experiences. Mental health professionals living and working in RRvR areas for the first time, however, might not always be adequately prepared,

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and may not fully appreciate the changes in lifestyle and approach that are sometimes required for successful and satisfying RRvR living. Blurred Boundaries Compounding the limited availability of preferred choices is the fact that mental health service provision in RRvR locations can become allconsuming. Due to the microcosmic nature of many RRvR communities, it can often be hard to remove oneself from the work environment. Mental health clients, for example, might be in the same choir or church group, or in the same tennis club as the mental health service provider. Smaller social networks can result in mutual friendships leading to social occasions where avoidance of conversations related to work may be difficult to navigate. When grocery shopping at the only supermarket in town, it might be hard to dodge conversations with former or current clients about the way in which they are currently coping. Moreover, mental health professionals might discover some of their clients are other parents sharing the sideline with them as they barrack for their children’s sporting team (Barnett 2016). The Nature of the Work The very nature of mental health work in RRvR settings can make self-care both especially important and also much more difficult. The effects of natural disasters, for example, such as cyclones and bushfires can affect mental health professionals both personally and professionally, as well as their clients. Moreover, farming communities experience droughts, loss of commercial income, downturn in the local economy, and the devastation of crops and livestock. These occurrences impact on the social and emotional well-being of all the people immersed within those communities. Mental health professionals can, simultaneously, be coming to terms with the loss of their own home or livelihood, while assisting clients to deal with the losses they have experienced. Ironically, it is by being a resident in an RRvR region that a mental health professional may be able to provide the most effective services to other residents of the region, but this also leaves them vulnerable to personally experiencing the same devastating tragedies that can wreak havoc in RRvR communities. Atypical Career Trajectories While career progression can often be a very positive event in a person’s life, in RRvR contexts, it may be problematic, not least because of shortages of staff and ongoing recruitment difficulties; people can be promoted to levels for which they do not have sufficient training, capabilities, or adequate support. They can, for example, be promoted to management positions when they do not have the required skills to effectively lead and manage staff or a client crisis. This knowledge and skills deficit can have negative consequences for themselves, their staff, and members of the community they serve. Carey (2019), for example, highlights the fact that, in some RRvR communities where there is a university presence, health professionals are recruited to academic positions for which, if the recruitment concerned a similar metropolitan position, they would not even be considered. Mental health and other health professionals, therefore, can occupy positions for which they are underqualified, inexperienced, and inappropriately prepared and supported, which can place undue pressure on them and their

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colleagues. Furthermore, inappropriate recruitment or promotion can raise community expectations about the services they might receive, and the skills, knowledge, and expertise of the person occupying the position. A mental health professional, for example, who is still within only a few years of graduation, might be appointed to a team leader or managerial role. Other professionals, such as medical practitioners and schoolteachers and principals, might have expectations about the services they would like this team leader or manager to provide, which might not be commensurate with this person’s current level of expertise. This can place undue pressure on the newly graduated professional for which they might not have appropriate coping strategies, support, and supervision. When people are promoted above their current level of competence and qualifications, additional recruitment and retention problems can be created. Recruitment is not just about locating and retaining staff per se. It is about securing and retaining the right staff. Some mental health professionals, however, reach levels within the workforce in RRvR settings that they would ordinarily take much longer to achieve, if working in a metropolitan location. Mental health professionals in such a situation might find it very difficult to leave an RRvR position, even if they are not enjoying it nor performing satisfactorily, because it would be highly unlikely they would obtain a similar position in the city. This situation prevents the service from being able to recruit staff who might be better qualified and suited to the work. From a self-care perspective, however, this can create significant dilemmas for these mental health professionals which may further erode their self-esteem and the services they provide to the community. Income and Job Security A related issue to the atypical career trajectories in some RRvR settings is the salaries that can be available to health and mental health professionals in certain contexts. In some RRvR places, mental health professionals can receive much larger salaries than they would receive in a similar metropolitan position. These salaries can mean that mental health professionals adopt particular lifestyles and may even become so financially committed that it is necessary for them to remain in the position. These financial obligations can create increased pressure for the mental health professional. While the matters raised so far are important to identify, discuss, and resolve, the reverse situation can also occur in RRvR areas and should not be ignored. It can be the case, for example, that nongovernment organizations in RRvR contexts operate on very restricted budgets which limits the recruitment of experienced and senior practitioners to their service. Some services, for example, might opt to recruit generic mental health workers rather than specialists such as psychologists or mental health nurses because of the salary implications. This can result, in some cases, with people being overqualified for the position to which they have been recruited. A recruitment issue such as this further impacts on the provision of appropriate supervision and support for those who are at the entry level of their professional career. A consequence can be similar to what was described in the previous section when early

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career professionals (defined as in the first 5 years of work) can be required to supervise new staff, such as new graduates, when these managers are still further developing their own competencies. Although fly-in fly-out (FIFO) mining and construction workers might seem vastly different from mental health professionals, the sources of their distress can be similar. Bowers et al. (2018) reported that 28% of the 1124 mining and construction workers who participated in their study reported high or very high levels of psychological distress. The sources of their distress were reported to be factors such as missing special events, relationship problems, financial stress, shift rosters, and social isolation (Bowers et al. 2018). Some of these problems such as shift rosters and missing special events could be a feature of FIFO work which many RRvR mental health professionals might not always experience. Other factors, however, such as relationship problems, financial stress, and social isolation may be highly relevant for mental health professionals in RRvR locations. The topic of financial stress should not be underestimated. Bowers et al. (2018) reported that FIFO mine workers who reported that they were financially stressed (62% of their sample) were six times more likely to report high or very high levels of psychological distress. Financial pressures, therefore, caused by either exorbitant or inadequate salaries, is an important concern.

Practice Implications A voluminous literature exists with regard to topics such as burnout and stress. The literature regarding topics such as resilience is just as expansive. While each of these subjects may have some relevance to our current understanding of self-care, it is beyond the scope of this chapter to review this literature in any detail. Our aim instead is to present a different, and we believe, exciting, innovative, and robust approach to the way in which we make sense of daily functioning, as well as the stress and other problems that can arise when this functioning is disrupted or otherwise compromised. If the approach we outline in this chapter is genuinely understood and embraced, the existing literature might be viewed as a resource for ideas and potential possibilities, rather than authoritative advice regarding ideal selfcare practices. The message we outline below emphasizes that the crucial component of effective self-care practice is the self. Practices that promote the enduring physical, psychological, and social functioning that one desires must be individually discovered and enacted. The reasons for the absolute importance of an idiosyncratic approach will be explained below. An ideal model of functioning should be able to explain normal as well as compromised conduct. It could be argued that understanding average and typical functioning is a necessary precursor to understanding how functioning can be disrupted and the ways in which it might be restored. One perspective suggests that routine daily functioning is an ongoing process of achieving desired results. Whether the result is getting to work on time, or packing children’s school lunches,

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or making the 2.00 pm meeting, our daily existence is one of accomplishing one feat after another and, often, many feat’s simultaneously. The Phenomenon of Control The process of producing desired results is known as control (Carey 2016). Organic, autonomous control is a natural phenomenon that might be nature’s greatest accomplishment. Fung (2016) describes homeostasis as the defining feature of life. Homeostasis is a control process. Thermoregulation is the homeostatic control process that keeps our body temperature stable within a fairly small range. Living things, in order to continue living, control. In this discussion of control, we include the complete spectrum of control processes – from those that could be considered automatic and outside awareness, to those that seem much more deliberate, planned, and intentional. As we will explain below, this range of activity is able to be integrated and synthesized into an elegant, holistic framework describing how living things go about the business of living. Nonliving things do not control, although some nonliving things such as household heating thermostats and cruise control systems in cars, have been designed as artificial control systems which mimic the control of living things. Control is a nonnegotiable aspect of life. If control stops, so too does life. William T. Powers (1973, 2005) explained how organic, autonomous control actually works, by articulating a robust and rigorous scientific theory called perceptual control theory (PCT). According to PCT, control is established through a process of negative feedback in which, whenever a controller senses a deviation away from a desired standard, they act to eliminate that deviation (Powers 1973, 2005). For example: if noise becomes too loud, a person might cover their ears or adjust the volume at the source; if the first sip of coffee is too scorching, the person might add cool water or milk or cream, they might wait, or they might blow gently on the surface. While the precise way in which the deviation will be rectified is not certain, it is certain that the deviation will be corrected. Note that individual preferences will determine how deviations are corrected. Negative Feedback Having a clear understanding of the way in which the term “negative feedback” is used in PCT is essential to understanding the theory. Powers (1973, 2005) was a medical physicist and a control systems engineer. He used the term “negative feedback,” therefore, in an engineering sense. In some ways, it is unfortunate that the much more common understanding of “negative feedback,” particularly in areas such as psychology, mental health, HR, and education, has to do with criticism and unwanted comments. We could call this negative feedback “colloquial negative feedback” (CNF) as opposed to the “engineering negative feedback” (ENF) that Powers (1973, 2005) describes. ENF is the mechanism that makes homeostasis and other control processes work. A simple example might assist with understanding the mechanics. Let’s say Sarah is on her way to work which means she is driving for about 30–40 min on long, straight stretches of road. She likes the speedometer in her car telling her she is travelling at

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110kmh. As she drives, Sarah looks down from time to time to see what the speedometer is telling her. On this particular occasion, Sarah notices that the needle is indicating her car is travelling at 100kmh. This means there is a difference of 10kmh between how fast Sarah wants to be travelling and how fast she is travelling. Sarah slightly depresses the accelerator pedal so that what “is” (100kmh) now creeps up to what she “wants” (110kmh). The result of her action is to reduce or negate the 10kmh difference. Suppose that, a few minutes later, she notices that the speedometer needle is now hovering at around 117kmh. While what she “wants” is still 110kmh, what “is” is now 117kmh. So, there is now a difference of 7kmh between what she “wants” and what “is” (from now on referred to more briefly as wants and is). Without even really having to think about it, Sarah eases the pressure on the accelerator pedal ever so slightly and notices the needle moving back towards the desired 110kmh. Once again, the result of Sarah’s actions is to reduce or negate the difference between is and wants. Notice that in these two examples, Sarah used the opposite actions to achieve the same result. In PCT, actions are not the important thing to focus on. The matter of ultimate importance from the inside perspective of the behaving entity is the personally experienced result of the actions, not the actions themselves. The purpose of ENF, therefore, is always to negate the difference between wants and is so that the world, as we experience it, remains as we expect it to be. From an engineering perspective, positive feedback is that feedback which increases, or adds to, the difference between wants and is. If you’ve ever covered your ears in response to a very unwelcome screech from the positive feedback being transmitted through loudspeakers, you’ll have a sense of just how problematic positive feedback can be. The world of organic, autonomous control can take some getting used to. Control concepts are regularly misunderstood but, once they are accurately appreciated, control appears to be just the way things are. Control seems just like the way things are because, from the perspective of living, control is just the way things are. So, in this topsy turvy world, the negative feedback of control systems is a very positive thing, and positive feedback is a very negative thing. It is in the sense of reducing a difference between is and wants that the feedback is negative. The purview of criticism or harsh comments is CNF, not ENF. Health Is Control ENF has been identified at all levels of biological, psychological, and social functioning making it a genuine mechanism for a biopsychosocial model (Carey et al. 2014a). As mentioned above, thermoregulation is an example of ENF control at a biological level. Maintaining a sense of satisfaction and achievement occurs through ENF at a psychological level. Sustaining relationships over years and through hardships is an example of ENF at a social level. The robustness of the control model described by PCT (Powers 1973, 2005) allows us to define health itself as control (Carey 2016). Health is the maintenance of important variables in their desired states. In other words, health is the ongoing ability to keep wants and is matching each other at all levels of social, psychological, and biological functioning. Cancer and multiple sclerosis are examples of

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compromised control (or an inability to make is match wants) at a biological level. Indecision and stress are examples of compromised control (or an inability to make is match wants) at a psychological level, and bullying, discrimination, and harassment are examples of compromised control (or an inability to make is match wants) at a social level. Developing an understanding and appreciation of the ubiquity and fundamental importance of control in health generally and self-care more specifically is crucial. An accurate understanding of how control works can provide important clues to the way in which self-care can be maintained on an ongoing basis. Becoming clearer about who we are – or what our important wants are – and how we can be who we are through ENF will enable us to remove barriers more easily and to build on strengths that already exist. Lessons from Control As outlined above, on a daily basis, we accomplish a staggering, ceaseless number of results. Control is nothing more mysterious than maintaining balance in our lives through the achievement of these results. To obtain these results, we constantly monitor the match between wants and is, and the differences are swiftly and relentlessly rectified. Matching your appearance to the way you want it to be is a result. When you first get out of bed in the morning and gaze into the mirror, a difference between wants and is occurs which will be eliminated within the next hour or so. Fitting an unexpected and distressed client in for a brief appointment is another result. Withdrawing money from an automatic teller machine at lunchtime is yet another result. All day, every day, we continually achieve results. The observation that results are important to us, in order to be able to make desired or expected results happen over and over again, is crucial in appreciating that we have to continually vary what we do in order to maintain a sense of control. This is the central idea to the process of control. As Sarah so decisively illustrated for us, sometimes we do the opposite thing to achieve the same result. The positioning of our car provides a further example of the principle of “stability in the face of variability.” To achieve the result of keeping our car where we want it on the road, we turn the steering wheel to the left. At other times, to achieve the same result, we turn the steering wheel to the right. Varying our actions to keep results constant is the hallmark of control (Marken 1988). Control Is All About Goals Results are only accomplished because we have goals that tell us what it is we want in any given circumstance (Marken and Carey 2015). The goals are our wants. From a PCT (Powers 1973, 2005) point of view, the important thing about a goal is how it functions, not what it is called. In the same way that “negative feedback” has a precise and specific meaning from an engineering perspective, the concept of a “goal” has a similar precise and specific meaning within PCT. For organic, autonomous, negative feedback control systems, the “goal” is the signal in the system that specifies how much input is to be achieved. In PCT parlance, the goal is known as a “reference” (Powers 1973, 2005). When we’re in a

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dark room, the control systems concerned with the size of our pupils sets goals for how big our pupils will be while we are in that environment so that wants and is for light input match. If we suddenly walk out into bright light, is is now much greater than wants so we squint to reduce the amount of light input being received until the goals for pupil size get adjusted and wants and is match once more. So, in PCT, it is not the word that is used on any particular occasion that is important. It is how whatever the concept being described functions that is of utmost interest. A reference by any other name really does function just the same and smell just as sweet. Many other words can be used that all describe a similar idea of something being accomplished, attained, or achieved. A desired state of affairs if you like (Carey et al. 2015). Words such as aim, goal, expectation, purpose, grail, target, belief, desire, attitude, mission, dream, ambition, value, aspiration, and intention all suggest a desired state of affairs, something to be realized. Each of these words depicts a particular wants state. The important point about the way in which goals function is that they tell us what to sense not what to do. In other words, they tell us what is must be. As illustrated above, sometimes the opposite doings (actions) such as moving the steering wheel to the left and right, or pushing down on the accelerator pedal or relaxing pressure on it, can achieve the same result. Another important point about goals is that they are highly individual. Your goals are yours and yours alone. Although “shared goals” is a topic that’s often used in settings such as workplaces, we can’t ever share goals like we might pass around slices of a scrumptiously decadent chocolate truffle layer cake. Sharing goals can only ever happen metaphorically. This is a profoundly important point for understanding work, life, and play. The way a mental health professional organizes their schedule; the types of clients they like to see; the way they like to work with individuals, groups, or communities, remotely or face-to-face; how many people they see; and many other considerations, all have to do with a person’s goals. And goals are all about results. Goals Are Organized Hierarchically It is important to understand that every single thing we do is governed by goals, in concert with the environmental circumstances in which we are currently situated. And all goals are “nestled” within a hierarchical network, such that we achieve one goal as a means of keeping higher order goals in their desired states. Practically, this simply means that we achieve the goal of starting the car so that we can achieve the goal of getting to work on time, so that we can achieve the goal of building a successful career, so that we can achieve the goal of making a difference to the world, so that we can achieve the goal of being who we want to be. Of course, following your own “personal trail” of where achieving the goal of starting the car might lead could wind up in a completely different place. Also, the goal of starting the car might be used for different higher order purposes on the weekend. Thinking about the “why” to any particular goal or outcome that’s at the front of your mind can often reveal the higher order purposes lurking in the background.

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Reflecting on “how” you’re going to produce the outcome you want can help to highlight lower order goals that prepare you to spring into service. So, you could follow the trail above back down from who you want to be to turning the key in the ignition. How can you be the person you want to be? By making a difference in the world. How can you make a difference to the world? By building a successful career. How can you build a successful career? By getting to work on time. How can you get to work on time? By starting the car. A moment’s reflection on reading this might bring you to the conclusion that your own answers might have been somewhat different. That is as it should be. This simple exercise highlights the precious uniqueness of our network of results-creating control systems governed by internally specified goals. Even when people have similar aspirations such as “building a successful career,” there will still be important nuances as to how that career unfolds within the network into which it must be woven for each individual. For example, you might not even own a car! Understanding the hierarchical nature of goal functioning can be invaluable for appreciating the seemingly contradictory behavior that can sometimes occur. A result-producing system at any particular level keeps its wants and is matching each other by changing the standard for the goal at the level below. Let’s say, for example, that Harrison has important goals related to companions, friendships, and other relationships. To help keep all his wants-is pairings matched at this level, he uses goals about many things such as the activities he participates in, how often he contacts people, the things he comments on when he is in other people’s company, and so on. Another thing he uses that are his goals about honesty. Harrison thinks honesty is important in any relationship. At times, however, he is aware that he varies his level of honesty so that his relationship goals remain undisturbed. A good friend, for example, recently asked Harrison what he thought about the new shirt the friend had just bought. The friend clearly seemed pleased with the expensive new addition to his wardrobe and, while Harrison privately thought it looked ghastly, he provided a much more favorable endorsement to his friend. That is, he varied the level of honesty he was satisfied with, so his friendship wants and is didn’t suffer a needless jolt. Problems Should Be Understood as Problems of Control If life is control, then problems of living must be understood as control problems. Control can be compromised in a number of ways. Sometimes, due to new environmental conditions, you might not have the necessary knowledge immediately available to control what you want. Being a new resident of Kigali (the capital of Rwanda) and not speaking the local language of Kinyarwanda has meant that TAC has had numerous instances of not being able to achieve what he wants in a straightforward manner. One of the first things he did when he arrived in Kigali was to purchase a mobile phone and organize a bank account. There is a marvelous system in Rwanda that allows people to move money between bank accounts and mobile phones (called mobile money) which can then be used to pay for groceries, taxis, tennis lessons, power bills, and most other goods and services. Unfortunately, the instructions for how to do this are all in Kinyarwanda. It didn’t matter, therefore, how earnestly TAC

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studied the words, or how much he tapped the numbers on his phone, he couldn’t close the wants-is gap for this particular results-achieving system without substantial assistance. After a period of time of flailing around, he discovered a translation app and is now controlling satisfactorily again. A lack of knowledge can indubitably disrupt control. Control can also be disrupted by overwhelming and insuperable environmental circumstances. Natural disasters such as bushfires, floods, droughts, hurricanes, cyclones, tornadoes, tsunamis, and earthquakes can devastate individuals, families, and communities. Other issues such as poverty and high unemployment rates can also have detrimental impacts. As with a lack of knowledge, as horrendous as these events can be, people gradually take stock, rebuild lives, and get themselves back on track. Communities might even develop greater strength, through new networks and better resources, than they had before. A third type of control problem is especially important and particularly relevant to the topic of self-care. Sometimes, situations arise when the results-achieving efforts of one control system are thwarted, or even counteracted, by the results-achieving efforts of another control system. Conflict between two people is commonly and easily recognized. Perhaps a manager wants a mental health professional to see a particular client group or work in a particular way that is at odds with how the mental health professional wants to work. The more the manager insists, the worse it is for the mental health professional, and if the mental health professional takes a stand, the situation will deteriorate for the manager. Conflicts between people are never pleasant; however, the most potentially damaging and detrimental conflict is when it occurs within a person. Intra rather than inter conflict is a serious impediment to psychological functioning and well-being. Intrapersonal conflict is conflict between goals. At different times, for one reason or another, it can arise that reducing the difference between wants and is for one system actually increases the difference for another system (for example, Chantal might want to be a good colleague by helping to finalize a report that is due in an hour, but might also want to be a good parent by watching her son’s tennis match in half an hour’s time). Goal conflicts can result in problems such as emotional exhaustion, lack of social integration with other professionals, inadequate supervision and support, and insufficient professional training opportunities (Jameson and Blank 2007). In 2016, a vivid description of potential goal conflict was provided by Jayclyn Pascoe in a newsletter circulated by the Central Australia Health Service. Jayclyn lived in a small town in the Northern Territory and was discussing her journey of becoming an Aboriginal Health Practitioner. She referred to the education and training she had undertaken as well as the important people who had influenced her decisions. She said, “The hardest aspect of the past 30 months has been prioritising between family, work, study and travel.” The necessity of prioritizing between important areas of one’s life provides fertile ground for conflict to flourish. Conflict, the situation of seeking two opposing goals at the same time, is the most common way in which control can be compromised (Carey 2008). Conflict from a PCT perspective can be considered a generic formulation of an a-diagnostic

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approach to mental health and psychological and social distress including trauma (Carey et al. 2015; Carey et al. 2014b). It is beyond the scope of this chapter to explain and discuss conflict in detail. It might be useful to highlight, however, that, from a PCT perspective, any choice situation is, essentially, a conflict (Carey et al. 2015). Should I have the dukkah crusted pork belly or the slow roasted goat osso bucco? Will I order the South African Cab Sav or the Californian Zinfandel? When one considers the number of choices we successfully negotiate every hour of every day, it is clear that we are generally superbly adroit at solving conflicts. Sometimes, however, conflicts endure and, when this occurs, the full range of symptoms of psychological and social distress can arise. A range of goal conflicts can exist for RRvR workers. Ironically, a conflict can emerge between engaging in self-care practices and fulfilling other obligations. Sometimes, due to environmental changes, goals that previously were not in conflict can be pitched against each other. Perhaps a new manager, for example, arrives in a work unit and establishes different routines, schedules, and expectations than had been in place before. These alterations to work arrangements might create the context for conflicts between personal and professional goals for some of the staff. In terms of what we have discussed so far, some goal conflicts could include the following: • A goal to maintain self-care practices versus a goal to be available to clients and colleagues • A goal to maintain professional boundaries versus a goal to become fully engaged in community and personal social events • A goal to manage one’s own affairs after a local disaster versus a goal to assist and support others to cope and recover • A goal to perform well in one’s appointed position versus a goal to continue one’s own career development • A goal to maintain one’s standard of living versus a goal to take a job with a lower salary to achieve a better quality of life. Each of these examples illustrates a conflict between goals that may make selfcare both more difficult and also more relevant and important. As with all other aspects of control, the experience of conflict in terms of which goals become conflicted, how the conflict manifests, and for how long it persists, will all be individual considerations. Importantly, the successful resolution of the conflict, and achievement of “balance” by accomplishing one’s objectives, is also something that the individual alone can accomplish. Others can provide support and encouragement, but the conflicted person must find their own solution. Crucially, novel solutions need to be found because, with conflicts, there is no logical or existing solution that will lead to elimination of the conflict. It is a new perspective or a new way of approaching situations that must be discovered. Successful resolution of existing conflicts and the minimization of the impact of future conflicts will enable an enhanced awareness and understanding of oneself as well as an appreciation of the priority of self-care for creating a balanced and

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satisfying life in RRvR places. Importantly, the community will also benefit from the outcome in ensuring more ethical, competent, and sustained services. Ideally, an individual mental health professional’s commitment to effective and ongoing selfcare practices might demonstrate to managers the responsibility of the workplace to facilitate flexible schedules, as well as to provide support and supervision for their staff. The challenge of maintaining self-care in RRvR settings compared to metropolitan areas is that some competing goals may be easier to “keep off the battlefield” in metropolitan locations. Metropolitan areas often have a greater range of opportunities to engage in activities that satisfy individual interests. Professional boundaries may be easier to achieve and maintain given the population size and the geographic opportunities to work and live in different locations. The impact of local disasters might not be personally experienced at all or may be minimized. Also, there is usually a greater concordance between career opportunities, salary, and developing of competence. The opportunity for flexible schedules, support, and supervision is also more likely to be available in metropolitan areas. While these advantages are easier to achieve in metropolitan compared to RRvR locations, with ingenuity and a genuine desire to improve situations, the necessary changes can occur in the RRvR setting. It is clear from the literature that, in order to further develop the mental health workforce in RRvR to meet population needs, there is a genuine and urgent need to look to creative practice models (Edmunds and Harris 2015; Struber 2004). So What? What’s the Point for Self-Care? Recognition of the importance of control has major implications for self-care. Self-care is synonymous with control. Focusing on the difference between wants and is throughout our individual networks is a crucial aspect of ongoing effective functioning and ensuring contentment and satisfaction. The minimization of these differences can be more difficult in some circumstances and contexts, but the urgency of the imperative remains undiminished. Control will not go away. The clearer we can become about the goals that are important to us and the things we need to continue experiencing to obtain the results we want, the more ideal will be both our personal and professional lives. A professional development workshop designed to help mental health and other health professionals develop and sustain this clarity is described in the section “Case Study.”

Case Study This chapter has explored the nature of control including the disruptions to control that can arise due to conflict. While the form of conflict is standard, the manifestation of particular conflicts is always idiosyncratic. It is not surprising, therefore, that what may be a meaningful self-care strategy for one person, may in fact, not suit another. As mentioned above, the plethora of literature on self-care can be useful as far as providing a range of options and strategies to manage problems that might be identified as burnout and stress. Improvements to emotional and social well-being

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might be noticed as a result of using these strategies. Unless one understands, however, the nature of what is underlying the (di)stress, selecting a self-care strategy from the range of strategies available, is likely to be problematic. It is only by appreciating the nature of our conflicts that we can better understand what is meaningful in managing our social and emotional well-being. In that respect, no one strategy can provide a definitive solution that will work for all. The ideas we have described in this chapter formed the basis of a self-care workshop delivered to remote and very remote health professionals as part of postgraduate coursework offered through Flinders University in Alice Springs. The workshop was titled “Looking After #1” (meaning taking care of oneself as a priority) and was organized as an action research project between 2015 and 2019. By being based on the principles of PCT, Looking After #1 is a strengths-based, holistic approach to self-care. Ethics approval was obtained from the Flinders University Social and Behavioural Research Ethics Committee (SBREC). A preliminary analysis was conducted after six workshops which indicated that participants generally found the workshop interesting and informative (Carey and Martin 2018). The workshop is organized around a workbook which guides participants through a series of questions. The questions focus on goals, goal hierarchies, and goal conflict (for example, exercises throughout the workbook in the form of questions, ask participants to reflect on the things they like to achieve as a professional, a parent, a friend, and so on). Participants are encouraged to consider successful existing self-care strategies and reflect on the times they work well and the times they are not as helpful as they could be. The workshop alternates between brief periods of information and instruction and then time for individual reflection and group discussion. One of the topics that is discussed early in the workshop is the difference between good self-care and being selfish. The workshop itself is organized as an enjoyable and fun self-care experience. Fresh coffee and delicious food are provided, gentle music is played during reflection and discussion times, scented candles are burned, and a variety of colorful and light-hearted materials are available for participants to decorate their workbooks. A range of colored pens and crayons are supplied as well as colorful stickers, stamps, feathers, glitter, and glue. Perhaps the most notable aspect of the workshop, however, is that successful self-care strategies, practices, and attitudes are not provided or suggested. The assumption from the PCT formulation of conflict is that novel solutions are required to resolve conflict. The workshop, therefore, provides time for participants to generate their own unique strategy solutions through individual reflection and small and whole group discussion but no time is allocated to providing participants with lists of what they could do. Participants are also invited to reflect on their own successful self-care practices which they have used in the past, and to review these strategies in terms of barriers and possible areas for improvement. During the period of the action research project, variation was introduced into the course, sometimes by design and sometimes serendipitously. Regardless of the way in which the changes occurred, they helped to identify areas where improvements could be made and highlight aspects that were working well. The duration of the

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workshop varied but was generally 4 h. One successful innovation that was appreciated by participants was to begin the workshop on the afternoon of 1 day and finish it on the morning of the next day. Participants reported finding it valuable to reflect on their learnings overnight. Having different psychologists who were familiar with the concepts facilitate and co-facilitate the workshop at different times was also helpful and added confidence to the usefulness of the ideas. Between February 2015 and July 2019, 15 workshops were provided. Postworkshop evaluations were distributed at every workshop along with information about the action research project and invitations to participate. Workshop attendees were under no obligation to participate or to complete the evaluations. If participants consented to participate in the study, they could also indicate if they agreed to be contacted in 3 months’ time with a follow-up evaluation. Because of the action research nature of the project, data were not collected on variables such as gender and occupation of the people completing the surveys. The great majority of the participants, however, were female and worked as very remote area nurses. A total of 278 people participated in the 15 workshops. Of those, 238 (86%) consented for their postworkshop evaluations to be included in the research. A further 110 (40%) of those consenting to be part of the research also agreed to be contacted in 3 months’ time. From the 110 people agreeing to be contacted in 3 months’ time, 20 (18%) returned completed follow-up surveys. Table 1 provides the average ratings of the 238 people completing postworkshop evaluations and consenting to participate in the research. Generally, the results indicated that people found the workshop informative, interesting, relevant, useful, and helpful. In addition to the numerical ratings, people had the option of commenting on the strengths of the workshop, improvements that could be made, and any other comments they wanted to suggest. The majority of the participants indicated with their comments that they valued the workshop and didn’t have ideas for improvement. As can happen with these kinds of evaluations, when people did make suggestions for improvement, they were sometimes contradictory. Some people thought the workshop should be shortened, others felt it would be better longer; some thought there was too much group discussion, others thought there was not enough. These are excellent examples of the individuality of control and the importance of structuring environments so that people have the freedom to control the things that are important to them. In terms of the strengths of the workshop, participants mentioned the skills and expertise of the presenters. They also appreciated the group interactions, the novelty and simplicity of some of the ideas, and the opportunity to have dedicated time to reflect on self-care. Many people specifically mentioned that they appreciated the awareness raising and thought challenging aspect of the workshop. Participants also found the workbook useful. At the 3-month follow-up evaluation, people were asked just five questions to minimize response demand. They were asked to comment on: how they would assess their self-care practices at that time (rated on a scale from 1 – awful, to 10 – ideal); their current self-care practices; their current level of professional satisfaction; any improvements to the workshop they would recommend; and anything else they

n 238

Interesting 7.8

Informative 7.9

Evaluation items

Relevant 7.9

Useful 7.6

Helpful 7.6

I understand self-care better than I did before 7.1

I feel more confident to practice self-care than I did before 6.8

Table 1 Average postworkshop evaluation survey ratings on a scale from 1 (totally disagree) to 10 (totally agree) I would recommend this workshop to friends and colleagues 7.6

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wanted to add. Of the 20 people who returned these evaluations, 19 people provided ratings. The range of the ratings was 5.5–9 (mean ¼ 6.6, median ¼ 7, and mode ¼ 8). Most participants indicated they were more aware of self-care since the workshop and that their self-care habits had improved, for example: after the workshop I was more open to taking opportunities related to Self Care and joined a local session which explored options including mindfulness, relaxation, creative writing and general self-acceptance skills. Generally more motivated. It always helps to be reminded about the need for caring for oneself. Frequently this is pushed out by other life pressures. The workshop also highlighted that self-care need not be very complicated – a mere acknowledgment is a good start.

A minority of participants felt their self-care was the same or could be better, but no one indicated their approach to self-care had deteriorated. The majority of people also indicated they were more professionally satisfied, while a small number suggested they were transitioning to a new career. Very few suggestions were offered for improvement. People generally indicated that they enjoyed the workshop and got a lot out of it. There was a suggestion that offering strategies could be useful, although other people recognized that the most effective strategies are self-generated. One participant commented: I enjoyed the blank work book as I took from that the message that inside myself I have the resources to fill in the blanks.

Once again, the novelty of the approach and perspective was highlighted as a positive aspect, as was having dedicated time to reflect on one’s career and wellbeing. While a study of this nature, like all studies, has limitations, there is some evidence to suggest that conceptualizing self-care from the perspective of control, goals, goal hierarchies, and goal conflict is a useful approach. Generally, people appeared to find the ideas engaging, interesting, and useful. This current work justifies further research on the Looking After #1 workshop including investigating the approach with different professions and in different contexts. Perhaps a focus on control, goals, goal hierarchies, and goal conflict could become part of the language within work settings between managers, staff, and colleagues to promote enhanced control in the workplace for greater contentment, satisfaction, and well-being for all.

Concluding Comments and Recommendations Understanding control as a natural phenomenon, and a crucial element of maintaining “balance,” would help mental health and other health professionals, as well as health service managers, to organize health and mental health services in a way that facilitates better control for them and the clients of these services. Disruptions to control (for example, through conflicted goals) will always result in distress

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and compromised functioning. Findings ways to arrange environments so that more people more of the time can control the things that are important to them would help to build and maintain a high-functioning mental health workforce. Organizations could introduce policies and guidelines to ensure that people were appropriately qualified before being recruited to various positions. Once people are appointed to positions, providing the necessary supports such as supervision, pleasant environments, and flexible schedules could help people control those things that are personally important. Increasing a general understanding throughout the workplace of the significance of both personal and professional goals and how they function could also assist managers and staff to thrive and flourish. Individuals who understand control and how it functions are able to review their goals and the hierarchical structure within which they are situated on a frequent basis. They will be clear that when they are bothered or unsettled, it is likely to be because of a goal conflict that has developed. Examining the conflict and exploring other goals that might be related to it can help to lead to the appearance of solutions that can be surprising and novel (for example, a psychologist might arrive at the conclusion that boundaries can be appropriately relaxed without being compromised). Sometimes these ideas appear as sudden “Aha!” insights and at other times the realization can seem more gradual. Potential individual solutions that appear as a “steady stream,” a “jumbled whirl,” a “sporadic string,” or something else entirely can all benefit from a moment’s pause and inspection. Sometimes the sparkliest diamond of an idea has the spikiest, least enticing initial appearance. Control is the key. Understanding yourself and the things that are important to you will help you achieve a more contented and satisfying existence on an ongoing basis both professionally and personally. Control is not something to be avoided. It should be embraced, understood, and celebrated. Learning to control the things we value without preventing others from doing likewise is the key to successful, thriving social living. When individuals, families, and communities understand their own controlling natures, they will be able to genuinely help more people more of the time. From a control perspective, helping others can, paradoxically, be the best self-care strategy of all.

Take Home Messages • Control is a natural phenomenon that is fundamental to all aspects of health and essential to self-care. • Self-care is particularly important in RRvR locations where the distinction between personal and professional lives may not be as easily discernible or demarcated but individuals must find their own unique self-care solutions – strategies and advice from others are unlikely to be enduringly successful. • The goals an individual pursues in any given context will have a strong influence on the degree to which the individual functions successfully in that context. • Goal conflict can be understood as a generic formulation for disruptions to psychological functioning such as stress, distress, and burnout.

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• Understanding the idiosyncratic hierarchical organization of goals can help individuals become clearer about the values and beliefs which are most important to them and lead to greater long-term satisfaction and contentment.

References Asante JO, Li MJ, Liao J, Huang YX, Hao YT. The relationship between psychosocial risk factors, burnout and quality of life among primary healthcare workers in rural Guangdong province: a cross-sectional study. BMC Health Serv Res. 2019;19(1):447. Australian Psychological Society. APS code of ethics. Melbourne: Author; 2007. Barnett JE. An introduction to boundaries and multiple relationships for psychotherapists. Multiple relationships in psychotherapy and counseling: Unavoidable, common, and mandatory dual relations in therapy, (2016), 17. Bowers J, Lo J, Miller P, Mawren D, Jones B. Psychological distress in remote mining and construction workers in Australia. Med J Aust. 2018;208(9):391–7. Carey TA. Conflict, as the Achilles heel of perceptual control, offers a unifying approach to the formulation of psychological problems. Couns Psychol Rev. 2008;23(4):5–16. Carey TA. Health is control. Ann Behav Sci. 2016;2(1):13. Carey TA. Academics in the bush: are rural, remote and very remote Australians being sold short? Aust J Rural Health. 2019;27(5):372–3. Carey TA, Martin K. Looking after #1: a short report of the interim analysis of a self-care course for remote health professionals. Aust J Rural Health. 2018;26:295–7. https://doi.org/10.1111/ ajr.12399. Carey TA, Mansell W, Tai SJ. A biopsychosocial model based on negative feedback and control. Frontiers of Human Neuroscience. 2014a;8:94. https://doi.org/10.3389/fnhum.2014.00094. http://journal.frontiersin.org/Journal/10.3389/fnhum.2014.00094/abstract Carey TA, Mansell W, Tai SJ, Turkington D. Conflicted control systems: the neural architecture of trauma. Lancet Psychiatry. 2014b;1:316–8. Carey TA, Mansell W, Tai SJ. Principles-based counselling and psychotherapy: a method of levels approach. London: Routledge; 2015. Edmunds M, Harris M. Challenges to student transition in allied health undergraduate education in the Australian rural and remote context: a synthesis of barriers and enablers, (2015) Fung J. The obesity code: unlocking the secrets of weight loss. London: Scribe Publications; 2016. Jameson JP, Blank MB. The role of clinical psychology in rural mental health services: defining problems and developing solutions. Clin Psychol Sci Pract. 2007;14(3):283–98. Marken RS. The nature of behavior: control as fact and theory. Behav Sci. 1988;33:196–206. https://doi.org/10.1002/bs.3830330304. Marken RS, Carey TA. Controlling people: the paradoxical nature of being human. Brisbane: Australian Academic Press; 2015. O’Connor K, Neff DM, Pitman S. Burnout in mental health professionals: a systematic review and meta-analysis of prevalence and determinants. Eur Psychiatry. 2018;53:74–99. Paulson LR, Casile WJ, Jones D. Tech it out: implementing an online peer consultation network for rural mental health professionals. J Rural Ment Health. 2015;39(3–4):125. Powers WT. Behavior: the control of perception. Chicago: Aldine; 1973. Powers WT. Behavior: the control of perception. 2nd ed. New Canaan: Benchmark; 2005. Rothenburger DA. Physician burnout and well-being: a systematic review and framework for action. Dis Colon Rectum. 2017;60:567–76. Struber JC. Recruiting and retaining allied health professionals in rural Australia: why is it so difficult? Int J Allied Health Sci Pract. 2004;2(2):2.

Part IV Important Areas of Practice in Rural, Remote, and very Remote Mental Health

Suicide and Self-Harm: It’s Everyone’s Business

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Factors: Challenges for Rural and Remote Service Provision . . . . . . . . . . . . . . . . . . . . . . . . Internal Factors: Common Factors of the Rural and Remote Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . Practical Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Directed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Backing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Capacity Building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Leadership/Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Development/Strategic Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practitioner Directed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Appropriateness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Service Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Globally suicide is often reported as being one of the top ten causes of death across many countries, and so suicide and self-harm are global issues that warrant closer inquiry. The global suicide rate is estimated to be over 10 per 100,000, and those who self-harm have higher suicide risks. Many countries have found that the rate of suicide increases with greater distances from major centres. There are a number of specific external and internal factors that have been found to contribute to suicide in rural and remote communities. External factors include access to S. J. Lutkin (*) · B. Buckby James Cook University, Townsville, QLD, Australia e-mail: [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_24

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services and trained professionals, unemployment, financial constraints, and limited infrastructure. Internal factors include social cohesion, historical legacies, and values and beliefs. This chapter provides a conceptual model to guide practitioners in undertaking community suicide prevention planning with a focus on community-led as well as practitioner-led domains. This model aims to guide practitioners in applying suicide prevention planning in rural and remote locations. The community-led domain centres on community capacity building and ensuring community engagement to foster success, whereas the practitionerled domain centres on information provision, promoting social cohesion, and acting as the communication channel between community and organizations. The primary driver of the model assumes that community engagement and ownership is essential for strategies to be effective in rural and remote communities. The main aim for this chapter is to assist rural and remote practitioners in their role of preventing suicide and self-harm in communities.

Introduction Many health professionals will work with clients who are experiencing suicide ideation or self-harming at some point in their career. In locations where there are fewer health professions, greater levels of psychological distress, and fewer services, the chance of working with a suicidal or self-harming client increases. The demand for health professional services can be overwhelming at times so it is important that professionals working with clients with mental health symptoms have a good understanding of the factors involved. This chapter begins by outlining the prevalence of self-harm and suicidal behavior with some comparison of Australian statistics to other countries and then focuses on the unique aspects of rural and remote communities that are infrequently addressed in suicide literature and research. Self-harming behavior is a significant issue particularly among younger age groups with 12-month prevalence among Australian adolescents aged 14–15 reported as 15% for girls and 4% of boys, and such behavior increases risk of suicide (Daraganova 2017). Australian Bureau of Statistics preliminary data from 2018 shows 3046 deaths by suicide which is a rate of 12.2 per 100,000 (8.3 deaths per day). The rate of male suicide is more than three times greater than that for females. In 2018, the age-specific rate for males was 18.7 per 100,000 (2320 deaths by suicide) and for females was 5.8 per 100,000 (726 deaths by suicide) with the highest proportion of deaths as 54.8% for adults aged 30–59 years, followed by age groups 15–24 years (38.4%) and 25–34 years (29.4). In 2018 within the young adolescent age group, males aged 0–14 years had the lowest suicide rate (0.5 per 100,000), and those 15–19 years were at 17.3 per 100,000. Adolescent females aged 0–14 years were at 0.4 per 100,000. In the 15–19-year group, there were 52 deaths (7.2 per 100,000). A recent global meta-analysis by Lim et al. (2019) found that of the 686,672 children and adolescents, they identified that the aggregate lifetime and 12-month prevalence of non-suicidal self-injury were 22.1% (95% CI: 16.9–28.4%) and 19.5% (95% CI: 13.3–27.6%), respectively. The likely contributing factors, according to the authors, were full-time school attendance, non-

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Western countries, low- and middle-income countries, and also that geographical locations could contribute to the higher aggregate prevalence of suicidal behaviors, deliberate self-harm, and non-suicidal self-injury. Although self-harm is not always associated with suicide, there is considerable overlap in the influential factors that contribute to self-harming behavior that can proceed to suicide, so self-harm is always a consideration when examining suicide risk (Daraganova 2017). There are multiple reasons offered for self-harming behavior with the most common being to manage emotions or to self-punish (Daraganova 2017; Martin et al. 2010). Death can be a consequence either intentionally or unintentionally and is therefore an imperative consideration in suicide assessment as repeated self-harm is a strong predictor of suicide with risk increasing to between 1.8 and 5 times higher in those who self-harm (Bergen et al. 2012; Daraganova 2017). Suicide is worldwide and most prevalent in the 15- to 29-year age group globally with most (78%) occurring in low- and middle-income countries (WHO 2019). There are acknowledged difficulties in reporting and collecting suicide data across nations due to different statistical criteria for classifying a death as well as cultural understandings of suicide. Therefore, cautious comparison must apply when considering suicide mortality by region. The World Health Organization (WHO) estimates a global suicide rate of 10.5 per 100,000 in 2016 (WHO 2019). In many countries suicide rates in rural areas surpass that of regional and metropolitan areas. Although the demographics of the populations most at risk may change across countries, the fact remains that as remoteness increases, and as the population reduces, the suicide rate increases (Handley et al. 2012). The phenomenon of higher suicide rates in rural and remote communities has been identified across the globe in the USA, Canada, Australia, New Zealand, Germany, and China (Burrows et al. 2013; Ferguson et al. 2004; Helbich et al. 2017; Qi et al. 2014; Singh and Siahpush 2013; Wang et al. 2014). In the Western Pacific Region, rates of suicide per 100,000 in Australia (12.2) and New Zealand (12.6) are similar and higher in 2018 compared to 2016. Other regional neighbors in 2016 were lower, Papua New Guinea (7), Singapore (7.9), and Micronesia (11.3), while Japan (14), Mongolia (13.3), Kiribati (15.2), and Korea (20.2) are higher. However, it is notable that the colonized countries’ rates also inflate due to higher suicide rates among the Indigenous populations worldwide. In many countries rural and remote populations are a small percentage of the overall population and often include minority and culturally diverse groups with occupations that are dependent on environmental or global demand. The higher suicide rate and additional related risk factors such as isolation in rural and remote locations require specific focus by all health professions when working in such communities, particularly when there are fewer support services as distance increases from highly populated areas (Handley et al. 2012). When a suicide occurs within a rural and remote community, the impact is experienced throughout the community. Suicide has a “ripple effect” through the community with direct effect on close others and rippling outward to another (estimated) 135 people likely to be affected in some way from 1 suicide (Cerel

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et al. 2016). However, one could hypothesize the rate to be higher in small rural and remote communities where lives are interconnected in multiple contexts. There are also heightened concerns regarding contagion and cluster effects in rural and remote communities, as clusters are often young people (Haw et al. 2013; Reser 1989a). The rationale or factors offered as explanations for the increase in suicides in rural and remote areas are explored in this chapter. The troubling phenomenon of higher rates of suicide in rural and remote locations has implications for health professionals considering undertaking work in rural and remote locations who must develop essential training, knowledge, and skills of all aspects of suicide including specific factors that influence suicide in rural and remote locations.

Distinctive Features A factor across contexts is that the majority of people who experience suicide ideation do not actually want to die. It is the intolerable psychological pain, negative thoughts of self, feelings of hopelessness, loss of connectedness, and perceived burdensomeness that contribute to highly emotional states when suicide becomes a viable escape option (Chu et al. 2017). However, it is a permanent solution to temporary problem. Therefore, it is important for close others, and particularly health professionals, to recognize psychological distress and risk of suicidality. General practitioners, for example, are time pressured and possibly more confident than skilled as the first point of contact for a suicidal person as Michail et al. (2017) found. Even the use of questionnaires such as the Patient Health Questionnaire intended to identify depression and suicidality cannot aid identification of mental disorders or psychological distress if a direct question about suicidality is not included. For example, a short appointment provides little time to gather data, and the Patient Health Questionnaires are frequently used in short form, e.g., two or four item versions that might identify the possibility of depression but excludes Question 9 that explicitly targets suicide risk (Carey et al. 2014). This highlights the need to ensure all health professionals and frontline staff have in-service education to improve awareness of the risks for suicide and self-harming behavior at the first contact (Michail et al. 2017). The major risk factors for suicide are the same for rural and remote as well as metropolitan areas across the Western Pacific and Southeast Asia. Risk factors include being male, previous history of suicide attempts, history of substance use, a mental health condition, relationship conflict, death of a loved one (particularly by suicide), physical illness, and access to means. Other risk factors include younger age, unemployment, lower socioeconomic status, psychological distress, alcohol use, and neuroticism (Handley et al. 2012). Overall females have a higher prevalence rate of self-injury (Daraganova 2017; Martin et al. 2010) although a significantly lower rate of suicide compared to males. Other factors specific to rural and remote locations and their nuanced influence should also be considered. In this chapter these risk factors are broadly defined as internal and external factors to the individual. External factors are those elements that the individual has limited control over and

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are often a reality of living in rural and remote locations. These factors include the accessibility of services, the skills and continuity of the workforce, location distances, infrastructure, and the industry and employment levels. Internal factors relate to how connected people feel within the community, social cohesion, and culture, which can be specific to ethnic groups, work, or the community itself.

External Factors: Challenges for Rural and Remote Service Provision A major complaint of people living in rural and remote communities is poor access to services, particularly health services offering specialist care. Internationally there is no agreed singular set of core primary healthcare services that should be available in rural and remote locations (Carey et al. 2013). Adequately distributed services across the rural and remote communities require services to meet the local health needs of the community. With this in mind, Thomas et al. (2015) proposed a methodology of adequately distributing services for small communities of less than 100 to 1000 to inform policy based on expert opinion. The categories of care for any one community related to population of the town. The smaller the town, the fewer services to be situated there supported by distant specialist services. The categories of services were Care of the Sick and Injured; Public Health/Illness Prevention; Mental Health/Social and Emotional Wellbeing; Rehabilitation; Maternal and Child Health; Oral/Dental Health; Sexual and Reproductive Health; and Allied Health Services. The tenth Australian Rural and Remote Mental Health Symposium Communiqué notes that “Well-trained and qualified mental health professionals are essential for adequate service delivery in rural and remote areas given the breadth of practical skills required. Retention of highly qualified staff needs support.” The communiqué also emphasized the importance of early intervention, prevention, and mental health promotion in rural communities and notes that “There appears to be so much rhetoric in this area and so little funding or action. In small rural communities this is doubly important due to the lack of specialist secondary or tertiary level care, if someone becomes unwell” (Roberts and Miller 2019). In the absence of highly skilled generalist and specialist health and mental health professionals, e-mental health technology can provide additional support for practitioners and patients from anywhere without travel cost. When travel distances are vast, or short with difficult access to isolated communities, e.g., in developing countries and remote regions of Australia, the distribution of health and mental health professionals are often inadequate to suit community need. In this regard, prior rural and remote practical experience during university training can provide a community immersion experience and can positively influence some future career choices for some. Without prior experience, inexperienced new graduates accepting positions with limited supervisory support, inadequate resourcing, and managing complex cases are less likely to integrate into the community and leave sooner.

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Difficulties attracting suitable and well-qualified professionals to such regions and retaining them once there is an ongoing challenge. Cosgrove, Hussain, and Maple (2015) identified several retention themes, staffing is difficult, small towns are a persistent challenge, and decisions to leave are influenced by high workload, reduced resources, working in small teams, unmet expectations about rural living/ lifestyle, and lack of prior social connectedness to the community. Other barriers to relocation which include accessing appropriate housing, limited continuing education opportunities for the mental health professional and their children, safety concerns, and limited infrastructure and resources are all reasons offered for either not working or staying in rural and remote areas (Belaid et al. 2017). The churn of practitioners who stay for a relatively short time and then leave means that knowledge of the community, local services, and support networks for people with mental health issues is constantly being relearned, suicide prevention programs are disrupted, and relationships of trust and respect with patients/clients have to be rebuilt on each occasion. Suicide prevention programs and community training initiatives lose momentum in such circumstances as Roberts and Miller’s communiqué noted. The importance of a reliable therapeutic alliance between the practitioner, the mental health client, and the community in which they live has been shown to improve patient activation, so stability and continuity of the mental health workforce have a direct effect on positive change (Allen et al. 2017). The higher levels of practitioner change also lead to some cynicism in small communities about how long the new practitioner will stay and reluctance to go over personal histories yet again. The health workforce and mental health professionals who choose to live and work in rural and remote locations often grew up in the area and choose to return to live and work there after graduation (Morell et al. 2014). Poor access to services is further exacerbated by barriers to help seeking that include structural constraints such as cost, transport, attitudinal constraints such as confidentiality, stigma, and time constraints (Handley et al. 2014). Lack of public transport is a significant obstacle in rural and remote areas, and other travel options can have a significant financial and time cost. The absence of public transport associated with rural and remote areas also means that individuals may be more likely to drive while drinking (Burrows et al. 2013). The higher mortality rate associated with rural and remote motor vehicle accidents has been attributed to longer distances to travel, higher speeds, not wearing seatbelts, and less access to prompt medical care (Raatiniemi et al. 2016). There is no reliable method to estimate how many “accidents” are suicides. People living and/or working in rural and remote areas also use higher-risk vehicles over long distances and on poorly maintained roads and use mechanical equipment more frequently, particularly in occupations such as farming and mining, and therefore have higher associated risks of injury than urban dwellers (Burrows et al. 2013). As many people are employed in farming and mining industries, there is increased vulnerability to climate and global financial fluctuations that directly influences physical and psychological health, well-being, and financial security. In such circumstances of extreme financial and psychological stress, suicide risk increases, methods of lethal self-harm are easily available, and help seeking among the farming community is low (Brew et al. 2016).

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Farming and mining occupations require working in areas that are quite remote and isolated. Rates of suicide are higher in farming communities which are by definition more isolated, with fewer mental health services, and where transport is poor, too expensive, or unavailable (Kunde et al. 2017; Stark et al. 2011). Higher psychological distress among farmers and their spouses has been identified by comparison with non-farming populations (Brew et al. 2016; Hounsome et al. 2012). Contributing situational stressors such as relationship conflict, alcohol use, long working hours, physical illness, access to firearms, and drought amplify the risk of suicide among the farming population (Kunde et al. 2017). This population that already has some extenuating risk factors can be deeply affected by climate changes such as droughts and floods or global low demand and/or prices for products. A less discussed issue is the effect of a decline in farming and mining on other associated businesses within the local community, creating a ripple effect through the community, thereby increasing psychological distress and low life satisfaction (Judd et al. 2006). The functional impact of job loss due to a decline in farming results in the need to sell all assets is described in John’s story (Case Study 1). Unemployment in particular has a ripple effect as psychological distress is related to an increase in illegal drug use and an increase in binge drinking (Colell et al. 2015; Nagelhout et al. 2017). For some it goes further; Martin et al. (2010) found that a high proportion of people who self-injure are also smokers, binge drinkers, and illicit drug users. It is well understood that the risk of suicide increases when under the influence of substances. Suicide risk could potentially be somewhat mitigated among high-risk groups in small rural and remote communities if the community promotes social integration and sense of purpose or shared vision for the future among the mostly young self-harming substance users (Kõlves et al. 2012).

Internal Factors: Common Factors of the Rural and Remote Lifestyle Some internal factors could be considered more common in rural and remote locations. Feeling connected to the community is one element that many who live in rural and remote communities believe is important to the well-being, loyalty, and pride in the community which is supported by evidence from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. Berry and Welsh (2010) were able to show that higher participation in the community contributed to social cohesion and to better health, particularly mental health. Some communities are not instantly open to this form of connectedness, for example, in high fluidity groups, such as in mining communities, or minority cultural groups, locals may be suspicious of newcomers detracting from the social cohesiveness of the community. Mining communities, for example, are more likely to contribute to relationship breakdowns, poor family health, and lack of social connectedness (Mactaggart et al. 2016). Community connectedness and social cohesion differ in importance across cultures. Minority groups more commonly reside in rural and remote areas, and the connection to others, particularly family, is associated with community protective

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factors for both suicide and alcohol disorders (Philip et al. 2016). On the other hand, conflicts within the family for collectivistic and some minority cultures have been linked to an increased risk of suicide (Zhang and Wang 2012). The loss of family support in some cultural contexts has a significantly detrimental effect on personal well-being. Other factors linked to culture can also have an impact on well-being, such as the perception of racism to suicide ideation (Walker et al. 2017). For many native cultural groups, the connection to land is extremely important, and the displacement from land can cause psychological distress that transmits to future generations creating an historical legacy. The experience of racism and historical trauma can lead to mistrust in community newcomers. Often local community members will need to “vouch” that the newcomer has good intentions toward the community before they can effectively operate in the community. Culture also has an influence on the perception and meaning of suicide. Historically, in many cultures, there have been acceptable forms of self-killing such as the now obsolete Hindu practice of suttee during which a widow immolated herself on her husband’s funeral pyre, or hara-kiri which was a ritual suicide practiced by the Japanese samurai, or altruistic suicides of the elderly at times of famine among the Inuit of Canada (Kral 2016). In Australia pre-colonial altruistic suicides among Aboriginal and Torres Strait Islander peoples were infrequent incidences (Leenaars et al. 1999; Reser 1989b). For many native first peoples high suicide rates relate to historical colonization, war, displacement from land, removal of children, accessible alcohol, and loss of culture and traditions. In rural and remote practice, such history affects the lived experience and mental health of people in the present. As cultures differ across regions, aspects of rural and remote communities differ from urban and metropolitan areas. Isolated rural communities have differing values and beliefs, ones that value male stoicism and self-reliance in the face of adversity and with strong sense of rural identity (Alston 2012; Collins et al. 2017). These values inhibit help seeking which is viewed as weakness and self-harm and suicide taboo topics. Internationally, farmers are at higher risks of suicide when compared to the non-farming community (McIntosh et al. 2016; Milner et al. 2015; Bossard et al. 2016). Reluctance to use health services among farmers was identified in a longitudinal cohort study, correlated with poorer well-being; physical and mental health associated with “weakness” seems likely to be a contributing factor to the higher suicide rate (Alston 2012; Brew et al. 2016; McIntosh et al. 2016). Although the mining industry itself may not contribute to greater risk, psychosocial factors such as strain on relationships, shift work, and isolated locations can increase the risk of suicide among miners (McPhedran and De Leo 2014).

Practical Implications With all the additional factors that must be considered when working in a rural and remote community, it is clear why suicide prevention cannot be a “one size fits all.” Rural and remote locations require different approaches for mental health practice in recognition that when one solution works in one community, it may be less

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successful or even fail in the next (Pierce et al. 2016). Therefore, no single model is able to meet the specific needs of all rural and remote communities as they require local knowledge, connections, credibility, and flexibility to be effective (Pierce et al. 2016). Specifically designed programs for local needs should be included in the development of a suicide prevention and intervention plan based on common core elements. Figure 1 provides a conceptual model for suicide prevention planning to guide practitioners in the development of suicide prevention interventions in rural and remote communities. The model includes eight elements of sustainable community solutions for suicide prevention including Cultural Appropriateness, Service Collaboration, Community Backing, Strategic Planning and Evaluation, Education, Communication, Community Leadership and Elders, and Capacity Building. These domains can be divided into two components, community directed, comprised of Community Leadership and Elders, Capacity Building, Community Backing, and Strategic Planning and Evaluation, and practitioner directed, including Cultural

Community Leadership / Elders Capacity Building Community directed suicide prevention

Service Collaboration

Culturally appropariate

Sustainable Community Solutions

Practitioner / services directed suicide prevention

Community Backing

Strategic Planning / Evaluation

Communication

Education

Fig. 1 A conceptual model for rural and remote suicide prevention planning

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Appropriateness, Communication, Education, and Service Collaboration. The model is flexible enough to be individualized to meet the local community’s needs and allows local groups to clearly understand the elements to be considered when developing a community suicide prevention plan.

Community Directed Handley et al. (2012) identified the distress associated with limited infrastructure and services is related to suicide ideation and the situation is unlikely to change; however, smaller communities have the essential ingredients for resilience, resourcefulness, and being solution-focused to develop and build capacity (Robinson and Carson 2015). This resourcefulness could include the use of novel ways to provide services, for example, through the use of Internet-delivered services in some areas.

Community Backing When examining the appropriateness of solutions such as eHealth, the availability of Internet access should be considered. The audience for such services such as older adults may be less comfortable with Internet-delivered services and highlights the need to consult with the community as to their needs. There are also ethical considerations in providing services through the Internet, such as how increased suicidality is to be managed locally and which services are provided at a distance. People experiencing distress from mental health issues, including suicidal thoughts, have been found more willing to try Internet-delivered treatments, despite reluctance in rural and remote areas for this method (Handley et al. 2014). However, promotion of community ownership, partnered with information packages to fully inform, being endorsed by community leaders and elders, there can be a shift in perception, again highlighting the need for community backing of any proposed solution. The accessibility of health and well-being services and the level of service integration perceived by residents has been shown to improve well-being (Collins et al. 2017). This suggests that having community members input into solutions may be vital to service use and increases in well-being.

Capacity Building Building the capacity of the community should not only focus on increasing infrastructure or services but of the people in the community itself. For too long suicide has been a taboo subject with many myths hindering community action, but the identification of suicidality in others is essential to intervention. Programs that upskill local community members to identify and intervene can be effective in rural and remote communities. There are a number of “gatekeeper”-type programs that build the capacity of the community in this way. Although programs may differ slightly in content, they work on the basis of community members identifying those that may be thinking of suicide

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and helping access the services as necessary. Models that use gatekeepers as part of a suicide prevention program have been shown to be an effective component to a suicide prevention strategy (van der Feltz-Cornelis et al. 2011).

Community Leadership/Elders The inclusion of community, and in particular community leaders and elders, can be vital in the implementation of suicide prevention programs. In many small rural towns, there are community leaders that by “vouching” for a particular prevention strategy can engage the community in a way an outsider would find difficult to achieve. Furthermore, the top-down approach to service provision fails to consider the community perspective and “insider knowledge” that could improve quality and community-matched service provision (Farmer and Nimegeer 2014). The inclusion of community-defined specific needs can make or break a service or prevention program, and it must be appropriate for the community as shown by Case Study 2. Without community backing for a program, there may be little uptake or interest in a suicide prevention program. Community-appropriate suicide prevention programs also need to be part of a bigger strategic plan for the community. A sound strategic plan needs to consider socioeconomic disadvantage as a contributing factor to suicide risk; however, this cannot fully account for differences, and other contextual factors such as the social determinants of health should also be taken into account (Collins et al. 2017).

Community Development/Strategic Plans The development of community strategic plans is important to the success of a suicide intervention program. Without knowledge of local issues, a strategic plan could fail to have any impact, and without regular evaluation, it can stall or lose effectiveness as described in Case Study 3. Specifically designed, communitymatched suicide prevention program involving community members supported by qualified practitioners is more likely to be embraced by the community (Farmer and Nimegeer 2014). These strategic plans should consider all aspects of the community and the priorities. For example, if the community has an increase in suicides among adolescents, then the focus may be to implement programs in schools, education material promoted through social media, the training of youth to identify and assist peers in getting help, and community activities that target this age group.

Practitioner Directed There are many effective practitioners working in rural and remote locations that strive to provide the best services with limited resources. Often health and mental health practitioners are the conduit within a community for sharing knowledge, developing programs, and increasing community connectedness. Developing social capital through

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increased social connectedness can act as a protective factor but how much is good enough? The National Research Council (2014) notes that measurable outcomes of such activity are mostly unknowable, given that the nature and strength of relationships vary over time and across places. Despite this there are clear indications of the positive impact that health and mental health practitioners can have in rural and remote locations.

Education An essential part of most strategic suicide intervention plans is a community education program. The health and mental health practitioner are often key to implementing such education. The content in such programs aims to increase knowledge of mental health, to reduce the mental health and suicide stigma, and to increase skills to assist help seeking behaviors. Effective training is essential for community members to offer help to a suicidal person, someone self-harming, and family members, which are all important components of a suicide intervention and post-vention plan. Gatekeeper components of a suicide prevention program, such as specific training on identifying signs of suicidality and effective questioning about suicidality, have been shown to be effective in an overall suicide prevention strategy (Capp et al. 2001; van der Feltz-Cornelis et al. 2011). Educational programs that provide the skills in suicidality identification and questioning can also expose community members to the local health and mental health practitioners and increase familiarity, thereby possibly reducing a help seeking barrier.

Cultural Appropriateness Many effective suicide prevention programs have been developed for communities of all sizes. However, cultural appropriateness should be considered when choosing a program for a specific community. There is some limited evidence of effective suicide prevention training developed within and delivered by specific cultural groups. For example, Teo et al. (2016) found that community-led training is suitable for cultural minority groups. This clearly suggests that local ownership of the program through active participation must be considered in the development of a suicide prevention program to ensure that it is appropriate to the cultural context of the community (Nasir, Kisely, Hides, Ranmuthugala, Brennan-Olsen, Nicholson, et al. 2017). Although there are national suicide prevention programs in use, other specifically designed suicide prevention programs specifically designed by community members have also been developed (Hearn et al. 2016). This demonstrates the possibility of designing specific programs to meet the needs of the community or ethnic group.

Service Collaboration One aspect of community that is also an important component of suicide prevention programs is enhancing community connectedness through empowering locals with

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knowledge and skills in suicide prevention with some ongoing support in the program development phase. Often this is achieved through the collaboration and sharing of limited resources between services. Health and mental health practitioners’ ability to be flexible, creative, and holistically focused as well as willingness to work with others can be a vital component of community connectedness and suicide prevention programs. A sense of community has been shown to improve individual well-being and is influenced by social cohesion and the ability to integrate into the community, which is more difficult in communities with fluid transitory populations or those communities that are less welcoming to newcomers (Collins et al. 2017). It will require local champions to foster community-relevant social engagement during challenging times. Recent longitudinal and crosssectional research supports the hypothesis that social engagement has independent beneficial effects on depression and suicidal ideation, particularly for men; however, for women, it is different and likely to be less positive possibly due to “gendered experiences” such as voluntary caring roles often carried out by women (Landstedt et al. 2016; Handley et al. 2012). Nevertheless, lower social support, loss of belongingness, and low engagement in the community are associated with suicide ideation (Handley et al. 2012). This highlights the importance of practitioners being aware of community connections from small group activities such as quilting groups, fishing clubs, sporting groups, or men’s sheds to large community events such as family fun days, agricultural shows, local industry expos, and community concerts. However, connectedness does not necessarily mean being active in community groups; it can be as simple as knowing your neighbor or being greeted or acknowledged at the local shop or on the street.

Communication Community suicide prevention networks rely on organizations working together to implement a suicide prevention plan. Organizations tend to be more connected around information and resource sharing and less collaborative around infrastructure and training, so this may need good negotiation and diplomacy skills by the practitioner (Menger et al. 2015). It has also been suggested that the best way an organization can improve its collaboration with other organizations is through regular communication and developing trusting relationships (Menger et al. 2015). This could indicate the need for developing collaborative networks that meet on a regular basis to provide an ongoing identification of the communities needs and evaluate the strategies being implemented. Therefore, the mental health practitioner in rural and remote locations not only needs to work with individuals but also needs to effectively communicate and work toward bringing organizations together to ensure a whole community suicide prevention program can be implemented.

Concluding Comments and Recommendations Rural and remote practitioners have a unique contribution to the well-being of the members of the communities they serve. It is important that practitioners working in these locations have an understanding of not only the factors that influence the

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community but also the developing strong relationships with leaders and service providers. By focusing on the multiple domains identified in the conceptual suicide prevention model, rural and remote practitioners can actively assist rural and remote communities to take ownership of suicide prevention; after all, suicide prevention is everyone’s business.

Take-Home Messages • There are many specific factors that influence suicide risk in rural and remote communities. • Rural and remote communities are unique and one size does not fit all. • Community involvement in suicide intervention programs is essential for success. • The rural and remote practitioner should be active in engaging the community and developing effective collaborations.

Case Studies Case Study 1: The Impact of Being Disconnected John was a 17-year-old white male who presented to a youth mental health service due to low mood. During the initial assessment, it became clear that John was depressed and also experiencing thoughts of suicide; most worryingly was that John felt hopeless, could see no future for himself, and did not see the point of continuing his life. John had previously been happy and focused on the future, but some recent major changes to his life meant that he was struggling to readjust. John had previously lived on a farm, and although he was in his last year at school, he would spend much of his free time working on the farm. It was his expectation that when he finished school, he would start working on the farm with his father, a job that he thoroughly enjoyed. Unfortunately, circumstances changed and his grandparents who owned the farm decided they had to sell and so this meant that not only did John’s parents lose their job but the whole family had lost their home. John’s family had moved to a rural mining community in the hope that his father could find work at the mine. John had re-engaged in school, but his lowering mood had started to impact on his grades. John felt his whole life had been turned upside down. He had felt very connected to the land, the open spaces, the animals, and the freedom that comes with living and working on a farm. He no longer could see future options for himself. The community had no mental health inpatient unit, and a decision needed to be made as to whether he should be hospitalized. As John had already been struggling with being disconnected from the farm, it was felt that further disconnecting him from the few supports he had left, his family, would not be in his best interest. Therefore, psychiatric review was organized and medication prescribed, family support was enlisted, and a careful safety plan was devised. John had regular intensive therapeutic support with the mental health service to help him address some of the underlying issues. Intervention with John required a multi-

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system approach to avoid hospitalization which may have proved to be more detrimental. Thankfully after only four weeks, some improvement was seen, and this continued until discharge. Case Study 2: Did You Ask What We Needed and Will It Fit with Us A small isolated community with a population of just over 500 that is heavily connected to farming has been experiencing drought for a number of years, and the locals are experiencing the associated difficulties. The government was concerned about the possible increase in suicide and put forward a tender for the provision of suicide prevention and well-being programs across the affected area. This tender was not won by a local organization but one from a major city. The organization proceeded to contact local councils to distribute flyers to announce when their workshops would be in town. Being a stoic and closed community, very few community members attended the workshop, and the external organization could not understand why the workshop had not been successful. A few months later, a prominent local elderly man suicided after receiving a terminal health diagnosis. The local community was shaken by this, and they requested a local organization provide suicide awareness training to prominent locals such as council members, library assistant, and Post Office manager in a bid to prevent this from occurring again. Despite the prevention program being a national program, the participants did not feel that they could take on board all of the aspects of the program. Although the participants felt they had learned much from the program, they were still unwilling to ask if someone may be suicidal directly as this did not meet with the community’s culture. Case Study 3: When a Community Came to Crisis Point An increased number of suicides that escalated to 3 times the national average occurred in a rural mining community with a population of approximately 22,000. The community initially had a segmented and disjointed approach to the suicides, but as the suicides continued, without any obvious pattern, it became obvious that a different approach needed to be taken. Luckily the community already had an effective mental health network that comprised of the local service providers, associated services, and community members that met monthly to identify community issues, gaps in service provision, and opportunities to work collaboratively on issues of community mental health and well-being. The number of suicides was raised with the network, and it was agreed that a separate, more dynamic team may need to be set up to address this growing issue. The team comprised of the most prominent mental health services in the community both government and nongovernment, prominent local support services, and a representative from the police. This group initially agreed to make it a closed group due to the urgency of need to put strategies in place to assist the community. When examining the issues that needed immediate intervention, a number of areas were identified. The main issues identified were non-health professionals communicating with the media and the media reporting inappropriate material which did not follow guidelines on media and suicide, school staff were limited in their knowledge on how to communicate to

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students and parents, and multiple services could become involved as there was no collaboration. The outcome of this was that services became overwhelmed and community members were concerned for loved ones. The team developed a strategic plan that addressed the needs at different population levels. Funding was able to be gained to assist in the setup of the group, and this allowed the strategic plan to be implemented at a faster pace. The media were provided with education around the reporting of suicide and were asked to communicate with the group for media releases. The schools were provided support and materials around how to discuss suicide issues with students and schools were given assistance in developing action plans. Mental Health First Aid training was offered to teachers with almost half of the teaching staff at the public high school completing the course. Collaboration between services allowed parent and community information and education sessions and an ongoing educational program for the community was decided upon. This provided education to the community on a gatekeeper basis and to also reduce the myths often found around suicide. The implementation of this team allowed the community to take some control over the situation and develop a longer-term strategy to reduce suicide. Although significant progress was made in reducing the number of suicides over the following two years, the group failed to re-evaluate their effectiveness after the initial progress was made and without the engagement of other community members, and the closed nature of the group, community backing waned and impacted the group’s ability to effectively implement strategies.

References Allen ML, Le Cook B, Carson N, Interian A, La Roche M, Alegria M. Patient-provider therapeutic alliance contributes to patient activation in community mental health clinics. Admin Pol Ment Health. 2017;44:431–40. Alston M. Rural male suicide in Australia. Soc Sci Med. 2012;74(4):515–22. Belaid L, Dagenais C, Moha M, Ridde V. Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger. Hum Resour Health. 2017;15:60. Bergen H, Hawton K, Waters K, Ness J, Cooper J, Sleeg S, et al. How do methods of non-fatal selfharm relate to eventual suicide? J Affect Disord. 2012;136:526–33. Berry HL, Welsh JA. Social capital and health in Australia: an overview from the household, income and labour dynamics in Australia survey. Soc Sci Med. 2010;70(4):588–96. Bossard C, Santin G, Guseva Canu I. Suicide among farmers in France: occupational factors and recent trends. J Agromedicine. 2016;21(4):310–5. Brew B, Inder K, Allen J, Thomas M, Kelly B. The health and wellbeing of Australian farmers: a longitudinal cohort study. BMC Public Health. 2016;16(1) Burrows S, Auger N, Gamache P, Hamel D. Leading causes of unintentional injury and suicide mortality in Canadian adults across the urban-rural continuum. Public Health Rep. 2013;128 (6):443–53. Capp K, Deane F, Lambert G. Suicide prevention in Aboriginal communities: application of community gatekeeper training. Aust N Z J Public Health. 2001;25(4):315–21. Carey TA, Wakerman J, Humphreys JS, Buykx P, Lindeman M. What primary health care services should residents of rural and remote Australia be able to access? A systematic review of “core” primary health care services. BMC Health Serv Res. 2013;13(1):178.

23

Suicide and Self-Harm: It’s Everyone’s Business

529

Carey M, Jones K, Meadows G, Sanson-Fisher R, D’Este C, Inder K, et al. Accuracy of general practitioner unassisted detection of depression. Aust N Z J Psychiatry. 2014;48(6):571–8. Cerel J, Maple M, van de Venne J, Moore M, Flaherty C, Brown M. Exposure to suicide in the community: prevalence and correlates in one U.S. State. Public Health Rep. 2016;131(1):100–7. Chu J, Khoury O, Ma J, Bahn F, Bongar B, Goldblum P. An empirical model and ethnic differences in cultural meanings via motives for suicide. J Clin Psychol. 2017;73(10):1343–59. Colell E, Sánchez-Niubò A, Delclos GL, Benavides FG, Domingo-Salvany A. Economic crisis and changes in drug use in the Spanish economically active population. Addiction. 2015;110(7):1129–37. Collins J, Ward BM, Snow P, Kippen S, Judd F. Compositional, contextual, and collective community factors in mental health and well-being in Australian rural communities. Qual Health Res. 2017;27(5):677–87. Cosgrove C, Hussain R, Maple M. Factors impacting on retention amongst community mental health clinicians working in rural Australia: a literature review. Adv Mental Health. 2015;13:58–71. Daraganova G. Self-harm and suicidal behaviour of young people aged 14–15 years old [Internet]. Australian Institute of Family Studies. 2017 [cited 24 February 2019]. Available from: https:// aifs.gov.au/publications/self-harm-and-suicidal-behaviour-young-people-aged-14-15-years-old Farmer J, Nimegeer A. Community participation to design rural primary healthcare services. BMC Health Serv Res. 2014;14(1):130. Ferguson SG, Blakely TA, Allan B, Collings S. Suicide rates in New Zealand: exploring associations with social and economic factors. Wellington: Ministry of Health; 2004. Handley TE, Inder KJ, Kelly BJ, Attia JR, Lewin TJ, Fitzgerald MN, et al. You’ve got to have friends: the predictive value of social integration and support in suicidal ideation among rural communities. Soc Psychiatry Psychiatr Epidemiol. 2012;47(8):1281–90. Handley TE, Kay-Lambkin FJ, Inder KJ, Attia JR, Lewin TJ, Kelly BJ. Feasibility of internetdelivered mental health treatments for rural populations. Soc Psychiatry Psychiatr Epidemiol. 2014;49:275–82. Haw C, Hawton K, Niedzwiedz C, Platt S. Suicide clusters: a review of risk factors and mechanisms. Suicide Life Threat Behav. 2013;43(1):97–108. Hearn S, Wanganeen G, Sutton K, Isaacs A. The Jekkora group: an aboriginal model of early identification, and support of persons with psychological distress and suicidal ideation in rural communities. Adv Mental Health. 2016;14(2):96–105. Helbich M, Blüml V, de Jong T, Plener PL, Kwan MP, Kapusta ND. Urban-rural inequalities in suicide mortality: a comparison of urbanicity indicators. Int J Health Geogr. 2017;16:39–51. Hounsome B, Edwards RT, Hounsome N, Edwards-Jones G. Psychological morbidity of farmers and non-farming population: results from a UK study. Community Ment Health J. 2012;48:503–10. Judd FK, Cooper A, Fraser C, Davis J. Rural suicide – people or place effects? Aust N Z J Psychiatry. 2006;40:208–16. Kõlves K, Milner A, McKay K, De Leo D. Australian Institute for Suicide Research and Prevention. Suicide in rural and remote areas of Australia. Brisbane; 2012. Kral M. Suicide and suicide prevention among Inuit in Canada. Can J Psychiatry. 2016;61(11):688–95. Kunde L, Kolves K, Kelly B, Reddy P, De Leo D. Pathways to suicide in Australian farmers: a life chart analysis. Int J Environ Res Public Health. 2017;14(4):352. Landstedt E, Almquist Y, Eriksson M, Hammarström A. Disentangling the directions of associations between structural social capital and mental health: longitudinal analyses of gender, civic engagement and depressive symptoms. Soc Sci Med. 2016;163:135–43. Leenaars A, Anowak J, Brown C, Hill-Keddie T, Aparti L. Genocide and suicide among indigenous people: the north meets the south. Can J Native Stud. 1999;19(2):337–63. Lim KS, Wong CH, McIntyre RL, Wang J, Zhang Z, Tran BX, et al. Global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents between 1989 and 2018: a meta-analysis. Int J Environ Res Public Health. 2019;16:4581. Mactaggart F, McDermott L, Tynan A, Gericke C. Examining health and well-being outcomes associated with mining activity in rural communities of high-income countries: a systematic review. Aust J Rural Health. 2016;24(4):230–7.

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S. J. Lutkin and B. Buckby

Martin G, Swannell S, Harrison J, Hazell O, Taylor A. The Australian national epidemiological study of self-injury (ANESSI). Brisbane: Centre for Suicide Prevention Studies; 2010. McIntosh W, Spies E, Stone D, Lokey C, Trudeau A, Bartholow B. Suicide rates by occupational group-17 states, 2012. MMWR Morb Mortal Wkly Rep. 2016;65(25):641–5. McPhedran S, De Leo D. Relationship quality, work-family stress, and mental health among Australian male mining industry employees. J Relatsh Res. 2014;5 Menger LM, Stallones L, Cross JE, Henry KL, Chen PY. Strengthening suicide prevention networks: interorganizational collaboration and tie strength. Psychosoc Interv. 2015;24(3): 155–65. Michail M, Tait L, Churchill D. General practitioners’ clinical expertise in managing suicidal young people: implications for continued education. Prim Health Care Res Dev. 2017;18:419–28. https://doi.org/10.1017/S1463423617000299. Milner A, Niven H, LaMontagne A. Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia. BMC Psychiatry. 2015;15(1):223. Morell A, Kiem S, Millsteed M, Pollice A. Attraction, recruitment and distribution of health professionals in rural and remote Australia: early results of the rural health professionals program. Hum Resour Health. 2014;12(1):15. Nagelhout G, Hummel K, de Goeij M, de Vries H, Kaner E, Lemmens P. How economic recessions and unemployment affect illegal drug use: a systematic realist literature review. Int J Drug Policy. 2017;44:69–83. Nasir B, Kisely S, Hides L, Ranmuthugala G, Brennan-Olsen S, Nicholson G, et al. An Australian indigenous community-led suicide intervention skills training program: community consultation findings. BMC Psychiatry. 2017;17:219. National Research Council. What should be measured? In: Prewitt K, Mackie C, Habermann H, editors. Civic engagement and social cohesion: measuring dimensions of social capital to inform policy. Washington, DC: National Academies Press; 2014. p. 33–56. Philip J, Ford T, Henry D, Rasmus S, Allen J. Relationship of social network to protective factors in suicide and alcohol use disorder intervention for rural Yup’ik Alaska native youth. Psychosoc Interv. 2016;25(1):45–54. Pierce D, Little F, Bennett-Levy J, Isaacs A, Bridgman H, Lutkin S, et al. Mental health academics in rural and remote Australia. Rural Remote Health. 2016;16:3. Qi X, Hu W, Page A, Tong S. Dynamic pattern of suicide in Australia, 1986–2005: a descriptiveanalytic study. BMJ Open. 2014;4(7):e005311. Raatiniemi L, Steinvik T, Liisanantti J, Ohtonen P, Martikainen M, Alahuhta S, et al. Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study. Acta Anaesthesiol Scand. 2016;60(5):668–76. Reser J. Australian aboriginal suicide deaths in custody: cultural context and cluster evidence. Aust Psychol. 1989a;24(3):325–42. Reser J. Aboriginal deaths in custody and social construction: a response to the view that there is no such thing as aboriginal suicide. Aust Aborig Stud. 1989b;2:43–50. Roberts R, Miller K. The 10th Australian Rural and Remote Mental Health Symposium Communiqué. Aust J Rural Health. 2019;27:442–3. Robinson G, Carson D. Resilient communities: transitions, pathways and resourcefulness. Geogr J. 2015;182(2):114–22. Singh GK, Siahpush M. Widening rural–urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969–2009. J Urban Health. 2013;91(2):272–92. Stark CR, Riordan V, Connor RO. A conceptual model of suicide in rural areas. Rural Remote Health. 2011;11(2):1622. Suicide rates (per 100 000 population) [Internet]. World Health Organization. 2017 [cited 25 September 2017]. Available from: http://www.who.int/gho/mental_health/suicide_rates/en/ Teo A, Andrea S, Sakakibara R, Motohara S, Matthieu M, Fetters M. Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention. BMC Psychiatry. 2016;16(1):211.

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Thomas SL, Wakerman J, Humphreys JS. Ensuring equity of access to primary health care in rural and remote Australia – what core services should be locally available? Int J Equity Health. 2015;14:111. https://doi.org/10.1186/s12939-015-0228-1. van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Grum AT, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32(6):319–33. Walker R, Francis D, Brody G, Simons R, Cutrona C, Gibbons F. A longitudinal study of racial discrimination and risk for death ideation in African American youth. Suicide Life Threat Behav. 2017;47(1):86–102. Wang C, Chan CLW, Yip PSF. Suicide rates in China from 2002 to 2011: an update. Soc Psychiatry Psychiatr Epidemiol. 2014;49(6):929–41. World Health Organization. Suicide in the world: global health estimates [internet]. World Health Organization. 2019 [cited 24 September 2020]. Available from https://www.who.int/publications/i/ item/suicide-in-the-world Zhang J, Wang C. Factors in the neighborhood as risks of suicide in rural China: a multilevel analysis. Community Ment Health J. 2012;48(5):627–33.

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James H. Bray, Brittany Zaring-Hinkle, and Jessica K. Perrotte

Contents Scope of Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance Use in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance Use in Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance Use in New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance Use in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unique Problems and Factors in Rural and Remote Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Disparities in Substance Use and Treatment Between Racial and Ethnic Groups . . . . . Prevention and Treatment of Substance Use and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Remote Therapies for Rural and Remote Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intervention Considerations Between Racial and Ethnic Minorities . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Substance abuse is a pervasive problem across the globe, impacting the health and well-being of those who abuse alcohol and substances and their family members. While this problem affects individuals across numerous demographic factors (e.g., gender, race and ethnicity, or socioeconomic status), there are different patterns and types of substance abuse in urban and rural areas. This chapter focuses on the unique aspects of alcohol and substance abuse in rural, frontier, and remote areas and examines health disparities and racial and ethnic differences in substance abuse. In addition, this chapter discusses special challenges in providing prevention and intervention services to the people who live in rural and remote areas of the world and the roles of psychologists in providing this care. J. H. Bray (*) · B. Zaring-Hinkle (*) Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA e-mail: [email protected]; [email protected] J. K. Perrotte Department of Psychology, Texas State University, San Marcos, TX, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_25

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Mr. Ward visited his general physician (GP), Dr. Montgomery, for a follow-up visit due to a work-related ranch accident in which he fell off a ladder, injured his left wrist, and hit his head. His initial visit was to an emergency department (ED) in the nearest city where they x-rayed his arm and determined he had a severe sprain that needed splinting and a mild concussion due to the fall. His wife accompanied him to the visit because Mr. Ward was unable to drive the long distance to the doctor’s office due to his injury. Dr. Montgomery evaluated his vital signs at this visit and lab tests from the ED visit and was concerned with the results. The evaluation showed that Mr. Ward’s blood pressure and blood sugar were elevated, indicating that his hypertension and diabetes were not under control. Dr. Montgomery was further concerned because this was the second work accident for Mr. Ward in the past 6 months and his chronic health problems were not under control. These issues persisted despite several visits that focused on the importance of taking his medications regularly and changing his diet. Mrs. Ward expressed worry about her husband’s health and behavior during the past year and how this was negatively impacting his job performance and family relationships. Mr. Ward scoffed and told them they did not understand the pressure he was under at work and now at home. The doctor had recently attended a workshop on screening for substance use problems in primary care and decided to evaluate Mr. Ward’s use of alcohol and other substances. During the screen, Mr. Ward admitted that he was drinking at unhealthy levels, had increased his drinking over the past year, and occasionally used pain medicines with alcohol to “feel better.” He indicated that sometimes he had a “few beers” at lunch while on the job. Dr. Montgomery learned that the two accidents were associated with days in which Mr. Ward had consumed several beers at lunch and taken pain medications. Given the level of Mr. Ward’s drinking and his inconsistent medication adherence, it was not surprising to the doctor that Mr. Ward’s blood pressure and diabetes were not under control. Dr. Montgomery told the Wards that he felt Mr. Ward needed help from a specialist who could better assess and treat his substance use issues. When Mr. Ward scoffed, he told him that the psychologist he was going to refer him to could also help him with needed lifestyle changes and medication adherence to help with his hypertension and diabetes. Mr. Ward stated that he was not crazy and didn’t have time to drive into the city to see a psychologist. Dr. Montgomery responded that he didn’t think he was crazy and the psychologist worked in this clinic and he just needed help with his medical problems. Mrs. Ward assured the doctor that she would make sure her husband went to see the psychologist and agreed they would schedule a follow-up appointment with the GP a month after the visit with the psychologist. As illustrated in the case, substance abuse as defined by the DSM is a pervasive problem, impacting the health and well-being of those who abuse alcohol and substances as well as their family members. While this problem affects individuals of every gender, race, ethnicity, and socioeconomic status, there are different patterns and types of substance abuse in urban and rural areas (Australian Institute of Health and Welfare 2017; SAMHSA 2012; Van Gundy 2006). In addition, access to treatment and recovery services are often more limited in rural and especially remote areas (Borders and Booth 2007; Bray et al. 2004; Knudsen et al. 2003; SAMHSA

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2012). This chapter focuses on the unique aspects of alcohol and substance abuse in rural and remote areas and examines health disparities, as well as racial, ethnic, and cultural differences in substance abuse. In addition, this chapter discusses special challenges in providing prevention and intervention services to the people who live in rural and remote areas of the world and the roles of psychologists in providing this care. With advances in basic scientific understanding of substance use and abuse and brain functioning, it is important to note that perceptions of substance abuse and its treatment have changed. What was once seen as an episodic problem is now viewed as part of a chronic disease model, requiring ongoing treatment for many months or years to ensure successful outcomes (McLellan et al. 2000; Saitz et al. 2009). Just as in the case of other chronic diseases (e.g., hypertension, diabetes), ongoing treatment is needed. If it is not provided, the problem will continue and escalate. Relapse is common without ongoing treatment and is therefore expected when treatment is withdrawn, just as blood pressure increases in people with hypertension who do not take their medication. For many substances it may take 1–3 years of ongoing treatment and support for a person to overcome their substance abuse problem (Elms et al. 2018; Kelly et al. 2017; Kelly et al. 2018). The challenge for people who live in rural and remote areas is the relative lack of access to treatment and the frequent need to travel to urban areas to engage in treatment. This places an undue burden not only on the person with a substance abuse problem but also on his/her family, as family participation is also a key ingredient for successful outcomes (Stanton 2009).

Scope of Substance Abuse The results from the 2015 United States National Survey on Drug Use and Health (NSDUH) are used as substance use and mental health indicators and highlight the severity of the problem. In 2015, there were 27.1 million people in the United Stated or 10.1 percent of people aged 12 or older who had illicit drug use in the past month prior to the survey. In Australia, the 2016 National Drug Strategy Household Survey (NDSHS) found that approximately 3.1 million (15.6%) people aged 14 or older reported having used an illicit substance in the prior 12 months (Australian Institute of Health and Welfare 2017). The New Zealand Drug Harm Index (2016) showed that the total number of drug users, including casual and dependent users, was 388,000 people (8.7 percent of total population; McFadden Consultancy 2016).

Substance Use in the United States The Treatment Episode Data Set (TEDS) Report examined the differences between rural and urban substance users in the United States (SAMHSA 2012). The goal of the TEDS report was to examine differences in rural and urban substance abuse and inform policymakers about the need to more effectively direct resources into

536 Table 1 Demographic characteristics among urban and rural admissions to treatment of people aged 12 or older from the SAMHSA Treatment Episode Data Set, 2012

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Primary drug of choice Cocaine Heroin Alcohol Marijuana Non-heroin opiates Methamphetamine Demographics People aged 26 or younger Non-Hispanic white Males Lack of health insurance High school diploma or GED Currently employed

Urban 11.9% 21.8% 36.1% 17.0% 4.0% 6.1% Urban 23.5% 38.1% 69.9% 61.9% 40.7% 16.6%

Rural 5.6% 3.1% 49.5% 20.9% 10.6% 6.3% Rural 34.2% 77.1% 68.3% 65.9% 46.1% 32.3%

combatting these problems. Specifically, this report suggested increasing the amount and the quality of the care received in rural areas. Using admissions at substance abuse treatment in rural and urban areas to evaluate the differences between the two contexts, the TEDS Report found several distinct differences in drug of choice at admissions (see Table 1). Further, the data showed that rural admissions were significantly more likely to be referred by the criminal justice system than to be self-referred. The TEDS Report listed the demographic characteristics between the urban and rural treatment admissions and found the people admitted to treatment in rural areas were younger than those in urban areas (see Table 1). In addition, rural admissions were less racially and ethnically diverse than those admitted to urban treatment areas. The TEDS Report indicated differences in both education and employment across people admitted from rural and urban areas as well.

Substance Use in Australia The 2016 National Drug Strategy Household Survey (NDSHS) found that people in remote and very remote areas were much more likely to have used an illicit drug in the prior year than people in major cities (14.4%), inner regional areas (14.9%), and outer regional areas, including remote (15.6%) and very remote (25%). Cannabis is the most commonly used illicit substance in Australia. Recent cannabis use in remote and very remote areas has increased from 11.4 percent in 2010 to 17.0 percent in 2016; this increase in cannabis use in remote and very remote areas reached 1.6 times higher than the national average of 10.4 percent in 2016. Pharmaceutical drug misuse accounted for the second most common illicit drug use and was the highest in remote and very remote areas (8.0%) and lowest in major cities (4.6%). Among misused pharmaceuticals, the most prevalent were painkillers/analgesics and opioids. Recent use also varied between the areas. That is, ecstasy use was highest in

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major cities, while meth/amphetamines were much more likely to be recently used by those in remote and very remote areas. People living in remote or very remote areas had no significant usage changes from 2013 to 2016 and were still more likely to smoke tobacco, drink at risky levels, and use cannabis and meth/amphetamines. However, they were much less likely to use cocaine and ecstasy compared with those in major cities. Additionally, those living in remote and very remote areas (37%) were more likely to drink harmful levels of alcohol on a single occasion compared to those in major cities (24%). Alcohol consumption levels increase as remoteness increases, with the most prevalence usage rates in very remote areas. Methamphetamine users were split into two main groups: those who used crystal/ice and those who used powder/speed. Ice/crystal users were less likely than powder/speed users to be currently employed (22% vs. 80%) and were more likely to live in outer regional, remote, and very remote areas (22% vs. 6.4%). Methamphetamines were used at 2.5 times higher rates in remote and very remote areas than those in major cities. In sum, those individuals who reported to be unemployed, Indigenous Australians, a sexual minority, or living in remote and very remote areas were consistently more likely to smoke tobacco daily, drink alcohol at risky levels, and use illicit drugs more than other population groups.

Substance Use in New Zealand The 2007/2008 New Zealand Alcohol and Drug Use Survey (2010) showed that 16.6 percent of people had used “any drug (excluding alcohol, tobacco and benzylpiperazine, or BZP party pills)” in the year prior. BZP party pills were used by 5.6 percent of people in the year prior, while 14.6 percent of people used cannabis. Although they are now considered illegal, BZP party pills were legal during the time of the survey and were thus not included in the counting of illicit drug use. When standardizing for age, men (but not women) living in socioeconomically disadvantaged areas had significantly higher rates of use in the prior year than those in more affluent areas. For those that had used in the year prior to the survey, 3.2 percent had received treatment in order to reduce their drug use. Those aged 25– 34 years were the least likely (1.3%) to have received treatment to reduce their drug use. When asked for reasons to not seek treatment when they wanted help in those aged 16–64 years, respondents answered with cost (8.2%), no local service available (7.2%), could not get in touch with doctor or service (6.8%), and no transport to get there/lack of child care (5.0%). Figure 1 shows the prevalence rates of drug use by ethnic group. It is important to note that of the total population, in both recent use and lifetime use, 1.0 percent of the population reported prescription painkiller use (used recreationally), while 0.1 percent of the population reported using opiates (e.g., heroin). Following only cannabis, BZP party pills had much higher recent usage prevalence rates than all other drugs with 5.6 percent of the total population having reported using them in the year prior to the survey. Overall, the survey showed

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Fig. 1 Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Prevalence rates of illicit drug use by ethnicity group

somewhat higher prevalence rates of any drug use in men, people in younger age groups, European/others, Māori, and people living in neighborhoods of higher socioeconomic deprivation (Ministry of Health 2010).

Substance Use in Europe According to the 2017 European Drug Report, there were 22 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) countries with sufficient data for trend analysis. This report shows that recent drug use (prior 12 months) was most prevalent among young adults. Approximately 18.7 million people, aged 15–34, had used recently, and of those, there were double the amount of males than females reporting the use of drugs. Cannabis was the most commonly used drug, and 17.1 million young adults (aged 15–34), or 13.9 percent of this age group reported recent use. Cocaine had the highest prevalence rates of recent use (2.3 million people aged 15–34, making up 1.9 percent of the age group) among illicit stimulant drugs used in Europe (EMCDDA 2017). The Crime Survey for England and Wales (CSEW; Office of National Statistics 2014) was created for the purpose of examining the trends in illicit drug use amonga) was created for the purpose of examining the trends in illicit drug use among a sample of residents in households in England and Wales who were 16–59 years old. In the 2013/2014 CSEW, urban areas (9.3%) had higher reports of recent drug use levels than those in rural areas (6.5%). A difference was found between respondents who lived in more rural areas (4.5%) and those who lived in less rural areas (2.3%).

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As evident from these surveys, there are different patterns of substance use between people in urban and rural areas. In many countries, people are at greater risk for using substances in rural areas. In addition, the pattern of use and types of drugs often differ in rural and urban areas. For practitioners working in rural areas or working with people from rural areas, it is important to be aware of these differences and understand the reasons behind the different rates and types of substance use. Factors that contribute to rural substance abuse will be discussed later in this chapter.

Unique Problems and Factors in Rural and Remote Areas There are pervasive substance use problems in rural and remote areas in many parts of the world. It should be noted that within each of the countries’ definitions of rurality and remoteness, access to care and services is always included in defining the terms (not just distance from an urban area or population density). There are unique problems and barriers to treatment in rural areas including the geographical dispersion of people (Love et al. 2016); economic barriers to obtaining the necessary healthcare (Love et al. 2016; McDonald et al. 2014); higher tolerance of adolescent alcohol use (Van Gundy 2006); transportation challenges (McDonald et al. 2014; Oser and Harp 2014; Pullen and Oser 2014); healthcare personnel shortages (NCASA 2002; Love et al. 2016; Thomas et al. 2009); providers without specific expertise in diagnosing or treating mental health (Hartley et al. 1998; Probst et al. 2006); lack of rural mental and behavioral health clinics (Love et al. 2016); lack of confidentiality (Hastings and Cohn 2013; Fortney et al. 2004); significantly lower levels of treatment utilization and completion when access is available (Clay 2007; Pringle et al. 2006; Borders and Booth 2007); rural isolation (Love et al. 2016); and social stigma against seeking mental and behavioral healthcare (McDonald et al. 2014; Notley et al. 2012). Another seemingly unique barrier to treatment in the United States is the disproportionately high rates of people in rural areas in poverty that are also uninsured or underinsured. Poverty multiplies the lack of access to care (Fitchen 1995; McDonald et al. 2005). In terms of more beneficial client outcomes, clients will stay longer and have better completion rates in treatment for substance abuse if the distance is shorter rather than farther that they must travel to obtain treatment (Beardsley et al. 2003; Fortney et al. 1995). Thus, it does not bode well for those in need of substance abuse treatment in rural, remote, and frontier areas where the travel distances are significantly longer than their urban counterparts. Substance abuse counselors identified four key barriers to successful client outcomes: inadequate funding, transportation challenges, bureaucratic challenges, and absence of interagency cooperation (Browne et al. 2016; Pullen and Oser 2014). Inadequate funding not only created problems with actively trying to fund education resources for substance use treatment programs but also led to an inability to hire and retain qualified counselors. Inadequate funding was particularly problematic in rural areas, causing issues such as a lack of basic facilities (e.g., dilapidated infrastructure) that was not conducive to facilitating recovery. Transportation challenges in rural

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areas involved scarce or no public transportation, considerable distance to travel from home to treatment facility, rising fuel prices, and lack of client resources to enable them to travel the distances to the facilities. Rural substance abuse counselors believed that lack of access to complimentary services (e.g., supervised detoxification and mental health services) hindered client success. Both rural and urban counselors alike criticized the lack of continuity in treatment services, or more plainly, there was no “continuum of care.” Furthermore, while there is a general lack of access to care, specialty care (e.g., substance abuse treatment and treatment catered to women or racial minorities) is virtually nonexistent (Knudsen et al. 2003; Oser et al. 2011). A general medical practitioner may be available relatively often or within a reasonable distance, but may not possess the skills or have the resources to care for a substance abuse problem (Bray and Rogers 1995; Hartley et al. 1998; Probst et al. 2006). There is an unmet need to provide training for those practitioners to be able to screen and provide brief interventions for substance use problems, as well as knowing how and when to refer to treatment with specialists (Bray and Rogers 1995; Bray et al. 2012).

Health Disparities in Substance Use and Treatment Between Racial and Ethnic Groups Later that day Dr. Montgomery saw a middle-aged aboriginal man, Mr. Henry, who also had uncontrolled diabetes and hypertension. Dr. Montgomery conducted a substance use screen and found that Mr. Henry was drinking at unhealthy levels, using marijuana regularly, and smoking about a pack of cigarettes per day. His substance use interfered with his work, and he had been laid off multiple times due to poor attendance and work performance. Because of lack of work, he was unable to afford his medications and regularly attend medical visits. While Dr. Montgomery talked to Mr. Henry about the need for treatment, he did not make a referral as he had with Mr. Ward. Dr. Montgomery noted to his nurse that Mr. Ward lived away from town that made treatment more challenging because of lack of transportation. Patterns of substance use and treatment vary as a function of race, ethnicity, and rurality. These racial, ethnic, and cultural differences are detected globally, as indicated by many sources of national data (Schmidt et al. 2007). In the United States, cannabis use, abuse, and dependence are greater for racial and ethnic minority group adults than for White adults (Wu et al. 2016). As mentioned previously, there is a higher prevalence of cigarette smoking and cannabis use between indigenous Australians and non-indigenous Australians (Australian Institute of Health and Welfare 2017). Similarly, in New Zealand the prevalence of smoking, heavy episodic drinking, cannabis, and methamphetamine use is higher among Māori individuals than those from other ethnic minority groups (see Fig. 1; Ministry of Health 2017). Racial and ethnic minority group members may experience disadvantage across the social determinants of health (e.g., excessive policing, lower education, and poverty, in addition to race and ethnicity) resulting in health disparities. This compounded disadvantage is thought to contribute to numerous adverse health

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outcomes, such as substance use (Glass et al. 2017). The intersection of these key factors related to substance use may be even more problematic for some racial and ethnic minority members living in rural areas (Boyd et al. 2007; Kramer et al. 2009) and create an accumulation of stressors that may exacerbate vulnerabilities to engaging in substance use (Boyd et al. 2007). Living in nonmetropolitan environments may put racial and ethnic minority members at risk for using certain substances. Specifically, individuals from an Asian background residing in nonmetropolitan settings had higher amounts of illicit drug use and marijuana use than those in metropolitan areas (Thomas and Compton 2008). For African Americans, the same was true for prescription drug misuse, but marijuana and illicit drug use were higher for those residing in larger metropolitan areas (Thomas and Compton 2008). Also, inhalant use, such as inhaling salts and paint vapers, is more prevalent for Mexican American females in remote areas when compared to urban areas. Among inhalant users, African Americans from remote areas are more likely to use inhalants in larger amounts than those from urban areas (Edwards et al. 2007). Racial and ethnic trends in substance use in rural and remote areas often echo those found in more urban settings. For instance, rural African American adults engage in more crack-cocaine use than Whites, while Whites engage in more crystal meth use than African Americans (Borders et al. 2008). Also, Native American youth within the Cherokee nation use more marijuana and chewing tobacco than non-Native American youth (Lynn-Landsman et al. 2016). There is further evidence of racial and ethnic differences in the use of substances among rural inhabitants of multiple countries. For example, in rural Taiwan, Aboriginal Taiwanese chewed betel quid (i.e., typically areca nut and slaked lime wrapped in a betel leaf) more than their Chinese counterparts (Chen et al. 2001). In a study of rural inhabitants of an area in southwest China, ethnic minorities (i.e., Jingpo and Dai) had a higher prevalence of alcohol use than Han Chinese (Duan et al. 2017). In rural Bangladesh, some groups (Oraon and Santal) were more likely than other groups (Hindu and Muslim) to engage in regular consumption of arrack, an alcohol beverage typically made from palm and/or date juice (Uddin 2008). However, the prevalence of substance use within and between ethnic minority groups does not always cleanly map onto similar patterns of health disparities related to substance use (Kramer et al. 2009; Lynn-Landsman et al. 2016). Reasons for treatment disparities. Studies in the United States and New Zealand indicate ethnic minority members experience disproportionate barriers to receiving healthcare. As illustrated in the case with Mr. Henry and Dr. Montgomery, some of these barriers may include racial or ethnic bias on the part of the provider. That is, some healthcare providers may hold implicit or explicit negative beliefs about patients from racial and ethnic minority groups (Nelson 2002; Paradies et al. 2013). Consequently, they may engage in discriminatory practices (Paradies et al. 2013), such as failure to refer a patient for substance use treatment when treatment is clearly needed. From racial and ethnic minority patients’ perspectives, experiences such as these can erode the trust placed in healthcare providers (Boulware et al. 2003), highlighting the pervasive and cyclical nature of provider bias and patient adherence.

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Other barriers to treatment for racial and ethnic minority members include perceptions of stigma and structural barriers, such as problems with transportation, having time to receive care, prohibitive costs associated with prescriptions, lack of insurance, and inherent bias by practitioners (Alang 2015; Ministry of Health 2017; Schmidt et al. 2007). It is likely the impediments to treatment experienced by racial and ethnic minorities that contribute to disparities in completion rates of substance use treatment programs. Indeed, racial and ethnic minority members engaging in substance abuse and enrolled in a treatment program are less likely to complete the program than individuals in the dominant racial and ethnic group (Guerrerro et al. 2013). A meta-analysis assessing the influence of race and ethnicity on the relationship between cognitive behavioral therapy (CBT) and substance use treatment engagement found that the reduction in substance use was significantly smaller for African Americans and Hispanics than for Whites. The same study also showed that African Americans and Hispanics had lower overall retention, engagement, and follow-up scores than Whites. The authors speculated that the weakness of this effect may be due to high attrition from the studies of racial and ethnic group members that may have rendered the scores of the remaining participants higher than they would have been if those who left the study had remained in the study (Windsor et al. 2015). When considered in the context of rurality, disparities experienced by racial and ethnic minority individuals may be even further complicated. Rural populations are often empirically treated as a homogeneous group. This leaves the function of important demographic variables (e.g., race and ethnicity) in health disparities research often overlooked (Bumgarner et al. 2017). Many of the factors that contribute to increased substance use (e.g., lowered income, lack of transportation, marginalization) may be particularly salient and/or prevalent among racial and ethnic minority members (Chan et al. 2015; Morojele et al. 2010). In addition, barriers to receiving healthcare (e.g., perceived stigma, limited access) may be more prevalent among rural inhabitants than their urban counterparts (Alang 2015; Thomas and Compton 2008), and it is suggested that these barriers are even more problematic for racial and ethnic minority rural residents (Bridges et al. 2014). Rural patients who receive substance use treatment are less likely to attend follow-up appointments at rural clinics (Chan et al. 2015). One study in rural America showed the vast majority of African American participants meeting the criteria for lifetime substance abuse or dependence do not receive treatment (Kramer et al. 2009). Part of the problem may lie in the lack of treatment facilities in rural areas and areas that have higher minority populations that accept insurance (Cummings et al. 2014).

Prevention and Treatment of Substance Use and Abuse To the extent that rural, remote, and frontier areas face unique barriers to substance use treatment, it may be particularly beneficial to implement early prevention programs for youth and adolescents in order to combat the growing prevalence of substance use (SAMHSA 2012). As Lambert et al. (2008) state, “Rather than craft

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intervention policies and programs one substance at a time, it is important to consider what can be done to enhance the infrastructure of rural communities to support substance abuse prevention and early intervention for rural youth and young adults” (p. 227). In turn, these early efforts may mitigate the intensive strain of the substance abuse and comorbid problems facing these areas. Prevention and early intervention efforts for substance use and abuse have demonstrated short- and long-term positive impacts (Catalano et al. 2011; Harrop and Catalano 2016). These programs are delivered within schools, families, and community settings. They include interventions for parenting programs, mentoring programs, normative change programs, and promotion of social and emotional competence. There are a number of school-based programs for adolescents that appear to be effective for reducing the increase in substance use, but not for stopping substance use, for example, Life Skills Training (Botvin and Griffin 2004), Raising Health Children (Hawkins et al. 1999), and Project Northland (Perry et al. 1996). Experimentation with alcohol and drugs appears to be common behavior for most adolescents, so the goal of prevention programs is to identify at-risk youth and stop the progression from experimentation to abuse (Getz and Bray 2005). Other programs have been developed for college students (e.g., Brief Alcohol Screening and Intervention for College Students; Dimeff et al. 1999) with similar results. Linking Psychologists and Primary Care Physicians. Collaboration between healthcare providers and the use of a collaborative practice model between psychologists and physicians to meet the multiple needs of patients is a growing area (Bray 2010; Bray et al. 2004). In rural areas, the lack of access to specialists increase pressures on primary care and general practice physicians to diagnosis and treat a broad spectrum of biomedical and psychosocial problems. Psychologists are represented in rural areas and are often the most highly trained mental health and substance abuse professionals functioning in rural communities. Having psychologists collaborate with physicians in rural and remote areas can improve the effectiveness of assessment and intervention. Bray and Rogers (1995) developed a demonstration program that linked psychologists and family physicians to improve the care of patients with alcohol and substance abuse problems. The program was successful in linking providers and in enhancing the level and quality of collaborative practice between these professionals. The predominant changes in the collaborative relationship were from selfcontained, independent practitioners to a collaborative relationship with limited referral and some consultation between professionals. The participants indicated that collaboration enhanced the effectiveness of each professional and resulted in better diagnosis and treatment of medical and psychosocial problems. Participants reported that the linkage improved their own sense of efficacy and satisfaction in working with patients with substance abuse problems. In addition, through the collaboration patients were provided enhanced treatment options for their problems. Although collaboration appears effective, there were a number of barriers identified to collaborative practice. Some of these are unique to rural practice (e.g., distance between providers and limited treatment resources), while others occur in both urban and rural settings (e.g., problems with reimbursement limitations). The following

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provides an example of a collaborative relationship for assessment and treatment of substance use problems. Dr. Montgomery referred Mr. Ward to the local psychologist, Dr. Vines, who shared space in the primary care clinic. Since the Wards were familiar with this clinic, they felt more comfortable coming for services. Dr. Montgomery had his staff send a referral note to Dr. Vines so that she was familiar with the case. During the first interview, Dr. Vines conducted an evidenced-based substance abuse assessment of Mr. Ward. She learned that he usually drank 6–8 beers per day, and he also used pain medication he obtained from his doctor and friends to help him with injuries and feel better. His drinking had increased to above healthy levels about 1 year ago. She also learned that for the past year he was under considerable stress at work and felt that his family was not sympathetic to his stress and this led to more drinking. When work stress was high, he would have a couple of beers at lunch to calm down. Dr. Vines explained to Mr. Ward how the range of substance use impacted him and how it was related to his other chronic health problems. Mr. Ward stated that he had no idea that his drinking was causing his hypertension and diabetes to spiral out of control. Dr. Vines began to assess Mr. Ward’s motivation to reduce his alcohol and substance use by exploring what he liked and disliked about using. He considered his concussion from falling off the ladder at work a “wake up call” and was receptive to changing his behavior. Dr. Vines worked with Mr. Ward to develop ways that he could reduce his drinking and pain medication use and deal with stress more effectively than turning to substances. Screening, Brief Intervention, and Referral to Treatment for Substance Use. Drs. Montgomery and Vines used the Screening and Brief Intervention and Referral to Treatment (SBIRT) model to work with Mr. Ward. SBIRT is a promising effort for both adolescents and adults for integration into primary and emergency medical care settings (AAP 2011; Babor et al. 2007; Madras et al. 2009). SBIRT is a public health approach to address substance use problems in primary and other healthcare settings (Babor et al. 2007; Bray et al. 2012; InSight Project Research Group 2009; Madras et al. 2009). Developed on evidence-based methods, the SBIRT technique screens adolescents and adults for substance use problems on a yearly basis. Screening adults for alcohol misuse and providing brief interventions in primary care settings is currently a recommendation of the US Preventive Services Task Force (AHRQ 2012) and included in US federally mandated healthcare reforms (U.S. Congress 2010). The American Academy of Pediatrics (AAP) recommends screening all adolescent patients for tobacco, alcohol, and other drug use with the SBIRT process and has strongly encouraged pediatricians to develop the skills and confidence necessary to adequately manage adolescent patients with substance use problems (AAP 2011). Importantly, SBIRT can be implemented in rural areas by primary care and mental health providers. Those who screen positive for risky and unhealthy substance use are then provided a brief intervention based on the Transtheoretical Model of Change (Prochaska et al. 1992) and Motivational Interviewing (Miller and Rollnick 2002). The Transtheoretical Model of Change (TTM) is a framework for understanding the process of behavior change and uses motivation as a key factor in the

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implementation of intentional change (Prochaska et al. 1992; Prochaska and DiClemente 2005). The model maps stages of change in progressive steps as follows: precontemplation; contemplation; preparation for action; action; maintenance; relapse; and recycling. The model is not linear, as people can jump from one step across multiple steps during the change process (e.g., from contemplation to action). This model has been used in substance abuse treatment to conceptualize treatment engagement and therapeutic progress that accord with natural change (Prochaska and DiClemente 2005). TTM suggests that identification of the substance abuser’s current stage of change may facilitate use of the most appropriate therapeutic method for that stage. Once the current stage is identified, providers may use Motivational Interviewing and other evidence-based practices to help people move along the change continuum. Motivational Interviewing (MI) is a non-confrontational approach that seeks to elicit the motivations to facilitate change for the individual (Miller and Rollnick 2002). Practitioners and advocates of MI believe in accepting people at their current stage of change and assisting them in the change process. There are four primary principles that guide the approach: (1) express empathy, (2) develop discrepancy, (3) roll with resistance, and (4) support self-efficacy (Miller and Rollnick 2002). MI focuses on helping the client/patient to develop discrepancies in current behavior and desired behavior by enhancing personal motivations to change. The psychologist facilitates problem solving by the client/patient and encourages self-efficacy through active reinforcement of the client/patient’s ability to change. The client/patient may not commit to abstinence, but any reduction in problematic substance use and/or commitment to positive behaviors is considered success. People who are abusing alcohol and other substances are given a brief intervention and, if needed, a referral to treatment. SBIRT is effective for helping risky drinkers reduce their alcohol consumption to more healthy levels and stop the progression to abuse levels (InSight Project Research Group 2009; Madras et al. 2009). The challenge for implementing SBIRT into primary care settings is a lack of training for both physicians and psychologists and is compounded for professionals in rural and remote areas who often do not get access to this type of training. Effective training programs have been developed for both groups of professionals (Bray et al. 2012, 2004; SAMHSA 2017; see special issue of Substance Abuse, Volume 33, on SBIRT), and psychologists can provide an important role in collaborating with their physician colleagues in providing these services. In the United States, SAMHSA has funded multiple projects to develop SBIRT services and training programs for healthcare professionals that include physicians, nurses, psychologists, social workers, and dentists (SAMHSA 2017). Bray et al. (2012) developed both in-person and online training programs to learn SBIRT skills. Content about SBIRT can be learned via online methods; however, SBIRT skills and motivational interviewing require coaching and in-person training. In addition, Bray and colleagues developed an SBIRT app that is available for free in the iTunes and Google Play stores. This app guides the user through the SBIRT process and provides the screening tools and scripts to utilize SBIRT in practice.

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Remote Therapies for Rural and Remote Populations Use of Telehealth. Given the relative lack of substance abuse providers and treatment facilities in rural and remote areas, use of telehealth and telecommunication services is being developed and expanded across the world (Benavides-Vaello et al. 2013; Ross et al. 2016; ▶ Chap. 11, “Telemental Health in Rural and Remote Contexts”). Applications of these technologies have the potential to reduce disparities in the delivery of substance abuse services. Research indicates that telehealth for substance abuse treatment is effective and produces higher completion rates to traditional services, and some clients/patients prefer this form of treatment because of convenience and perceived increase in confidentiality (Batastini et al. 2016; Benavides-Vaello et al. 2013; SAMHSA 2012). Benavides-Vaello et al. (2013) identified the following advantages of telehealth in rural practice: (1) telehealth provides an opportunity for providers in urban areas to provide services to rural patients; (2) these methods provide a means to store and share patient records; (3) the client/patient has reduced travel time and cost; (4) family separation is reduced and/or family members can be included in sessions; and (5) reduced number of appointments. Clients/patients in rural areas are satisfied with these types of services, and these therapies are acceptable across cultural lines. These methods reduce feelings of isolation for providers, enable quick consultations and assistance, and increase opportunities for collaboration. In addition, Gates and Albertella (2016) concluded that research supports the use of telephone counseling for the treatment of alcohol abuse in the short term. However, there is insufficient research on the use of telephone counseling for drug abuse. Telehealth is a useful strategy for offering treatment to individuals from rural and remote areas; however, this mode of treatment must be considered in light of potential barriers to implementation. These barriers include reimbursement limitations for the provider, significant startup and maintenance costs, and regulatory limitations in practicing across jurisdictions. While it may be legal for someone in one country to provide services to a client/patient in another country, within a country there are often license restrictions on providing services across states and territories. However, just like we receive technical assistance from other countries, it may soon be possible for providers in other countries to offer evidence-based treatment via Skype, FaceTime, or other means for significantly cheaper than what a client/patient can find in his/her own country (Bray 2010). Overall, the utilization of these services is increasing and is likely to continue to increase as new innovations in technology make telehealth more available and affordable and viewed by consumers as an acceptable substitution for in-person treatment (Batastini et al. 2016). Use of E-Therapies. E-therapy is the provision of mental health services by a licensed mental healthcare professional via e-mail, video conferencing, virtual reality technology, chat technology, web-based applications, online therapy, internet-operated therapeutic software, or any combination of these (Barak et al. 2009; Sucala et al. 2012). The internet and other technologies provide new opportunities for improving access to psychotherapeutic interventions that are readily accessible without the constraints of time and distance (Postel et al. 2008). Although

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they are not limited to any particular place or location, these technologies are adaptable to rural and remote areas. However, the lack, or quality, of internet services in rural and remote areas limits their application. Reviews of the effectiveness of e-therapy are limited due to the recency of their development. However, there is good indication that e-therapies are effective and offer a real alternative or supplement to traditional face-to-face therapies (Barak et al. 2009; Bergman et al. 2018). Empathic, warm, and therapeutic relationships can be formed and maintained with online interventions. Given that the therapeutic relationship often accounts for the majority of the variance in all psychotherapies, it is critical that this be studied and methods developed to increase the therapeutic relationship using online interventions.

Intervention Considerations Between Racial and Ethnic Minorities Many established interventions described in the previous section are well received across diverse rural populations. For example, Native American youth living in a reservation community have demonstrated a willingness to engage in MI in order to reduce underage drinking (Gilder et al. 2011). Telehealth delivered to rural Native American veterans has also been shown to be a promising area for intervention development (Bumgarner et al. 2017). Other prevention and intervention research shows that specific treatments may be particularly useful for implementation with racial and ethnic minority members. For instance, receiving drink refusal training was more effective for reducing heavy drinking in African American participants than White participants (Witkiewitz et al. 2011). Increasing mental health literacy, as with the Mental Health First Aid (MHFA) program, can help members of a rural community identify substance use disorders and effectively navigate someone experiencing a substance use disorder toward a treatment facility (Crisanti et al. 2015). However, some of the identified weaknesses of MHFA are that the curriculum for training instructors is only available in English and the training lacks cultural sensitivity in general (Crisanti et al. 2015). Not surprisingly, there is a call from researchers to implement culturally tailored prevention and intervention substance use programs to better meet the needs of racial and ethnic minority rural inhabitants (e.g., Lauricella et al. 2016; Okamoto et al. 2016). Understanding the sociocultural predictors of substance use across different racial and ethnic groups is important for informing tailored interventions and prevention programs. For example, African Americans in rural Virginia are more likely to be involved in religious activities than Whites (Huebner et al. 2006), and involvement in religious activities may serve as a protective factor against substance use for African Americans and Hispanics (e.g., Hodge et al. 2001; Nasim et al. 2011). Support for the protective effects of religious involvement has been shown in rural and semi-rural Mexico as well (see Marsiglia et al. 2012). Given that rural communities are not likely to offer the same array of activities as urban communities, for some groups, extracurricular involvement (particularly that which reinforces moral practices) may be important for preventing substance use engagement. Interestingly,

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some research shows that people from different ethnic minority groups may differ on their susceptibility to social influence in terms of substance use (Akins et al. 2010; Gibbons et al. 2010). For example, African Americans and Hispanics are not particularly prone to using substances due to peer pressure when compared to Whites (e.g., Akins et al. 2010), while Whites and Hispanics are more vulnerable to parental substance use compared to African Americans (Akins et al. 2010). Certain familial factors (e.g., protective parenting) may protect rural African American adolescents from drinking alcohol more than urban African American adolescents (Clark et al. 2011). Recognizing this added familial protection for African Americans regarding substance use, researchers developed an intervention specifically for African American adolescents living in the rural south. This intervention (i.e., the Strong African American Families Program) emphasizes regulated parental communication to deter African American youth from engaging in multiple health risk behaviors (e.g., alcohol use, sexual behaviors; Brody et al. 2004). In addition, understanding how community-level factors may make a racial and ethnic minority group within a rural community at risk is important (Nasim et al. 2011). Both protective and risky community factors (e.g., attachment to community, accessibility of substances, respectively) influence substance use among African American rural adolescents more than their urban counterparts (Clark et al. 2011), suggesting a level of interdependence with the community in rural environments that is not seen in more populated areas. There is a robust body of literature showing that racial and ethnic minority members are often subjected to experiences of perceived discrimination as well as microaggressions, which in turn are frequently associated with increased substance use (e.g., Blume et al. 2012; Cheng and Mallinckrodt 2015; Gerrard et al. 2012; Hurd et al. 2014). Other research indicates immigrants living in rural areas may have a higher prevalence of speaking the language of their home country as opposed to the language of the mainstream, host country (Akins et al. 2008), which may create additional tension and distress. It is possible that racial and ethnic minority members within a predominantly mainstream rural environment may be particularly vulnerable to racial or ethnic discrimination and the associated distress and will have fewer resources with which to cope. Health disparities researchers wishing to implement effective programs targeting the reduction or elimination of substance use among racial and ethnic rural populations should be cautioned against taking a “one-size-fits-all-culturalgroups” culturally adapted approach. As noted by Okamoto et al. (2016), culturally adapted programs are created for one group and then generalized to another, whereas culturally grounded programs are created collaboratively within each community. Because of this, culturally grounded programs may better meet the needs of the respective community. An example is a program aimed at teaching native Hawaiian rural youth “culturally specific refusal strategies” when confronted with situations where there is an opportunity to (or pressure to) engage in drug use. This program found that taking cultural context into consideration is important for program effectiveness (Okamoto et al. 2016). This is an area that needs further development to meet the unique needs of minority populations in rural areas.

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It must be noted that, although this chapter discusses substance use patterns and disparities related to race and ethnicity among rural populations, health disparities among other minority rural populations (e.g., sexual orientation, military veteran status) are prevalent and problematic. Individuals with this “multiple-minority” status may be at an increased risk of engaging in substance use and experiencing related health disparities, all of which could be further complicated by residing in a rural area for each reason previously mentioned in this chapter (e.g., Bumgarner et al. 2017; Rhodes et al. 2011; Rosenkrantz et al. 2017). Moving forward, it is imperative that researchers and practitioners account for under-represented minorities of all groups to more comprehensively serve rural communities.

Summary and Conclusions Providing substance abuse services in rural and remote areas includes a number of challenges that are both similar and different than in urban areas. The major barriers are the lack of access to affordable services and specialists who provide these services. Individuals and families who have substance abuse issues often have nowhere to turn and are asked to travel long distances to obtain needed services. These obstacles are an added burden to family members participating in treatment and providing critical support for their family member who is suffering with substance abuse problems. The development of effective telehealth services and e-therapies for substance abuse disorders offers great potential for rural and remote populations to be able to obtain much needed services from competent professionals. However, these therapies need to be tailored to the unique challenges that are faced by racial and ethnic minorities. In addition, professionals need further education about health disparities in substance abuse to insure that they provide services to all of their patients. Psychologists can play an important and unique role in rural and remote practice (Bray and Rogers 1995; Miller and Rollnick 2002; Stanton 2009) as they have been at the forefront in developing evidence-based practices to both prevent and treat alcohol and substance abuse problems. One of the biggest challenges is to help support psychologists working in these settings and to develop incentives for living and working in rural and remote areas (Bray et al. 2004). It is clear that addressing these unmet needs will require changes in public policies to support the use of these technologies across jurisdictions, additional financial support to fund access to these technologies, and changes in reimbursement policies so that professionals can be paid for providing these critical services to peoples in rural and remote areas of our world.

References Agency for Healthcare Research and Quality (AHRQ). U.S. preventive services task force. Washington, DC: Department of Health and Human Services; 2012. Available at: http://www. uspreventiveservicestaskforce.org/. Accessed on 26 Apr 2012.

550

J. H. Bray et al.

Akins S, Mosher C, Smith CL, Gauthier JF. The effect of acculturation on patterns of Hispanic substance use in Washington state. J Drug Issues. 2008;38:103–18. Akins S, Smith CL, Mosher C. Pathways to adult alcohol abuse across racial and ethnic groups: an application of general strain and social learning theories. J Drug Issues. 2010;40:321. Alang SM. Sociodemographic disparities associated with perceived causes of unmet need for mental health care. Psychiatr Rehabil J. 2015;38:293–9. https://doi.org/10.1037/prj000013. American Academy of Pediatrics Committee on Substance Abuse. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128:e1330–40. https:// doi.org/10.1542/peds.2011-1754. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2016: detailed findings. Drug Statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW; 2017. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus. 2007;28:7–30. Barak A, Klein B, Proudfoot JG. Defining internet-supported therapeutic interventions. Ann Behav Med. 2009;38:4–17. Batastini AB, King CM, Morgan RD, McDaniel B. Telepsychological services with criminal justice and substance abuse clients: a systematic review and meta-analysis. Psychol Serv. 2016;13:20–30. Beardsley K, Wish ED, Fitzelle DB, O’Grady K, Arria AM. Distance traveled to outpatient drug treatment and client retention. J Subst Abus Treat. 2003;25:279–85. Benavides-Vaello S, Strode A, Sheeran B. Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review. J Behav Health Serv Res. 2013;40:111–20. Bergman BG, Greene MC, Hoeppner BB, Kelly JF. Expanding the reach of alcohol and other drug services: prevalence and correlates of US adult engagement with online technology to address substance problems. Addict Behav. 2018;87:74–81. https://doi.org/10.1016/j.addbeh.2018.06.018. Blume AW, Lovato LV, Thyken BN, Denny N. The relationship of microaggressions with alcohol use and anxiety among ethnic minority college students in a historically white institution. Cult Divers Ethn Minor Psychol. 2012;18:45–54. https://doi.org/10.1037/a0025457. Borders TF, Booth BM. Research on rural residence and access to drug abuse services: where are we and where do we go? J Rural Health. 2007;23:79–83. Borders TF, Booth BM, Han X, Wright P, Leukefelt C, Falck RS, et al. Longitudinal changes in methamphetamine and cocaine use in untreated rural stimulant users: racial differences and the impact of methamphetamine legislation. Addiction. 2008;103:800–8. https://doi.org/10.1111/ j.136-0443.2008.02159.x. Botvin G, Griffin K. Live skills training: empirical findings and future directions. J Prim Prev. 2004;25:211–32. Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Power NR. Race and trust in the health care system. Public Health Rep. 2003;11:358–65. Boyd MR, Baliko B, Cox MF, Tavakoli A. Stress, coping, and alcohol expectancies in rural African-American women. Arch Psychiatr Nurs. 2007;21:70–9. https://doi.org/10.1016/j. apnu.2006.11.001. Bray JH. The future of psychology practice and science. Am Psychol. 2010;65:355–69. Bray JH, Rogers JC. Linking psychologists and family physicians for collaborative practice. Prof Psychol Res Pract. 1995;26:132–8. Bray JH, Enright ME, Easling I. Psychological practice in rural primary care. Chapter in. In: Frank R, McDaniel SH, Bray JH, Heldring M, editors. Primary care psychology. Washington, DC: American Psychological Association; 2004. p. 243–58. Bray JH, Kowalchuk A, Waters V, Laufman L, Shilling EH. Baylor SBIRT medical residency training program: model description and initial evaluation. Subst Abus. 2012;33:231–40. https://doi.org/10.1080/08897077.2011.640160.

24

Substance Abuse in Rural and Remote Areas

551

Bridges AJ, Andrews AR, Villalobos BT, Pastrana FA, Cavell TA. Does integrated behavioral health care reduce mental health disparities for Latinos? Initial findings. J Lat Psychol. 2014;2:37–53. https://doi.org/10.1037/lat0000009. Brody GH, Murry VM, Gerrard M, Gibbons FX, Molgaard V, McNair L, et al. The Strong African American Families Program: translating research into prevention programming. Child Dev. 2004;75:900–17. Browne T, Priester MA, Clone S, Iachini A, DeHart D, Hock R. Barriers and facilitators to substance use treatment in the rural south: a qualitative study. J Rural Health. 2016;32:92–101. Bumgarner DJ, Polinsky EJ, Herman KG, Fordiani JM, Lewis CP, Hansen SK, Rutschman R, Bonnell M, Cardin SA. Mental health care for rural veterans: a systematic literature review, descriptive analysis, and future directions. J Rural Ment Health. 2017;41:222–33. https://doi. org/10.1037/rmh0000078. Catalano RF, Haggerty KP, Hawkins JD, Elgin J. Prevention of substance use and substance use disorders: the role of risk and protective factors. In: Kaminer Y, Winters KC, editors. Clinical manual of adolescent substance abuse treatment. Washington, DC: American Psychiatric Publishing; 2011. p. 25–63. Center for Behavioral Health Statistics and Quality. 2016. Key substance use and mental health indicators in the U.S.: results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16–4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/ data/. Chan Y, Lu S, Howe B, Tieben H, Hoeft T, Unützer J. Screening and follow-up monitoring for substance use in primary care: an exploration of rural-urban variations. J Gen Intern Med. 2015;31:215–22. https://doi.org/10.1007/s11606-015-3488-y. Chen K, Chen C, Fagot-Campagna A, Narayan MV. Tobacco, betel quid, alcohol, and illicit drug use among 13- to 35-year-olds in I’Lan, rural Taiwan: prevalence and risk factors. Am J Public Health. 2001;91:1130–4. Cheng H, Mallinckrodt B. Racial and ethnic discrimination, posttraumatic stress symptoms, and alcohol problems in a longitudinal study of Hispanic/Latino college students. J Couns Psychol. 2015;62:38–49. https://doi.org/10.1037/cou0000052. Clark TT, Nguyen AB, Belgrave FZ. Risk and protective factors for alcohol and marijuana use among African-American rural and urban adolescents. J Child Adolesc Subst Abuse. 2011;20:205–2011. https://doi.org/10.1080/1067828X.2011.581898. Clay R. Rural substance abuse: overcoming barriers to prevention and treatment. SAMHSA Newslet. 2007;15:1–5. Crisanti AS, Pasko DK, Pyeatt C, Silverblatt H, Anastasoff J. Disseminating challenges associated with Mental Health First Aid in New Mexico: insights from instructors. J Rural Ment Health. 2015;39:13–21. https://doi.org/10.1037/rmh0000013. Cummings JR, Wen H, Ko M, Druss BG. Race and ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the U.S. JAMA Psychiat. 2014;71:190–6. [Data File]. https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-update. Dimeff LA, Baer JS, Kivlahan DR, Marlatt GA. Brief alcohol screening and intervention for college students. New York: Guilford Press; 1999. Duan S, Jin Z, Liu X, Yang Y, Ye R, Tang R, et al. Tobacco and alcohol use among drug users receiving methadone maintenance treatment: a cross-sectional study in rural prefecture of Yunnan Province, Southwest China. Br Med J Open. 2017;7:e3014643. https://doi.org/ 10.1136/bmjopen-2016-014643. Edwards RW, Stanley L, Plested BA, Marquart BS, Chen J, Thurman PJ. Disparities in young adolescent inhalant use by rurality, gender, and ethnicity. Subst Use Misuse. 2007;42:643–70. https://doi.org/10.1080/10826080701202262. Elms E, Savic M, Bathish R, Best D, Manning V, Lubman DI. Multiple pathways to recovery, multiple roads to well-being: an analysis of recovery pathways in the Australian life in recovery survey. Alcohol Treat Q. 2018;36:482–98. https://doi.org/10.1080/07347324.2018.1490158.

552

J. H. Bray et al.

European Monitoring Centre for Drugs and Drug Addiction. European Drug Report 2017: trends and developments. Luxembourg: Publications Office of the European Union; 2017. Fitchen JM. Spatial redistribution of poverty through migration of poor people to depressed rural communities. Rural Sociol. 1995;60:181–201. Fortney JC, Booth BM, Blow FC, Bunn JY, Cook CAL. The effects of travel barriers and age on the utilization of alcoholism treatment aftercare. Am J Drug Alcohol Abuse. 1995;21:391–406. Fortney J, Mukherjee S, Curran G, Fortney S, Han X, Booth B. Factors associated with perceived stigma for alcohol use and treatment among at-risk drinkers. J Behav Health Serv Res. 2004;31:418–29. Gates P, Albertella L. The effectiveness of telephone counseling in the treatment of illicit drug and alcohol use concerns. J Telemed Telecare. 2016;22:67–85. Gerrard M, Stock ML, Roberts ME, Gibbons FX, O’Hara RE, Wang C, Wills TA. Coping with racial discrimination: the role of substance use. Psychol Addict Behav. 2012;26:550–60. https:// doi.org/10.1037/a0027711. Getz JG, Bray JH. Predicting heavy alcohol use among adolescents. Am J Orthopsychiatry. 2005;75:102–16. Gibbons FX, Pomery EA, Gerrard M, Sargent JD, Weng C, Wills TA, et al. Media as social influence: racial differences in the effects of peers and media on adolescent alcohol cognitions and consumption. Psychol Addict Behav. 2010;24:649–59. https://doi.org/10.1037/a0020768. Gilder DA, Luna JA, Calac D, Moore RS, Monti PM, Ehlers CL. Acceptability of the use of motivational interviewing to reduce underage drinking in a Native American community. Subst Use Misuse. 2011;46:836–42. https://doi.org/10.3109/10826084.2010.541963. Glass JE, Rathouz PJ, Gattis M, Joo YS, Nelson JC, Williams EC. Intersections of poverty, race/ ethnicity, and sex: alcohol consumption and adverse outcomes in the U.S. Soc Psychiatry Psychiatr Epidemiol. 2017;52:515–24. https://doi.org/10.1007/s00127-017-1362-4. Guerrerro EG, Marsh JC, Duan L, Oh C, Perron B, Lee B. Disparities in completion of substance abuse treatment between racial and ethnic groups. Health Serv Res. 2013;48:1450–67. https:// doi.org/10.1111/1475-6773.12031. Harrop E, Catalano RF. Evidence-based prevention for adolescent substance use. Child Adolesc Psychiatr Clin N Am. 2016;25:387–410. Hartley D, Korsen N, Bird D, Agger M. Management of patients with depression by rural primary care practitioners. Arch Fam Med. 1998;7:139–45. Hastings SL, Cohn TJ. Challenges and opportunities associated with rural mental health practice. J Rural Ment Health. 2013;37:37–49. Hawkins JD, Catalano RF, Kosterman R, Abbott R, Hill KG. Preventing adolescent health-risk behaviors by strengthening protection during childhood. Arch Pediatr Adolesc Med. 1999;153:226–34. Hodge DR, Cardenas P, Montoya H. Substance use: spirituality and religious participation as protective factors among rural youths. Soc Work Res. 2001;25:153–61. Huebner AJ, Shettler L, Matheson JL, Meszaros PS, Piercy FP, Davis SD. Examining ethnic differences in predictors of female adolescent smoking in rural Virginia. J Child Adolesc Subst Abuse. 2006;15:63–81. https://doi.org/10.1300/J029v15n03_05. Hurd NM, Varner FA, Caldwell CH, Zimmerman MA. Does perceived racial discrimination predict changes in psychological distress and substance use over time? an examination among Black emerging adults. Dev Psychol. 2014;50:1910–8. https://doi.org/10.1037/a0036438. InSight Project Research Group. SBIRT outcomes in Houston: final report on InSight, a hospital district-based program for patients at risk for alcohol or drug use problems. Alcohol Clin Exp Res. 2009;33:1374–81. Kelly JF, Bergman BG, Hoeppner BB, Vilsaint CL, White WL. Prevalence and pathways of recovery from drug and alcohol problems in the United States population: implications for practice, research, and policy. Drug Alcohol Depend. 2017;181:162–9. Kelly JF, Greene MC, Bergman G. Beyond abstinence: changes in indices of quality of life with time in recovery in a nationally representative sample of U.S adults. Alcohol Clin Exp Res. 2018;42:770–80.

24

Substance Abuse in Rural and Remote Areas

553

Knudsen HK, Johnson JA, Roman PM, Oser CB. Rural and urban similarities and differences in private substance abuse treatment centers. J Psychoactive Drugs. 2003;35:511–8. Kramer TL, Han X, Booth BM. Young adult, rural, African American stimulant users: antecedents and vulnerabilities. J Ethn Subst Abus. 2009;8:378–99. https://doi.org/10.1080/15332640903327393. Lambert D, Gale JA, Hartley D. Substance abuse by youth and young adults in rural America. J Rural Health. 2008;24:221–8. Lauricella M, Valdez JK, Okamoto SK, Helm S, Zaremba C. Culturally grounded prevention for minority youth populations: a systematic review of the literature. J Prim Prev. 2016;37:11–32. https://doi.org/10.1007/s10935-015-0414-3. Love MM, Cohn TJ, Pierce TW, Hastings SL. Trends in injection use among prescription opioidmisusing individuals in the rural U.S. J Rural Ment Health. 2016;40:180–92. Lynn-Landsman SD, Komro KA, Kominsky TK, Boyd ML, Maldonado-Molina MM. Early trajectories of alcohol and other substance use among youth from rural communities within the Cherokee nation. J Stud Alcohol Drugs. 2016;77:238–48. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280–95. Marsiglia FF, Ayers SL, Hoffman S. Religiosity and adolescent substance use in Central Mexico: exploring the influence of internal and external religiosity on cigarette and alcohol use. Am J Community Psychol. 2012;49:87–97. https://doi.org/10.1007/s10464-011-9439-9. McDonald TW, Harris SM, LeMesurier EA. Mental health care issues in a predominantly rural and frontier state: results and implications from a comprehensive survey. J Rural Community Psychol. 2005;E8 McDonald TW, Curtis-Schaeffer AK, Theiler AA, Howard EKM. Provider’s perceptions of prevalent mental and behavioral health problems: differences and similarities across, urban, rural, and frontier areas. J Rural Ment Health. 2014;38:36–49. McFadden Consultancy. Research report: the New Zealand drug harm index 2016. 2nd ed. Wellington: Ministry of Health; 2016. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc. 2000;284:1689–95. Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 2nd ed. New York: Guilford Press; 2002. Ministry of Health. Drug use in New Zealand: key results of the 2007/08 New Zealand alcohol and drug use survey. Wellington: Ministry of Health; 2010. Ministry of Health. 2017. Annual Data Explorer 2016/17: new Zealand Health Survey. Morojele NK, London L, Olorunju SA, Matjila MJ, Davids AS, Rendall-Mkosi KM. Predictors of risk of alcohol-exposed pregnancies among women in an urban and a rural area of South Africa. Soc Sci Med. 2010;70:534–42. https://doi.org/10.1016/j.socscimed.2009.10.040. Nasim A, Fernander A, Townsend TG, Corona R, Belgrave FZ. Cultural protective factors for community risks and substance use among rural African American adolescents. J Ethn Subst Abus. 2011;10:316–36. National Center for Addiction and Substance Abuse (NCASA). No place to hide: substance abuse in mid-size cities and rural America. New York: NCASA (Columbia University); 2002. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94:666–8. Notley C, Maskrey V, Holland R. The needs of problematic drug misusers not in structured treatment: a qualitative study of perceived treatment barriers and recommendations for services. Drugs: Educ Prev Polic. 2012;19:40–8. Office of National Statistics. Drug misuse: 2013/2014 Crime Survey for England and Wales. London: Home Office; 2014. Okamoto SK, Kulis S, Helm S, Lauricella M, Valdez JK. An evaluation of the Ho’ouna Pono Curriculum: a pilot study of culturally grounded substance abuse prevention for rural Hawaiian youth. J Health Care Poor Underserved. 2016;27:815–33.

554

J. H. Bray et al.

Oser CB, Harp KL. Treatment outcomes for prescription drug misusers: the negative effect of geographic discordance. J Subst Abus Treat. 2014;48(1):77–84. Oser C, Leukefeld C, Tindall M, Garrity T, Carlson R, Falck R, Wang J, Booth B. Rural drug users: factors associated with substance abuse treatment utilization. Int J Offender Ther Comp Criminol. 2011;55:567–86. Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med. 2013;29:364–87. https://doi.org/10.1007/s11606-013-2583-1. Perry CL, Williams CL, Veblen-Mortenson S, Toomey TL, Komro KA, Anstine PS, McGovern PG, Finnegan JR, Forster JL, Wagenaar AC, Wolfson M. Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence. Am J Public Health. 1996;86:956–65. Postel MG, de Haan HA, De Jong AJ. E-therapy for mental health problems: a systematic review. Telemed E-Health. 2008;14:707–14. Pringle JL, Emptage NP, Hubbard RL. Unmet needs for comprehensive services in outpatient addiction treatment. J Subst Abus Treat. 2006;30:183–9. Probst JC, Laditka SB, Moore CG, Harun N, Powell MP, Baxley EG. Rural urban differences in depression prevalence: implications for family medicine. Fam Med. 2006;38:653–60. Prochaska JO, DiClemente CC. The transtheoretical model. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; 2005. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol. 1992;47:1102–14. Pullen E, Oser C. Barriers to substance abuse treatment in rural and urban communities: counselor perspectives. Subst Use Misuse. 2014;49:891–901. Rhodes SD, McCoy TP, Hergenrather KC, Vissman AT, Wolfson M, Alonzo J, et al. Prevalence estimates of health risk behaviors of immigrant Latino men who have sex with men. J Rural Health. 2011;28:73–83. https://doi.org/10.1111/j.1748-0361.2011.00373.x. Rosenkrantz DE, Black WW, Abreu RL, Aleshire ME, Fallin-Bennett K. Health and health care of rural sexual and gender minorities: a systematic review. Stigma Health. 2017;2:229–43. Ross J, Stevenson F, Lau R, Murray E. Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update). Implement Sci. 2016;11:146–58. https:// doi.org/10.1186/s13012-016-0510-7. Saitz R, Larson MJ, LaBelle C, Richardson J, Samet JH. The case for chronic disease management for addiction. J Addict Med. 2009;2:55–65. Schmidt LA, Ye Y, Greenfield TK. Ethnic disparities in clinical severity and services for alcohol problems: results from the National Alcohol Survey. Alcohol Clin Exp Res. 2007;31:48–56. Stanton M. Systemic treatments for substance use disorders. Chapter in. In: Bray JH, Stanton M, editors. Handbook of family psychology. London: Wiley; 2009. p. 637–49. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality. The 2012 TEDS Report: a comparison of rural and urban substance abuse treatment admissions. Rockville; 2012. Substance Abuse and Mental Health Services Administration (SAMHSA), Screening, Brief Intervention, and Referral to Treatment (SBIRT). Rockville, MD. 2017. https://www.samhsa.gov/ sbirt. Accessed 27 Jan 2018. Sucala M, Schnur JB, Constantino JJ, Miller SJ, Brackman EH, Montgomery GH. The therapeutic relationship in e-therapy for mental health: a systematic review. J Med Internet Res. 2012;14:1–13. Thomas YF, Compton WM. Rural populations are not protected from drug use and abuse. J Rural Health. 2008;23:1–3. https://doi.org/10.1111/j.1748-0361.2007.00116.x. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the U.S. Psychiatr Serv. 2009;60:1323–8. U.S. Congress. H.R. 3590 Patient Protection and Affordable Care Act. Washington, DC. 2010. Available at: http://www.opencongress.org/bill/111-h3590/show

24

Substance Abuse in Rural and Remote Areas

555

Uddin ME. Arrack drinking patterns among Muslim, Hindu, Santal, and Oraon communities in the Rasulpur Union of Bangladesh: a cross-cultural perspective. J Drug Educ. 2008;38:405–24. https://doi.org/10.2190/DE.38.4.g. Van Gundy K. Substance abuse in rural and small town America: A Carsey Institute Report on rural America. Durham: Carsey Institute, University of New Hampshire; 2006. Windsor LC, Jemal A, Alessi EJ. Cognitive behavioral therapy: a meta-analysis of race and substance use outcomes. Cult Divers Ethn Minor Psychol. 2015;21:300–13. https://doi.org/ 10.1037/a0037929. Witkiewitz K, Villarroel NA, Hartzler B, Donovan DM. Drinking outcomes following drink refusal skills training: differential effects for African American and Non-Hispanic White clients. Psychol Addict Behav. 2011;25:162–7. https://doi.org/10.1037/a0022254. Wu L, Zhu H, Swartz MS. Trends in cannabis use disorders among racial and ethnic population groups in the United States. Drug Alcohol Depend. 2016;165:181–90. https://doi.org/10.1016/j. drgualcdep.2016.06.002.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Frameworks and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Reasoning in Medicines Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Decreased Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communication Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physiological Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter discusses the quality use of medicines in the management of mental health conditions in rural and remote settings. It addresses the clinical reasoning processes, frameworks and policies that support safe and effective use of medicines. Recognizing that many people are able to maintain or regain their health without using medicines and not all instances of mental distress require a T. Speare (*) · D. Tsai Centre for Remote Health, Flinders University, Alice Springs, NT, Australia e-mail: tobias.speare@flinders.edu.au; [email protected] A. Gilbert Top End Health Service, Northern Territory Government, Darwin, NT, Australia e-mail: [email protected] M. Tabart Central Australia Health Service, Northern Territory Government, Alice Springs, NT, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_26

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pharmacological remedy. The chapter highlights the distinctive features of rural and remote practice necessary for the safe and appropriate use of medicines in the treatment of mental health conditions. These include decreased access to health services and reliable medicine supply chains, cultural diversity, communication challenges, physiological variations, and translation of medicinal trial data to clinical practice. The risks associated with medicine use can be minimized through a structured approach to the decision-making process, incorporating principles of quality use of medicines, good medicines management framework, best practice and standard treatment guidelines, and use of evidence based resources.

Introduction The first duties of the physician is to educate the masses not to take medicine. (Sir William Osler, circa 1904 (Bean 1950))

This aphorism for clinicians applies just as importantly now as it did when originally penned, with one major caveat. The pharmaceutic armamentarium at a physician’s disposal at that time was not likely to be effective and indeed, it was more likely to cause harm. The twentieth century was a golden age in the discovery of effective, efficacious and safe medicines to manage the variety of ailments that trouble humanity. The introduction of lithium in the 1950s for the treatment of mania was the prelude to a cascade of similar discoveries that heralded a seismic shift in the management of mental health conditions that were previously untreatable. Other medicines soon followed, including chlorpromazine and tricyclic antidepressants, called psychotropic medicines due to the effects upon emotion and behavior (Usher et al. 2009). Persons debilitated by depression and mania experienced dramatic results and amazing remissions following treatment with new psychotropic medicines. These soon became integral in the pharmacopoeia for the treatment of mental health conditions (Lieberman et al. 2000). However the transition to a pharmacological paradigm led to conflict between competing treatment approaches, particularly adherents of the psychoanalytic psychotherapy movement (Lieberman et al. 2000). Enthusiasm for psychotropic medicines gradually waned as initial optimism in the efficacy of the medicines remained unfulfilled, and the limitations of psychotropic medicines were realized. The medicines did not alleviate all symptoms of mental illness, and many people continued to be severely disabled and frequently relapsed. Extremely high rates of adverse effects and harm, including death, lead to increasing resistance to their use (Usher et al. 2009). The 1990s witnessed a second wave of novel psychotropic medicines becoming available, including a number of atypical antipsychotic medicines and selective serotonin reuptake inhibitors (Lieberman et al. 2000). The new medicines demonstrated similar efficacy in treating mental health conditions with improved safety

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profiles. The significantly reduced incidence of debilitating side effects made them more acceptable to patients and health professionals.

Ethical Considerations The use of medicines in mental health raises unique ethical considerations. Persons experiencing mental illness may have greater vulnerably, decreased autonomy and encounter significant stigma (Robertson 2012). In addition, the therapeutic relationship between persons experiencing mental illness and the health professional plays a unique role in achieving treatment outcomes (Robertson 2012). The rights of persons with mental health conditions are protected under state and territory legislation, usually Mental Health Acts. The legislation details the care, treatment, and protection that should be afforded people with mental illness, including conditions related to involuntary treatment (Usher et al. 2009). The United Nations Convention on the Rights of Persons with Disabilities stipulates the expectations, in a broad global context, regarding the use of psychotropic medications (Table 1) (Office of the High Commissioner for Human Rights 1991).

Frameworks and Policies Motivated by the World Health Organization (WHO), countries around the world are implementing national medicine policies to ensure that essential affordable medicines of acceptable quality, safety, and efficacy are available (World Health Organization 2002). Australia’s National Medicines Policy (NMP) comprises four interdependent components necessary to achieve the primary goal of healthy patients through optimizing health outcomes (Fig. 1) (Commonwealth Department of Health and Ageing 2002). Quality use of medicines (QUM) is a central component of the NMP, which encompasses four key principles: judicious use, appropriate use, safe use, and efficacious use of medicines (Table 2) (Department of Health and Aging 2002). QUM encourages a collaborative approach between all stakeholders, including healthcare consumers, healthcare providers, health care facilities, the medicines industries, media, health-care funders and purchasers, and governments, to achieve the best possible use of medicines to improve health outcomes. The term “medicine” Table 1 United Nations Convention on the Rights of Persons with Disabilities, extract Principle 10- Human rights with regard to psychotropic medications Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purposes and shall never be administered as a punishment or for the convenience of others. Except for clinical trials, mental health practitioners shall only administer medication of known or demonstrated efficacy. All medication shall be prescribed by a mental health practitioner authorized by law and shall be recorded in the patient’s records Ref: UN General Assembly 1991; Office of the High Commissioner for Human Rights 1991

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Fig. 1 Australia’s national medicines policy. (© 2002 Commonwealth of Australia as represented by the Department of Health)

Table 2 Principles of quality use of medicines Judicious use Selecting management options wisely. Medicines, whether prescribed, recommended and/or selfselected should be used only when appropriate, with non-medicinal alternatives considered as needed Appropriate use Choosing suitable medicines if a medicine is considered necessary. Choosing the most appropriate medicine, taking into account factors such as the clinical condition being treated, the potential risks and benefits of treatment, dosage, length of treatment, and costs Safe use Using medicines safely and effectively to get the best possible results. Misuse, including overuse and underuse, should be minimized. Improving people’s ability to solve problems related to medication, such as negative effects or managing multiple medications Efficacious use Medicines must achieve goals of therapy by delivering beneficial changes in actual health outcomes Source: (Department of Health and Aging 2002)

includes prescription, non-prescription, and complementary medicines. It is not possible to have QUM if people cannot afford the medicines they need. Nor is it possible to have QUM if the available medicines are not safe or effective. It is not sensible to have high-quality effective medicines unless they are used appropriately.

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Clinical Reasoning in Medicines Management Medicines are one of the most common forms of therapeutic intervention. However, it is important to recognize that not all instances of mental distress require a pharmacological remedy and not all medications are tolerated or improve quality of life (Diamond 1985). A psychological overreliance on a medication to remedy the “chemical imbalance,” a common explanation for a mental health condition, can lead to the erroneous belief that patients are not responsible for their feelings or actions and consequently their self-agency in recovery is eroded (Lurie 1991). There can be an overreliance on medication use when other treatments, such as psychological and social interventions, may be more appropriate. The safe and appropriate use of medicines can have a huge impact on a person’s health and quality of life. Managing medicines is a complex exercise requiring the application of specific knowledge and skills to treat patients holistically, ensuring consideration is given to comorbidities and other medicines. Appropriate medicines management should maximize effectiveness, minimize risks, minimize costs, and respect patient choices. The use of medicines is a balancing act determined by risk-benefit analysis. An analysis requires awareness of issues relevant to the broad context of medicine use, including the risks of harm, side effects, and financial costs to the individual and broader costs to society, balanced against the benefits of taking medicines, and the consequences of inadequately managed disease. Additionally, it is important to recognize that not everyone’s risk is the same. The use of medicines in some individuals is associated with greater risk of harm that outweighs the potential benefits. The best treatment options are tailored to an individual’s personal needs and priorities. Patient involvement in treatment decisions has been demonstrated to result in beneficial effects on health outcomes (Arora and McHorney 2000). Since the early days of psychopharmacology, there has been a dramatic expansion in the number of pharmacological agents for the management of mental health conditions (Table 3) and the available formulations (Table 4). The various medications and formulations serve to enhance patient outcomes, convenience, adherence, and comfort. In this context, it is vital the use of medicines is based on a structured and systematic process underpinned by sound clinical reasoning and supportive systems, including policies and frameworks. In the early 1990s, the WHO developed a Guide to Good Prescribing that provides a structured step-wise approach to assist in the management of medications (de Vries et al. 1994). The Guide to Good Prescribing has been adapted to the Australian context in the Prescribing Competencies Framework and conceptual model of prescribing (Fig. 2) (Cardiff 2017; Lum et al. 2013; NPS 2012). The application of clinical reasoning, the cognitive processes health professionals use to determine appropriate management, is essential in achieving high-quality care (Cutrer et al. 2013). When clinical reasoning fails, errors occur that can lead to poor delivery of care and harm to patients. If a medicine is deemed necessary, treatment decisions based on recommended frameworks guide the selection of the most

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Table 3 Medicines used in management of mental health conditions in Australia Antidepressants Tricyclic antidepressants Amitriptyline Clomipramine Dothiepin (Dosulepin) Doxepin Imipramine Lofepramine Nortriptyline Trazodone Trimipramine Serotonin and noradrenaline reuptake inhibitors Desvenlafaxine Duloxetine Venlafaxine Other antidepressants Agomelatine Bupropion Mianserin Mirtazapine Moclobemide Reboxetine Trazodone Vortioxetine Antipsychotics Typical antipsychotics Benperidol Chlorpromazine Droperidol Flupentixol Fluphenazine Haloperidol Periciazine Perphenazine Pimozide Sulpiride Thioridazine Trifluoperazine Zuclopenthixol Mood stabilizers Lithium Sodium valproate

Selective serotonin reuptake inhibitors Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline

Monoamine oxidase inhibitors Isocarboxazid Phenelzine Tranylcypromine

Atypical antipsychotics Amisulpride Aripiprazole Asenapine Clozapine Lurasidone Olanzapine Paliperidone Quetiapine Risperidone Ziprasidone

Carbamazepine Lamotrigine (continued)

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Table 3 (continued) Medicines for anxiety and sleep disorders Benzodiazepines Alprazolam Bromazepam Chlordiazepoxide Clobazam Diazepam Flunitrazepam Loprazolam Lorazepam Nitrazepam Oxazepam Temazepam

Other medicines Buspirone Melatonin Zolpidem Zopiclone

Source: (Australian Medicines Handbook 2020; British National Formulary 2020)

Table 4 Advantages and disadvantages of psychotropic medicine formulations Medicine formulation Oral tablet/capsule

Oral extended/delayed release tablet/capsule Oral solution/suspension liquid

Orally disintegrating tablet/ wafer

Injection – short acting

Injection – intermediate and long-acting depot

Attributes Advantages: ability to easily adjust dosage. Inexpensive. More medicines available. Patient can self-administer Disadvantages: non-adherence can be an issue Advantages: less frequent administration leading to greater convenience and adherence. Patient can self-administer Disadvantages: non-adherence can be an issue Advantages: alternative when there is difficulty swallowing. Ability to easily adjust dosage. Inexpensive. Patient can selfadminister Disadvantages: non-adherence can be an issue. Requires additional administration skills and equipment. Syrups may affect blood glucose levels Advantages: alternative when there is difficulty swallowing. Ability to easily adjust dosage. Patient can self-administer Disadvantages: non-adherence can be an issue. Cannot be packed into dose administration aids Advantages: RAPID onset. Alternative when oral route is inappropriate Disadvantages: Primarily used in emergency situations. Patient discomfort. Requires additional administration skills and equipment Advantages: less frequent administration may improve adherence Disadvantages: delayed onset of action. Patient discomfort. Requires additional administration skills and equipment. If sideeffects occur, the medicine remains in the patient’s system for a long period of time

Source: (Australian Medicines Handbook 2020; British National Formulary 2020; Kaminsky et al. 2015)

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Fig. 2 Conceptual model of the four stages of prescribing. (Source: adapted from Cardiff 2017; Lum et al. 2013)

appropriate medicine for the treatment of a condition in terms of efficacy, safety, suitability, and cost. It ensures treatments are chosen in a rational, systematic, and unbiased manner following an assessment of evidence on individual merit.

Distinctive Features Rural and remote locations pose unique challenges in delivering health services to individuals and communities, particularly those living in very remote areas. As the distance from major cities increases, death rates increase, access to health services decline, and rates of preventable hospitalizations for chronic diseases markedly rise (Australian Institute of Health and Welfare 2020). Within the rural and remote context, achieving QUM often demands compromise, flexibility, and resourcefulness to overcome barriers (Hamrosi et al. 2006). This section will highlight some of the distinctive features that should be considered to ensure the safe and appropriate use of medicines in treatment of mental health conditions in rural and remote practice.

Decreased Access With increasing remoteness from major cities, there is diminishing access to health services, health professionals, and reliable medicine supply chains, particularly

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specialty mental health services and psychosocial and vocational rehabilitation (Table 5) (Australian Institute of Health and Welfare 2020). Decreased access to health professionals who may initiate and individualize medicines including doctors and nurse practitioners results in barriers and delays in initiation and tailoring of treatment, which in turn may influence treatment outcomes. In the remote setting, the majority of health services including pharmaceutical care are provided through primary health-care centres, predominantly staffed by nurses and Indigenous health workers, including Aboriginal and Torres Strait Islander Health Practitioners. Even the “nearest” health centre can be located hundreds of kilometers from a person’s home. Many of the staff in remote health centres have no formal mental health training or training in management of medicines, which may influence the level of care patients receive including the potential overreliance on medication. Access to specialist mental health services may be enhanced with technology, including teleconferencing, videoconferencing, and web-based communications. Professional development and education for the rural and remote health workforce, in relation to mental health and medicines management, will likely result in improved outcomes. Research has demonstrated that appropriate professional development is an important factor in workplace satisfaction and workforce retention (Humphreys et al. 2007). Access to medicines, particularly high-cost and new-to-market medicines, may be limited in rural and remote areas. If a patient is taking a medicine not readily available in a rural or remote area, they may experience challenges in ensuring ongoing supply. Health services in rural and remote areas will often stock a restricted formulary that may not include multiple medicines from a particular class. Rather than stocking all selective serotonin reuptake inhibitors, health services will stock one or two, such as sertraline and citalopram. Reduced access to evaluation and monitoring services, such as laboratory assays, makes the use of certain medications inappropriate where therapeutic drug monitoring is necessary. An example is the use of lithium or clozapine, which require regular therapeutic drug monitoring.

Table 5 Mental health professionals and pharmacist, full-time equivalents by remoteness in 2015 Major cities FTE per 100,000 population Mental health 90.4 nurse Psychiatrist 15.8 Psychologist 102.6 Pharmacista 85

Inner regional

Outer regional

Remote

Very remote

80.3

51.1

57.5

31.6

5.6 60.0 70

4.3 43.1 68

5.6 34.7 56

2.1 23.2 36

Source: Australian Institute of Health and Welfare 2017; Health Workforce Data 2015 Pharmacist data does not indicate a pharmacist who has specialized in mental health

a

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Cultural Diversity Culture may be defined as the beliefs and behaviors of family and social groups (Andary et al. 2003). It influences the way people view and experience health and illness and impacts on the beliefs, attitudes, and decisions around access and engagement in health care (Indigeneous Allied Health Australia 2013). Rural and remote areas are home to a multitude of cultures, including over 250 unique and distinct cultures of Aboriginal and Torres Strait Islander peoples in Australia who comprise a larger proportion of the population in rural and remote areas (Table 6) (Australian Bureau of Statistics 2013; Australian Government 2016). Being healthy in many cultures, including Aboriginal and Torres Strait Islander cultures, is not solely related to the physical well-being of an individual. It encompasses the social, emotional, and cultural well-being of the whole community and requires health care to be delivered in a culturally safe and responsive manner (Andary et al. 2003). Cultural safety in healthcare means “to provide care in a manner that is respectful of a person’s culture and beliefs, and that is free from discrimination” (National Aboriginal Community Controlled Health Organisation 2015). Cultural safety demands individuals reflect on their own culture acknowledging the power imbalance brought about by dominant systems and actively seek to ensure no “cultural harm” is done through actions which may impact on individuals and communities. Culturally responsive care expands on the concept of cultural safety and is an extension of patient-centred care. It requires a health professional to reflect and respond appropriately to the unique attributes of the person, family or community with whom they interact, paying particular attention to social and cultural factors (Indigenous Allied Health Australia 2013). In order to deliver QUM within a rural or remote location, it is vital that the health worker familiarizes themselves with the cultures of the population to whom they are providing care. Without understanding and accepting cultural beliefs and differences, patientcentred care and quality use of medicines cannot be achieved. It is the health practitioner’s responsibility to adequately prepare through research and cultural training when working in a location that may not be their usual setting. In particular, alternative treatment methods and traditional healers should be considered and engaged if it is the wish of the patient, family, and community. The role of traditional medicines, their safety, and efficacy have not been explored to the same extent as western medicines. Accepting the patient’s choice of treatment and building a Table 6 Population living in each remoteness area, percent indigenous and non-indigenous, 2011 census

Indigenous population Non-Indigenous population

Major cities 1%

Inner regional 4%

Outer regional 7%

Remote 16%

Very remote 45%

Australia 3%

99%

96%

93%

84%

55%

97%

Source: Australian Bureau of Statistics 2013

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trusting therapeutic relationship to openly share alternative treatment methods will ultimately benefit the patient and decrease the chance of medication misadventures.

Communication Challenges Effective communication is vital in ensuring good health. Poor communication is the most commonly cited reason for poor patient outcomes, including adverse medicine events (Easton et al. 2009). The communication, both oral and written, that occurs between patients and health professionals, prescribers and pharmacists, and between health professionals at the transfer of care is particularly susceptible to errors (Easton et al. 2009). The delivery of health care in rural and remote areas faces additional challenges in relation to communication (Table 7). The communication challenges present significant barriers when discussing complex issues such as treatment decisions. The employment of community health workers to act as community liaisons and cultural guides and use of appropriate resources, such as the Medicines Book for Aboriginal and Torres Strait Islander Health Practitioners and other specially developed tools, can greatly assist in addressing such barriers (Remote Primary Health Care Manuals 2017). Utilizing appropriate interpreter services is extremely important in effective communication rather than relying on family or others who have not received training in providing this service.

Physiological Variations Physiological characteristics, related to pharmacogenomics, pharmacology, and incidence of comorbidities, influence the safety and effectiveness of medicines (Fig. 3) (Ritter et al. 2016). Variations in physiological characteristics can influence whether a person will benefit from a particular medicine or suffer undesired effects (Zhou et al. 2009). People from certain ethnic backgrounds are more likely to have variations in physiological characteristics, which needs to be taken into consideration when initiating, administering or supplying medicines (Pirmohamed and Park 2001). Pharmacogenomics, the study of how genetics affect an individual’s response to medicines, plays an important role in determining the appropriateness of medicines in individual patients (Ritter et al. 2016). Genetic polymorphisms, variations in a person’s genes, are associated with differences in response to medicines. The presence of genetic polymorphisms can result in medication misadventures due to low or elevated drug concentrations, which can lead to treatment failure or dose-related adverse drug effects (Ritter et al. 2016). Polymorphisms can alter the drug concentration achieved in the patient’s body by increasing or decreasing the body’s ability to eliminate the drug. Furthermore, they can also influence drug efficacy through modulation of receptors and ion channels (Pirmohamed and Park 2001).

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Table 7 Additional challenges to communication in rural and remote areas in the Australian setting Challenges Languages spoken

Hearing loss

Health literacy

Cultural practices and beliefs

Rural and remote areas are home to many cultures and languages, including approximately 250 distinct Aboriginal and Torres Strait Islander language groups (Marmion et al. 2014). Many people who live in rural and remote areas do not speak English as a first language and many more are not able to read or write. Aboriginal English and pigeon are simplified forms of English commonly used during cross-cultural communication when there is no language equivalence (Andary et al. 2003; Eades 1991). To communicate effectively, it is crucial to understand basic Aboriginal English and pigeon vocabulary. Using difficult or complicated phrases can confuse and lead to loss of interest People living in remote areas have extremely high rates of hearing loss that affects ability to communicate. It is estimated that approximately 9% of Aboriginal and Torres Strait Islander people have significant hearing problems (Burns and Thomson 2013) Low health literacy is associated with poorer health status, worse outcomes, higher use of health services, increased cost to health-care system and premature death. Low health literacy is associated with a threefold increase in the likelihood of experiencing an adverse outcome (Australian Commission on Safety and Quality in Health Care 2014). It is estimated that almost 60% of Australian adults do not have a level of health literacy adequate to meet the complex demands of everyday life (Australian Bureau of Statistics 2008). While there is no national data on the health literacy of Aboriginal and Torres Strait Islander peoples or those living in rural and remote areas, people from vulnerable or disadvantaged groups are more likely to have low health literacy. It is therefore highly likely that Indigenous peoples and those living in rural and remote areas will have a low level of health literacy, making effective communication regarding health more challenging (Australian Commission on Safety and Quality in Health Care 2014) It is culturally inappropriate for individuals to discuss certain topics with others who are not permitted to possess that knowledge, particularly in relation to men’s and women’s health. Culturally safe and responsive care is vital to ensure effective communication (Andary et al. 2003)

The elimination of medicines from the body occurs via two processes: metabolism and excretion. The clearance of psychotropic medicines predominantly occurs via metabolism in the liver by the Cytochrome P450 (CYP) enzyme system into modified molecules that may or may not be active (Ritter et al. 2016). There are major sources of interindividual variability in the expression and activity of the CYP enzymes as a result of personal and environmental factors. These factors may influence the extent and rate of the metabolism of numerous psychotropics, primarily via CYP enzymes 3A4, 2D6, and 2C19, which are prone to genetic polymorphisms (Table 8) (Ritter et al. 2016; Zhou et al. 2009). The prevalence of pharmacogenomic variations varies between people of different ethnic backgrounds. Medicines and other substances, including dietary intake and cigarette smoke, influence the activity of the CYP enzymes (Ritter et al. 2016). Persons who are poor metabolizers or taking

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Fig. 3 Factors that influence pharmacology of medicines. (Source: adapted from Pirmohamed and Park 2001; Ritter et al. 2016)

medicines that inhibit enzyme activity have decreased enzyme activity, resulting in increased drug concentrations and greater likelihood of dose-dependent adverse effects. On the other hand, persons who are rapid metabolizers or taking medicines that induce enzyme activity have increased enzyme activity, resulting in decreased drug concentrations and greater likelihood of treatment failure (Fig. 4). The prevalence of chronic conditions is increasing nationally and is markedly higher in rural and remote areas, as well as indigenous populations around the world such as the Aboriginal and Torres Strait Islander peoples in Australia (Australian Health Ministers’ Advisory Council 2017; Australian Institute of Health and Welfare 2020). Chronic diseases, such as diabetes, cardiovascular disease, cancer and renal disease, and the medicines used to treat them, may interact with usual pharmacological processes, including drug clearance and distribution. These interactions influence the use of medicines in the management of mental illnesses as they may lead to decreased efficacy or unexpected side effects (Ritter et al. 2016). It is necessary to consider the implication of medicine’s side effect profile on a patient’s existing chronic condition. In particular, the increased risk of many psychotropic medications with metabolic syndromes and weight gain (Lambert 2011).

Translation of Medicinal Trial Data to Clinical Practice Before medicines are available to the public they are required to undergo clinical trials to determine their safety and efficacy (Fig. 5) (FDA 2017). It is not possible to include all people in a clinical trial, so developers of medicines assess the safety and efficacy of a medicine in a sample of individuals. The assumption is that the sample in the trial is representative of the target population, and the medicine will be as safe and as effective in the general population as is it in the sample. However while the general population is a kaleidoscope of individuals from many backgrounds with varied physiological characteristics, medicine trials tend to recruit a select portion of the population with limited spectrum and severity of

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Table 8 Main Cytochrome P450 enzymes involved in metabolism of psychotropic medicines and examples of ethnic variations Cytochrome P450 enzyme

CYP3A4

CYP2D6

CYP2C19

Medicines metabolized

Alprazolam Amitriptyline Aripiprazole Diazepam Haloperidol Imipramine Lurasidone Midazolam Mirtazapine Risperidone Ziprasidone Zolpidem

Amitriptyline Aripiprazole Chlorpromazine Clozapine Duloxetine Fluoxetine Fluvoxamine Haloperidol Imipramine Nortriptyline Olanzapine Paroxetine Risperidone Venlafaxine Zuclopenthixol

Amitriptyline Citalopram Escitalopram Imipramine Phenytoin

Ethnic variations

Poor metabolizers Asian: Generally poor Enhanced metabolizers African American: 60%

Poor metabolizers Caucasian: 6–10% Maori: 6–10% Asian: 0–1%

Poor metabolizers Caucasian: 5–14% African: 0–5% Asian: 0–1% Aboriginal: 25%

Medicines that significantly affect CYP enzyme activity

Induce metabolism Bosentan Carbamazepine Efavirenz Enzalutamide Etravirine Lumacaftor Modafinil Phenytoin Rifampicin St John’s wort Inhibit metabolism Aprepitant Ciclosporin Cimetidine Clarithromycin Diltiazem Erythromycin Fluconazole Fluvoxamine Grapefruit juice Imatinib Itraconazole Ketoconazole Posaconazole Ritonavir Verapamil Voriconazole

Induce metabolism Dexamethasone Rifampin Inhibit metabolism Bupropion Cinacalcet Duloxetine Fluoxetine Methadone Paroxetine Terbinafine

Induce metabolism efavirenz rifampicin ritonavir St John’s wort Inhibit metabolism clarithromycin fluconazole fluoxetine fluvoxamine ketoconazole omeprazole voriconazole

Source: Australian Medicines Handbook 2020; British National Formulary 2020; Griese et al. 2001; Zhou et al. 2009

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comorbidities. Minority groups, particularly First Nations peoples, are underrepresented, which means that it cannot be stated with a great degree of confidence that these medicines are truly safe and effective for them (Hussain-Gambles et al. 2004). Psychotropic medicine trials are significantly different to other medicine trials as the endpoints are not quantified by a definitive physiological measurement. The interpretation of results requires one to be mindful of the following considerations (Table 9):

Fig. 4 Medicine metabolism by Cytochrome P450 enzyme and effect of interactions. (Source: adapted from Australian Medicines Handbook 2020; British National Formulary 2020; Ritter et al. 2016)

Fig. 5 Medicine development process. (Source: adapted from FDA 2017; PhRMA 2015)

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Table 9 Considerations when applying trial data into clinical practice When considering a medicine regimen, it is important to weigh up the medicine effect against the side effect profile for the individual patient’s context Changes in symptom scores, including PANSS and BPRS, and other statistical outcomes frequently used in studies and trials may be more clinically meaningful when converted into number needed to treat and number needed to harm Consider if the trial tests for differences between medicine efficacy and placebo or medicine efficacy and standard reference compound Contrary to common perception, there is an absence of evidence suggesting a class effect for efficacy and tolerability of the conventionally categorized “first-generation or typical” and “second-generation or atypical” antipsychotics. Each medicine needs to be assessed individually for its effectiveness and tolerability

Selection bias

Placebo effect

Publication bias

Dosage

Treatment endpoints and outcome measures

Over the past few decades, there has been a trend of studies and trials excluding patients with higher disease severity. It has then been postulated as one of the reasons the amplitude of medicine effect detected in trials has gradually decreased (Hofer et al. 2000; Rutherford et al. 2014) Antidepressant trials have very prominent placebo effects, leading to a large number of unpublished studies with negative results. However, it does not necessarily mean that antidepressants do not work, as one can argue that they are equally as effective as the placebo. Placebo effect does exist in antipsychotic trials, though to a lesser degree than antidepressants (Rutherford et al. 2014; Rutherford and Roose 2013) A number of studies have recently disclosed researchers and medicine developers withholding clinical trials in the safety and efficacy of antidepressants that do not demonstrate positive outcomes. If these trials were included in meta-analysis and systematic reviews, it is likely the resultant medicine effect would be drastically lower and would potentially affect financial returns. A similar phenomenon is observed for other psychotropic medicines (Page et al. 2014; Turner et al. 2008) Most medicine trials do not use a standardized dose in their subjects. The wide dosage range for antipsychotics makes it difficult to make comparison between trials and translate to clinical practice The frequently used symptom scores, such as Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS), can provide a numerical measurement; however, these outcome assessments are heavily based on subjective reporting. The accuracy of these assessments are influenced by factors, such as inter-assessor variability, environmental influences and intra-patient perceptive variabilities, which makes the accurate interpretation of efficacy and tolerability of psychotropic medicines difficult (Page et al. 2014) (continued)

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Patient variables

Medicine company sponsorship Duration of trials

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Adherence to treatment is a major issue in psychotropic medicines trials. Although one may argue that it’s a true depiction of the real-life setting, the actual medicine effect and tolerability may be under-represented It has been demonstrated that studies sponsored by medicine companies are more likely to achieve better treatment outcomes (Lexchin et al. 2003) Most trials and studies have a short duration, usually a few months. One needs to be careful of drawing conclusions from these studies, as the study result may not be able to be extrapolated into long-term outcomes. This is also true for longterm side effects, such as metabolic syndrome

Practice Implications Health professionals in rural and remote settings often have an extended scope of practice different from urban counterparts that involves increased autonomy in dealing with medicines, including initiation, supply, and administration. As such rural and remote health professionals are required to have advanced level of knowledge and skills to ensure safe and effective use of medicines. The distinctive features of rural and remote practice that influence the safe and appropriate use of medicines in treatment of mental health conditions include decreased access to health services and reliable medicine supply chains, cultural diversity, communication challenges, physiological variations, and translation of medicinal trial data to clinical practice. Dealing with medicines is a complex exercise requiring the application of specific knowledge and skills to treat patients holistically, ensuring consideration is given to comorbidities and other medicines. The use of medicines is a balancing act. Where we are balancing the risks and costs of medicines against the benefits of taking medicines and the consequences of inadequately managed disease. Risks associated with medication use can be minimized through a structured approach to the decision making process, incorporating principles of quality use of medicines, good medicines management framework, best practice and standard treatment guidelines, and use of evidence based resources.

Case Study Case Study 1: Clinical Case

Charles is a 16-year-old man from a traditional Aboriginal background who does not speak the dominant language and has not attended school. Charles has a history of developmental trauma and significant loss with no male role models in his early life. He has used solvents, alcohol, and marijuana for a number of years, and the primary health-care staff suspect he may have some (continued)

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Case Study 1: Clinical Case (continued)

cognitive impairment related to solvents. Charles has already engaged in significant anti-social behavior and has been charged and placed in juvenile detention on a number of occasions. Charles has developed a psychotic illness characterized by blunted affect, thought disorder and distressing auditory hallucinations. Charles’ family believe that his illness results from a series of sorcerous attacks from malevolent spirits and have taken him to a number of traditional healers with some transient symptom relief. Charles’ family are resistant to the prescription of antipsychotic medications. 1. What resources are available in your community to support the patient and family to trial medication? 2. What would be the appropriate management plan? 3. How would you reinforce adherence with patients and families who have a differing disease attribution model? 4. What role do traditional therapies play in the care of a patient with psychosis?

Case Study 2: Access/Supply Issue

Maria is a 34-year-old mother of two young children and is 18 weeks pregnant. The pregnancy was unplanned. She lives and works as an administration assistant in a community 500 km from the closest general hospital and birthing suite. One of her children has recently been diagnosed with an autistic spectrum disorder. There is considerable conflict with her partner though he is reported to be an excellent father. Maria has a past history of recurrent major depression and has been on paroxetine for several years which she has found helpful. Her first episode of depression occurred after the birth of her second child and was characterized by persistent depressed mood, reduced ability to experience pleasure, morbid loss of self-esteem, initial insomnia, some loss of appetite, poor concentration, and transient thoughts of suicide. As there were no counsellors available paroxetine was prescribed and her depressive episode resolved within six weeks. Maria does not want to stop this. Maria comes into the clinic to see her midwife as she is worried her “depression is coming back.” Maria scores 14 on the Edinburgh Post Natal Depression Scale. 1. What would be the appropriate management plan? 2. Is paroxetine a suitable drug in pregnancy? 3. How would you manage a relapse into depression during pregnancy?

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Case Study 3: Refugee

Amena is a young Hazara refugee from Afghanistan who has recently moved to your rural community. Amena speaks limited English and cannot read or write. Amena presents to the health service seeking assistance with significant anxiety relating to events that occurred in Afghanistan. 1. What would be the appropriate management plan? 2. What resources are available to assist? 3. What distinctive features should be considered to ensure safe and effective use of medicines?

Conclusion It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. Sir William Osler, circa 1904 (Bean 1950)

Although psychotropic medicines have transformed the management of mental health conditions, it is imperative for clinicians to not be blinded to the person’s unique context when considering treatment approaches. The use of medicines can have powerful impacts on health outcomes, including dramatic improvements in quality of life and functioning, but they can also be associated with significant harms. The use of medicines is a balancing act. We are balancing the risks and costs of medicines against the benefits. It is important to recognize that not everyone’s risk is the same. The safe and appropriate use of medicines in treatment of mental health conditions requires the assessment of risk in each individual. Rural and remote practice requires the additional consideration of distinctive features, including reduced access to health services and reliable medicine supply chains, culturally safe and responsive practice, communication challenges, physiological variations, and the applicability of trial data. Risks associated with medication use can be minimized through a structured approach to the decision-making process, incorporating principles of quality use of medicines, good medicines management framework, best practice and standard treatment guidelines, and evidence-based resources

Take-Home Messages Use of medicines is a high-risk activity that can have powerful impacts on health outcomes and is associated with harm and death. The safe and appropriate use of medicines in treatment of mental health conditions in rural and remote practice requires the consideration of distinctive features, including reduced access to health services and reliable medicine supply chains,

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culturally safe and responsive practice, communication challenges, physiological variations, and the applicability of trial data. Risks associated with medication use can be minimized through a structured approach to the decision-making process, incorporating principles of quality use of medicines, good medicines management framework, best practice and standard treatment guidelines, and evidence-based resources.

References Andary L, Stolk Y, klimidis S, Klimdis S. Assessing mental health across cultures. Brisbane: Australian Academic Press; 2003. Arora NK, McHorney CA. Patient preferences for medical decision making: who really wants to participate? Med Care. 2000;38(3):335–41. Australian Bureau of Statistics. Health literacy, Australia, 2006. Australia, Canberra; 2008. Retrieved from https://www.abs.gov.au/ausstats/[email protected]/lookup/4102.0main+features20june +2009#endnote1 Australian Bureau of Statistics. Australian aboriginal and Torres Strait islander health survey: first results. Canberra: Australian Bureau of Statistics; 2013. Australian Commission on Safety and Quality in Health Care. Health literacy: taking action to improve safety and quality; 2014. Retrieved from Sydney http://www.safetyandquality.gov.au/ wp-content/uploads/2014/08/Health-Literacy-Taking-action-to-improve-safety-and-quality.pdf Australian Government. Australian indigenous cultural heritage; 2016. Retrieved from http://www. australia.gov.au/about-australia/australian-story/austn-indigenous-cultural-heritage Australian Health Ministers’ Advisory Council. National strategic framework for chronic conditions; 2017. Retrieved from Canberra http://www.health.gov.au/internet/main/publishing.nsf/ content/A0F1B6D61796CF3DCA257E4D001AD4C4/$File/National%20Strategic%20Frame work%20for%20Chronic%20Conditions.pdf Australian Institute of Health and Welfare. Australia’s health 2020: in brief. Australia’s health series no. 17 Cat. no. AUS 232. Canberra: AIHW; 2020 Australian Institute of Health and Welfare. Mental health services in Australia; 2017. Retrieved from Canberra http://mhsa.aihw.gov.au/resources/workforce/ Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2020. Joint Formulary Committee. British National Formulary. London: Pharmaceutical Press. 2020. Bean RB. Sir William Osler: aphorisms from his bedside teachings and writings. New York: Henry Schuman; 1950. Joint Formulary Committee. British National Formulary. London: Pharmaceutical Press. 2020. Burns J, Thomson N. Review of ear health and hearing among Indigenous Australians. Australian Indigenous HealthInfoNet. Perth, WA; 2013. Cardiff L. ASPRINH project prescribing assessment toolkit; 2017. Retrieved from Canberra https:// cdn3.scrvt.com/08ab3606b0b7a8ea53fd0b40b1c44f86/04e28a5e06baf490/d1e8a812ba02/ ASPRINH-Toolkit.pdf Commonwealth Department of Health and Ageing. The national strategy for quality use of medicines. Canberra; 2002. Cutrer WB, Sullivan WM, Fleming AE. Educational strategies for improving clinical reasoning. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):248–57. https://doi.org/10.1016/j.cppeds. 2013.07.005. de Vries T, Henning R, Hogerzeil H, Fresle D. Guide to good prescribing: a practical manual; 1994. Retrieved from Geneva http://apps.who.int/medicinedocs/pdf/whozip23e/whozip23e.pdf Department of Health and Aging. The national strategy for quality use of medicines. Canberra: Commonwealth of Australia; 2002.

25

Quality Use of Psychotropic Medicines in Rural and Remote Setting

577

Diamond R. Drugs and the quality of life: the patient’s point of view. J Clin Psychiatry. 1985;46(5 Pt 2): 29–35. Eades D. Communicative strategies in aboriginal English. In: Romaine S, editor. Language in Australia. Cambridge: Cambridge University Press; 1991. p. 84–93. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing Service. Sydney; 2009. FDA. The drug development process; 2017. Retrieved from https://www.fda.gov/ForPatients/ Approvals/Drugs/ucm405622.htm Griese EU, Ilett KF, Kitteringham NR, Eichelbaum M, Powell H, Spargo RM, . . ., Minchin RF. Allele and genotype frequencies of polymorphic cytochromes P4502D6, 2C19 and 2E1 in aborigines from western Australia. Pharmacogenetics. 2001;11(1):69–76. Hamrosi K, Taylor S, Aslani P. Issues with prescribed medications in aboriginal communities: aboriginal health workers’ perspectives. Rural Remote Health. 2006;6:2. Health Workforce Data. The national health workforce dataset-pharmacy 2015; 2015. Retrieved from Canberra, ACT http://www.health.gov.au/internet/main/publishing.nsf/content/health_ workforce_data Hofer A, Hummer M, Huber R, Kurz M, Walch T, Fleischhacker WW. Selection bias in clinical trials with antipsychotics. J Clin Psychopharmacol. 2000;20(6):699–702. Humphreys J, Wakerman J, Wells R, Kuipers P, Jones J, Entwistle P, Harvey P. Improving primary health care workforce retention in small rural and remote communities – how important is ongoing education & training? Australian Primary Care Research Institute, Australian National University. Canberra; 2007. Hussain-Gambles M, Atkin K, Leese B. Why ethnic minority groups are underrepresented in clinical trials: a review of the literature. Health Soc Care Community. 2004;12(5):382–8. https://doi.org/10.1111/j.1365-2524.2004.00507.x. Indigeneous Allied Health Australia. Position paper: Culturally responsive health care. Deakin West ACT; 2013. Kaminsky BM, Bostwick JR, Guthrie SK. Alternate routes of administration of antidepressant and antipsychotic medications. Ann Pharmacother. 2015;49(7):808–17. https://doi.org/10.1177/ 1060028015583893. Lambert T. Managing the metabolic adverse effects of antipsychotic drugs in patients with psychosis. Aust Prescr. 2011;34:97–9. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ. 2003;326(7400):1167. Lieberman JA, Golden R, Stroup S, McEvoy J. Drugs of the psychopharmacological revolution in clinical psychiatry. Psychiatr Serv. 2000;51(10):1254–8. https://doi.org/10.1176/appi.ps.51.10.1254. Lum I, Mitchell C, Coombes I. The competent prescriber: 12 core competencies for safe prescribing. Aust Prescr. 2013;36:13–6. Lurie SN. Psychological issues in treatment of the “chemical imbalance”. Am J Psychother. 1991;45(3):348–58. Marmion D, Obata K, Troy J. Community, identity, wellbeing:the report of the second national indigenous languages survey; 2014. Retrieved from Canberra ACT https://aiatsis.gov.au/sites/ default/files/products/report_research_outputs/2014-report-of-the-2nd-national-indigenous-lan guages-survey.pdf National Aboriginal Community Controlled Health Organisation. Cultural safety; 2015. Retrieved from http://www.naccho.org.au/promote-health/cultural-safety/ NPS. Competencies required to prescribe medicines: putting quality use of medicines into practice; 2012. Retrieved from Sydney NSW http://www.nps.org.au/_data/assets/pdf_file/0004/149719/ Prescribing_Competencies_Framework.pdf Page MJ, McKenzie JE, Kirkham J, Dwan K, Kramer S, Green S, Forbes A. Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Cochrane Database Syst Rev. 2014;(10):Mr000035. https://doi.org/10. 1002/14651858.MR000035.pub2.

578

T. Speare et al.

PhRMA. Biopharmaceutical research & development: the process behind new medicines; 2015. Retrieved from Washington, DC http://phrma-docs.phrma.org/sites/default/files/pdf/rd_bro chure_022307.pdf Pirmohamed M, Park BK. Genetic susceptibility to adverse drug reactions. Trends Pharmacol Sci. 2001;22(6):298–305. Remote Primary Health Care Manuals. Medicines book for aboriginal and Torres Strait islander health practitioners. 4th ed. Alice Springs: Centre for Remote Health; 2017. Ritter J, Rang H, Henderson G, Henderson G, Flower R. Rang & Dale’s pharmacology, vol. 8. Philadelphia: Elsevier Churchill Livingstone; 2016. Robertson M. An overview of psychiatric ethics; 2012. Retrieved from Gladesvillee NSW http:// www.heti.nsw.gov.au/Global/HETI-Resources/psvchiatry/An%20Overview%20of%20Psychi atric%20Ethics.pdf Rutherford BR, Roose SP. A model of placebo response in antidepressant clinical trials. Am J Psychiatry. 2013;170(7):723–33. https://doi.org/10.1176/appi.ajp.2012.12040474. Rutherford BR, Pott E, Tandler JM, Wall MM, Roose SP, Lieberman JA. Placebo response in antipsychotic clinical trials: a meta-analysis. JAMA Psychiat. 2014;71(12):1409–21. https://doi. org/10.1001/jamapsychiatry.2014.1319. Office of the High Commissioner for Human Rights. Principles for the protection of persons with mental illness and the improvement of mental health care. Geneva, Switzerland; 1991. Retrieved from https://www.who.int/mental_health/policy/en/UN_Resolution_on_protection_of_per sons_with_mental_illness.pdf Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358(3):252–60. https:// doi.org/10.1056/NEJMsa065779. Usher K, Foster K, Bullock S. Psychopharmacology for health professionals. Chatswood: Elsevier; 2009. World Health Organization. How to develop and implement a national drug policy. 2nd ed. Geneva: World Health Organization; 2002. Zhou S-F, Liu J-P, Chowbay B. Polymorphism of human cytochrome P450 enzymes and its clinical impact. Drug Metab Rev. 2009;41(2):89–295. https://doi.org/10.1080/03602530902843483.

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R. Elizabeth Capps, Kurt D. Michael, J. P. Jameson, and Kasey Sulovski

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Youth Mental Health in Rural and Remote Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . School-Based Mental Health Services and Barriers to Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modalities of School-Based Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . School-Based Health Centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . School Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . School-Based Telehealth and Telepsychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effectiveness of School-Based Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Establishing School-Based Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interdisciplinary Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . University-Community Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implications for Prevention and Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Positive Behavioral Interventions and Supports and Multitiered Systems of Support . . . . . Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engaging Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges of Working in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages: Keys for Effective Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment, Support, and Counseling (ASC) Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Youth Experiencing Success in Schools (Y.E.S.S.) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conjoint Behavioral Consultation (CBC) Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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R. E. Capps (*) · K. D. Michael · J. P. Jameson · K. Sulovski Department of Psychology, Appalachian State University, Boone, NC, USA e-mail: [email protected]; [email protected]; [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_27

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Abstract

Approximately one quarter of children and adolescents experience a diagnosable mental health disorder, during the previous year. Though prevalence rates of childhood mental disorders do not differ between rural and nonrural youths, rural youth face barriers to accessing mental health services including a lack of available, accessible, and acceptable mental health services. To address these barriers, school-based psychological services and school mental health (SMH) programs are innovations that increase access to mental health services in rural areas. In this chapter, we outline challenges to establishing effective SMH programs and offer suggestions for navigating them. Firstly, problems related to rural clinician shortages may be ameliorated through the formation of universitycommunity partnerships with an emphasis on interdisciplinary collaboration. Secondly, efficiently delivering effective services that enhance student functioning and well-being may be facilitated through the use of multilevel approaches to intervention and evidence-based practice. Thirdly, family and parent engagement is crucial for positive outcomes in rural areas particularly and may impact both the access to and effectiveness of services. Because these challenges exist to providing school-based mental health services in rural and remote schools, practitioners must carefully consider relationship-building in defining needs, building support for programming, establishing and delivering services, and monitoring the outcomes of services for effective practice in rural schools.

Introduction Mental health disorders impact a significant proportion of children and adolescents in the United States, with 12-month prevalence rates at 25% and lifetime estimates around one-third (Merikangas et al. 2009). While prevalence rates of mental health concerns do not substantially differ between rural and nonrural youth, rural youth experience higher rates of death by suicide (Fontanella et al. 2015) and prescription opioid misuse (Monnat and Rigg 2016). Less than half of youth with diagnosable disorders receive treatment (Merikangas et al. 2009) and this disparity is even starker for young people who reside in rural and remote regions (Inder et al. 2011). One innovation for reducing some of the access barriers is to provide emotional and behavioral health interventions in the context of the school. The status of rural and remote youth mental health and the unique barriers these youth face to accessing effective mental health treatment services will be the initial focus of the chapter. Then, providing school mental health (SMH) services will be discussed as a feasible approach to address the noted barriers and access challenges. Modalities of SMH will be discussed to assist practitioners in understanding diverse methods for delivery of site-based mental health services. We then briefly discuss the evidence base for the effectiveness of school-based services before discussing considerations for establishing school-based mental health services. This chapter then discusses important considerations for working in rural and remote schools,

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including implications for multilevel approaches to prevention, evidence-based delivery of services, and the importance of engaging families in school-based psychological service delivery. The chapter concludes by considering challenges to providing school-based psychological services and by providing recommendations for rural and remote practitioners to effectively establish and deliver schoolbased psychological services.

Youth Mental Health in Rural and Remote Communities In a given year, approximately 13–20% of youths in the United States experience a mental health disorder (National Research Council and Institute of Medicine 2009). Prevalence rates of childhood mental disorders do not differ when comparing rural and non-rural youths (Gamm et al. 2008; Lyneham and Rapee 2007). However, rates of suicide among rural adolescents are greater than rates of suicide among urban adolescents (Fontanella et al. 2015), even though studies have found no differences in rates of suicidal ideation among adolescents in rural and urban communities (Murphy 2014; Albers and Evans 1994). In addition, prescription opioid misuse is more prevalent among adolescents in rural communities when compared to adolescents in large urban communities (Monnat and Rigg 2016). Recent data also indicate that rates of drug overdose deaths among rural residents aged 12 and older have increased and surpassed rates of drug overdose deaths among urban counterparts (Mack et al. 2017). In accounting for these differences, economic disadvantages and isolation due to the geography of rural and remote communities have been implicated as two explanations (Lyneham and Rapee 2007). Thus, generally comparable prevalence rates of youth mental health concerns in rural and nonrural communities along with increased prevalence of youth suicide and opioid misuse in rural communities put the need to address mental health concerns among rural youth in sharp relief. There are, however, significant barriers to accessing mental health services in rural communities (National Research Council and Institute of Medicine 2009) including a lack of available, accessible, and acceptable mental health service providers (Owens et al. 2013). For example, there is a shortage of mental health professionals in rural communities (Ellis et al. 2009), and in particular there is a shortage of mental health professionals with expertise in child and adolescent mental health (New Freedom Commission on Mental Health 2004). When mental health service providers are available in rural communities, long travel distances to access care and inadequate health insurance coverage reduce rural residents’ access to mental health care (McDonnell and Fronstin 1999). Finally, stigma related to mental health concerns and utilizing mental health treatment is a frequently cited barrier in rural communities (Polaha et al. 2015), limiting the acceptability of mental health service utilization. Similarly, concerns about confidentiality, a lack of familiarity with treatment and service options, and difficulty trusting mental health service providers also create significant barriers to seeking mental health treatment in rural areas (Owens et al. 2007).

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Efforts to increase the availability, accessibility, and acceptability of mental health care in rural communities have included innovations to place mental health professionals in existing community agencies and systems. Schools in particular have been implicated as one such viable system given findings that most public schools in the United States have some regular access to a mental health specialist (Foster et al. 2005) and that almost half of children with mental health concerns who receive treatment do so entirely within the school (National Association of School Psychologists [NASP] 2008). Also, school-based mental health interventions may address aspects of schools that are related to youth mental health. For example, current mental health symptoms, including anxiety and depression symptoms, have been found to be correlated with school connectedness, and school connectedness has been found to predict symptoms of depression in sample of 2002 Australian adolescents (Shochet et al. 2006). In addition, because youth spend a significant amount of time at school from childhood to adolescence and that students’ mental health is related to their school success (Carey 2017), school-based mental health programming is a natural outlet for improving youth functioning. Further, schools are a key setting for mental health programming in rural communities (Macgarvey 2005) and are the most frequently utilized mental health service providers for rural children and adolescents (Lyneham and Rapee 2007). In particular, programs that fall under the umbrella term of school-based mental health services (Weist 1997) are innovations aimed at overcoming barriers to mental health service utilization for children, adolescents, and families.

School-Based Mental Health Services and Barriers to Utilization School-based mental health services may address many of the barriers to utilizing mental health services in rural communities and have been found to increase access to mental health services in rural areas and in areas where mental health treatment is limited (Owens et al. 2013). In practice, school-based services have been found to increase access and utilization of mental health services with evidence indicating that 98% of students receive mental health services when they are provided in the school setting compared to 17% of students who actually receive mental health services when referred to an outside clinic (Catron and Weiss 1994). Increased access to services is likely the result of the ways that school-based mental health services address barriers common in rural communities (Michael et al. 2009; Owens et al. 2008). To address barriers of accessibility and acceptability, students may conveniently and privately access school-based mental health services during the course of a school day without requiring additional travel. School-based psychological services are also a feasible option for rural families who have concerns about stigma, financial difficulties, and transportation issues that keep them from utilizing community providers (Owens et al. 2013). These services also provide costeffective methods for rural schools to provide their students with needed services not otherwise available in the community (Lee et al. 2017) that can be effecitvely delivered by teachers in the school (Franklin et al. 2012).

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Modalities of School-Based Mental Health Services School-based psychological services can provide a variety of mental health services to students, including early screening and identification of mental health concerns; mental health promotion and prevention programming; early and indicated intervention and crisis management; and consultation services to parents, teachers, and other school staff (Eckert et al. 2017). These services may be provided with varying emphases and scopes via several common modalities of school-based programming. Each model has its own strengths and weaknesses, and care should be taken to consider the resources and needs of each community when selecting an approach.

School-Based Health Centres School-based health centers (SBHCs) incorporate a multidisciplinary staff of providers, including nurses, doctors, and mental health professionals, with services encompassing both physical and mental health concerns, including primary care, health education, dental health services, and mental health services (National Assembly on School-Based Health Care [NASBHC] 2002; Strozer et al. 2010). Despite the broad spectrum of services offered, mental health frequently accounts for a significant proportion of services rendered. It is estimated that mental health referrals account for one-third to one-half of total referrals (Center for Health and Healthcare in Schools 2001). Thus, SSBHCs require additional investment in mental health services and mental health integration to respond to such needs.

School Mental Health School mental health programs (SMH; Michael et al. 2009), which were easier and more affordable to develop than SSBHCs, were developed as a method of addressing student mental health concerns due to a large proportion of SSBHC services utilized for mental health concerns (Flaherty et al. 1996). By design, SMH programs aim to enhance student well-being by providing services to promote emotional, behavioral, social, and academic functioning (Anderson-Butcher et al. 2017). To accomplish these aims, SMH incorporates a three-level approach to intervention incorporating universal, selective, and indicated intervention strategies. Universal interventions include strategies to prevent the development of mental health problems and enhance well-being across students. With a focus on students at risk of, and displaying, early signs of mental health concerns, selective interventions incorporate early intervention strategies to prevent the escalation of more intensive need. Students identified at a greater need for mental health services and support are assisted using indicated interventions of intensive and extensive strategies and supports. In rural communities, SMH providers often provide a range of mental health services across the continuum of care, including prevention programming, mental health screening and assessment, and intervention (Owens et al. 2013) across all three levels of

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intervention. However, SMH programs require a trained workforce able to adequately respond to mental health needs, which rural communities may not have available. In addition, when such staff are available in rural communities, SMH programs may divert service providers from the community in order to provide mental health services to students and families in the school.

School-Based Telehealth and Telepsychology Telehealth refers to the use of telecommunication technologies and electronic information to establish health care, health-related education, health administration, and public health over long distances (Health Resources and Services Administration [HRSA] 2015). Common telehealth methods include video conferencing, streaming media, and terrestrial and wireless communications. As a result, school-based telehealth clinics have begun to be established in rural communities to increase the availability and accessibility of health care providers (Burke et al. 2008). Telepsychology, or the use of the telehealth technology of real-time videoconferencing to provide psychological services (Nelson and Bui 2010), has been indicated as an innovation well suited to address barriers to utilizing mental health services in rural communities (Frueh 2015; Benavides-Vaello et al. 2013). Telepsychology can incorporate both psychological assessment and intervention with a variety of mental health concerns, though advantages and disadvantages compared to face-to-face psychological services are not well-studied (Nelson and Bui 2010). Implementing school-based telepsychology in rural schools has the potential to decrease stigma and increase access to faster, more specialized, and comprehensive services (Nelson and Bui 2010). However, establishing telepsychology requires both the psychologist and school-based clinic coordinators being proficient in the technology and having the knowledge of local referral sources, such as local crisis response and management agencies (Nelson and Bui 2010). In addition, both the school-based coordinator and remote psychologist must clearly discuss expectations and roles to anticipate concerns. Costs associated with establishing and sustaining school-based telepsychology technologies and software must also be considered. Technologies and software should be selected in terms of HIPAA-compliance and what is necessary for service delivery.

Effectiveness of School-Based Services A growing evidence base supports the effectiveness of school-based mental health services. SMH programs have been found effective in reducing problematic externalizing and internalizing behaviors and enhancing protective factors related to emotional distress (Fox et al. 1999) and emotional and behavioral symptoms by parent- and teacher-report (Sander et al. 2011). SMH services have also been found to be effective in reducing psychological symptoms (Albright et al. 2013; Kirk et al. 2018; Michael et al. 2013, 2016) including symptoms of adolescent depression

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(Shirk et al. 2009), symptoms of anxiety and depression associated with bullying (Berry and Hunt 2009), symptoms related to hyperactivity and impulsivity (Owens et al. 2008), symptoms of posttraumatic stress (Hansel et al. 2010), increasing positive self-esteem (Kahn et al. 1990), increasing positive social behaviors, including better family functioning (Mufson et al. 2004), and performing better academically (Fox et al. 1999; Sander et al. 2011; Michael et al. 2013). Important for rural communities, evidence indicates promising results of school-based assessment and management of suicidal risk using a protocol specific to the school context (Capps et al. 2019). Thus, evidence supports the implementation of school-based psychological services being able to effectively reduce psychological symptoms associated with poorer student functioning and enhance factors associated with positive student well-being.

Establishing School-Based Mental Health Services Establishing school-based mental health programs requires careful attention to both the needs of school and community members and relationship building with school and community members to determine what services are needed and what services may be acceptably delivered within the school (Hansel et al. 2010). Accomplishing these tasks to establish acceptable, effective, and sustainable SMH and school-based psychological services may be greatly aided through the development of two assets: interdisciplinary collaboration and university-community partnerships.

Interdisciplinary Collaboration Providing psychological services in the school setting allows for the opportunity to establish interdisciplinary collaboration for more well-rounded and comprehensive care. Indeed, interdisciplinary collaboration among school and health professionals lends itself well to the pursuit of facilitating students’ success in school via emotional and behavioral health services (Michael et al. 2014). Unique to schools, collaborating with teachers in the delivery of mental health services is especially important given that teachers are prominently positioned to promote student well-being in the school context (Carey 2017) and have been found to effectively deliver school-based interventions (Franklin et al. 2012), particularly for internalizing concerns (Franklin et al. 2017). Effectively accomplishing collaboration among professionals in the mental health, health, and education systems in this way requires an integration of services to avoid duplication and fragmentation of services (Michael et al. 2014), an openness to learning about differing perspectives and what these perspective may add to the provision of services (Mellin and Weist 2011), and integration and coordination across partners (Michael et al. 2014). Interdisciplinary collaboration is particularly useful in rural schools where resources may be low and staff may be serving multiple roles.

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However, there are challenges to establishing and maintaining effective integration of services and collaboration among professionals of different fields. First, school-based mental health services encompass different demands and expectations when compared to traditional mental health settings (Michael et al. 2014). For example, school-based mental health professionals may not have a traditional private office with concrete boundaries surrounding students’ and other personnel’s access, confidentiality, scheduled meetings, and session lengths (Michael et al. 2014). As a result, school-based mental health professionals must operate with a level of flexibility. Second, school-based mental health professionals must adequately address aspects of student functioning that manifest in the school setting as a result of mental health concerns (Michael et al. 2014). However, at the same time school-based mental health must also balance the demands of school and the demands of treatment (Michael et al. 2014). For example, individuals suffering from anxiety frequently avoid anxiety-provoking situations, which in the context of school-based treatment may manifest in the form of excessive absences related to school avoidance. With accumulated absences come the loss of class instruction time, and persistent absences may lead to class failure and even school dropout. While schools typically require regular class attendance and participation in the learning environment, the demands of school-based treatment require regular attendance and participation in treatment sessions that occur during the school day (and in place of class attendance). Thus, it is essential for school-based mental health professionals to address both anxiety symptoms and school refusal to enhance student well-being and functioning. Utilizing the knowledge and resources of school professionals is essential in addressing students’ educational needs and health. In the example of excessive persistent school absences related to anxiety, this might include collaborating with teachers to negotiate treatment meeting times that do not persistently detract from class attendance and collaborating with school administration and school counselors to address attendance issues with parents.

University-Community Partnerships School-based service providers working in partnership with universities may address several challenges to establishing and sustaining rural school-based mental health programs and enhancing the quality of services (Owens et al. 2013). Universitycommunity partnerships can bring to bear resources for school-based psychological services that may not otherwise be available. This can include utilizing SMH programs as training opportunities, whereby supervised graduate students deliver services while gaining experience to grow the SMH workforce. Additionally, university faculty and students can provide professional development for teachers and service providers and deliver consultation services for school-based mental health professionals (Owens et al. 2011). University partners may also assist school providers with the collection of program functioning and outcomes data, evaluation of needs and service outcomes to enhance the quality of services, and dissemination of findings to inform other rural school-based and SMH services (Owens et al. 2011;

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Owens and Murphy 2004). In addition, SBHCs may partner with medical and health science programs to staff their sites and provide primary care training to nursing and other health professional students who are also trained in evidence-based mental health interventions (Grossman et al. 2007).

Implications for Prevention and Intervention In addition to the treatment of existing emotional and behavioral issues, schoolbased psychological services often incorporate both prevention and early intervention programming. As previously mentioned, these school-based prevention and early intervention strategies are often implemented in a three-level approach of universal, selective, and indicated interventions (Anderson-Butcher et al. 2017). This multilevel approach to prevention and intervention services is well suited for rural schools where resources are often limited. There are varying models of multilevel approaches to school-based services, including Positive Behavioral Interventions and Supports (PBIS), Multi-Tiered Systems of Support (MTSS), and the Response to Intervention (RtI) model. However, selection of any intervention practice in the context of the school must carefully consider the appropriateness for the school environment and for a particular school, the school culture, and attitudes towards a particular treatment. Finally, effective school-based psychological services rely heavily on parent engagement for enhancing student well-being and establishing and sustaining school-based services.

Positive Behavioral Interventions and Supports and Multitiered Systems of Support PBIS is defined as “a framework for delivering both the whole-school social culture and additional tiers of behavior support intensity needed to improve educational and social outcomes for all students” (Horner and Sugai 2015, p. 80). In other words, PBIS is a multitiered approach devoted to changing behavior in students to improve their school experience. PBIS’s universal tier focuses on the creation of a schoolwide positive social culture (Horner and Sugai 2015). Specifically, the universal tier includes defining and imparting a set of behavioral expectations to students; generating a method for reinforcing these expected behaviors; implementing a reliable system for interrupting, correcting, and redirecting deviations from set behavioral expectations; and creating an efficient method to obtain and utilize data for further decision-making. The MTSS model expands on the RtI model to include resources to address students’ social and emotional needs in addition to academic supports. MTSS includes an evidence-based model of education that utilizes data-based problemsolving techniques to combine academic and behavioral direction and intervention to promote student well-being and functioning (Eagle et al. 2015). MTSS focuses on the universal implementation of interventions and the parallel delivery of

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interventions tied to at least three tiers of increasing support intensity (Horner and Sugai 2015). Tier I interventions are universal, meaning all students experience an evidence-based practice to promote well-being that is provided throughout the school. For example, universal interventions may include universal school-wide screening for behavioral, emotional, or academic problems and school-wide intervention programming, such as PBIS (Sulkowski and Michael 2014). Tier II serves approximately 10–15% of students for whom Tier I supports do not sufficiently meet their emotional and behavioral health needs. In the second tier, students are given more individual attention directed toward their personal needs. Tier II supports may include a systematic evaluation to determine the function of an identified behavioral concern, or a more comprehensive multitrait, multisetting, multiinformant assessment battery to better identify the nature of what is contributing to a behavioral or emotional concern (Sulkowski and Michael 2014). Selective interventions in this tier may also include group therapy or counseling approaches or less invasive individual interventions. Tier III is designed to monitor whether a plan is implemented and effective for an individual student. This high-intensity support is estimated to be needed by approximately 5% or less of students (Horner and Sugai 2015). Supports at this tier would include more intensive individualized interventions such as individual evidence-based therapy provided by a school-based practitioner (Sulkowski and Michael 2014). MTSS includes data-based decision making, evidence-based interventions, implementation fidelity, and systematic problem solving (Eagle et al. 2015). Data-based decision making entails universal screening for all students, the implementation of evidenced-based interventions throughout the tiers, and continuous progress monitoring to inform future direction for student supports at each tier. MTSS frequently serves as an overarching framework that connects the emotional, social, and behavioral supports of comprehensive PBIS and the academic supports characterizing RtI into a single, unified process. Rural Implementation. PBIS and MTSS are viable frameworks for service delivery in rural schools. In particular, PBIS serves as an effective means for teachers to implement an evidence-based practice tailored toward behavioral change (Fitzgerald et al. 2014). Utilizing teachers as a major implementer of school-based mental health services is particularly useful in under-resourced rural schools where mental health professionals are in short supply. MTSS in particular is well suited for students in rural schools because the students may receive services regardless of ability to pay (Fitzgerald et al. 2014). In addition, because rural schools tend to have fewer students, there is a greater opportunity for more individualized attention and services (Jimerson 2006). In addition, a multilevel approach incorporating schoolwide universal prevention and early intervention may be a cost-effective way to promote student well-being to reduce the development of greater impairment due to mental health concerns that necessitate more costly interventions. However, MTSS may be limited in rural areas given deficits in school finances and resources; a lack of time or personnel for effective implementation; a lack of space in school buildings to implement interventions outside of the classroom; and allocation of staff to additional and non-traditional roles for which they may not have the time or expertise to fulfill (Eagle et al. 2015; Fitzgerald et al. 2014). Schools in

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rural districts often have difficulty recruiting and retaining highly qualified teachers due to lower salaries and other limited opportunities available within more remote areas (Robinson, Bursuck, and Sinclair, 2013). Teachers chosen to implement the new protocols are those who are deemed most fit to do so, not by title, but by who is best to lead by example and to promote the core values of the evidence-based approach (Eagle et al. 2015). Thus, an inadequate or undertrained teacher workforce may be a barrier to MTSS implementation in rural schools. Finally, poverty and residential instability for students in rural schools may make MTSS and multilevel approaches difficult (Fitzgerald et al. 2014).

Evidence-Based Practice While school-based mental health services include a variety of interventions and services with evidence of effectiveness, not all school-based mental health practices may be described as being evidence-based (Hyde et al. 2003; Rones and Hoagwood 2000). Evidence-based practice (EBP) refers to a service delivery approach whereby providers utilize and incorporate empirical evidence, clinical expertise, and the values and preferences of those receiving services (Society for Clinical Child and Adolescent Psychology; Weist et al. 2014). There are a variety of evidence-based prevention and intervention practices specifically developed and tested for effectiveness for SMH and school-based programming (Weist et al. 2014). EBP also incorporates a wide variety of emphases in relation to SMH including across school-ages and development; across providers, including school social workers, psychologists, school nurses, school counselors, and related personnel; across emotional and behavioral health concerns; and spanning the continuum of care (e.g., assessment, prevention, promotion, intervention; Weist et al. 2014). However, increased effort is warranted to identify EBPs with demonstrated effectiveness in rural schools and communities given the differences between rural and nonrural areas and among rural communities (Carey 2017; see Michael and Jameson 2017 for discussion of rural treatment considerations for specific mental health disorders). While adapting current EBP for child and adolescent mental health concerns is a viable option for providing effective SMH and school-based services, there is a greater need for adding to the evidence base of effective and acceptable practices specific to rural schools.

Engaging Families A crucial consideration for rural school-based prevention programming is parent and family engagement in the delivery of services (Waguespack et al. 2012), especially given that a potential disadvantage of school-based services is reduced parental involvement. Engaging families in school-based programming requires establishing a collaborative and trusting relationship and effectively communicating to reduce barriers such as cultural differences, differences in expectations, and differences in

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history (Minke 2006). Parent and family engagement with school-based prevention at all levels is key to promoting youth well-being and generalizing change across the school and home environment, and it is therefore recommended that family members be included in the planning, implementation, and evaluation of school-based programming (Waguespack et al. 2012). Parental engagement is also important to the delivery of school-based psychological interventions, especially for younger children who rarely self-refer for services and for whom services usually include parent involvement (Lyneham and Rapee 2007). First, providing psychological services to students requires consent from parents or guardians. Consent for services typically requires parental identification of a mental health concern and subsequent identification of a need for help (Lyneham and Rapee 2007). Once parents or guardians provide consent, adequate engagement and involvement in the delivery of services is important for positive outcomes (Curtin et al. 2017). Thus, it is imperative to thoughtfully discuss the rationale for, and benefits of, services with parents while also being sensitive to parents’ perspectives and values. Additional strategies for increasing parents’ buy-in and reducing stigma might include referring to “counseling” or “services” rather than “psychotherapy” and underscoring the convenience of services that do not require additional transportation (Curtin et al. 2017). Meeting in-person with parents or guardians to have these discussions as part of gaining consent for services may be beneficial to enhancing parent engagement so long as discussions are open and school-based professionals facilitate communication with parents in an understandable way (Curtin et al. 2017). In addition, bringing a trusted member of the school staff into such discussions may be beneficial in better addressing parents’ concerns about services and increasing parents’ engagement.

Challenges of Working in Schools One major challenge to providing school-based psychological services in rural settings is meeting the cost of the provision of services with limited school and education budgets (Crockett 2012). Also, rural school-based programming may be challenged by a lack of school-based providers, whether that be a lack of licensed psychologists, nurse practitioners, psychiatrists, licensed professional counselors, or other service providers (Siceloff et al. 2017). While university-community partnerships and taking advantage of interdisciplinary collaborations may address this challenge, a shortage of school-based providers may cause a delay or gaps in the provision of school-based services (Siceloff et al. 2017). Finally, effective implementation and sustainability of school-based psychological services may be hindered if school administrators do not embrace school-based programming (Crockett 2012). As a result, time and attention must be paid to relationship-building with school and community members prior to implementing school-based services (Hansel et al. 2010). Such efforts may even address practical challenges to providing school-based services, such as finding a space to meet with

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students within the school, allowing students to be taken out of class for services, and pulling students out of class to meet in the most minimally intrusive way (Hansel et al. 2010).

Concluding Comments and Recommendations Providing SMH and school-based psychological services in rural and remote schools is an effective and practical innovation to overcome the barriers rural and remote students face in receiving accessible and acceptable mental health care. However, implementing and delivering school-based mental health programming requires careful attention and consideration to the beliefs, attitudes, and needs of the rural school staff, families, and students who the practitioners aim to serve. Also, delivering effective services that address identified needs in rural schools may be enhanced using multilevel approaches to prevention and intervention as well as EBP to improve youth functioning and well-being, though the evidence of effectiveness of such practices specifically in rural schools needs further examination. Accomplishing these aims may be difficult in rural and remote communities given limited resources and limited availability of mental health professionals. However, by taking advantage of available resources through collaborations between universities and communities and between health professionals from various backgrounds, barriers may be reduced to some extent to provide effective and sustainable schoolbased psychological services. Finally, school-based practitioners are encouraged to spend time and attention engaging parents and families in the process of identifying youth mental health needs and in the process of providing psychological services to improve outcomes. While challenges may exist to working in schools, these may be at least partially mitigated when practitioners intentionally cultivate relationships between school staff, parents, and families, community health providers, and universities to enhance available resources and provide effective mental health programming and services to promote youth well-being.

Take Home Messages: Keys for Effective Practice • Cultivate relationships between school staff members and families to identify needs as well as feasible and acceptable methods for addressing needs. • Take advantage of available resources through university-community partnerships and interdisciplinary collaborations to develop, deliver, and monitor the effects of school-based psychological services for sustainable and improved services. • Utilize multilevel approaches to prevention and intervention and EBP to improve the outcomes of school-based mental health programming. • Engage parents and families in program development and in the delivery of psychological services to improve the effectiveness of services and enhance youth well-being.

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Case Studies Assessment, Support, and Counseling (ASC) Center The Assessment, Support, and Counseling (ASC) Center is a school mental health program serving three high schools in rural North Carolina (Michael et al. 2009). Formed as a university-school partnership between Appalachian State University and three respective county schools, the ASC Center makes use of interdisciplinary collaboration, staffing its program with clinical psychology, marriage and family therapy, and social work graduate students supervised by two doctoral level licensed psychologists and with a master’s level licensed psychologist and a licensed school social worker serving as program coordinators. Service providers at the ASC Center regularly collaborate with school administration, teachers, school counselors, and school nurses to deliver evidence-based psychological assessment, intervention, and prevention services. ASC Center staff regularly seek to engage families in the provision and delivery of services. In addition, ASC Center service outcomes are evaluated every school year to monitor outcomes and improve services. Such evaluations have found that ASC services are effective in reducing psychological symptoms (Albright et al. 2013; Michael et al. 2013) and improving academic performance (Michael et al. 2013) among students served.

Youth Experiencing Success in Schools (Y.E.S.S.) Program Youth Experiencing Success in Schools (Y.E.S.S.) Program provided evidencebased intervention to improve the academic and behavioral functioning of elementary-aged children with inattentive and disruptive behavior problems in the school setting (Owens et al. 2005). The Y.E.S.S. Program functioned through a university-community partnership between Ohio University and several school districts in rural Ohio. As such, graduate student clinicians-in-training provided Y.E.S.S. Program services along with school counselors and school social workers. The Y.E.S.S. Program also actively addressed parent engagement by providing parent support meetings and parenting groups in its goal to improve collaboration between home and school for student well-being. Evaluation of Y.E.S.S. service outcomes have found services effective in reducing inattentive and disruptive behaviors and improving peer relationships and academic functioning among students served (Owens et al. 2005).

Conjoint Behavioral Consultation (CBC) Model Conjoint behavioral consultation (CBC; Sheridan and Kratochwill 2008) provides evidence-based indirect intervention that promotes partnerships between parents and schools to reduce behavior problems in children. In CBC, parents and teachers together plan and implement behavioral intervention plans under the guidance of

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trained specialists. Through this collaboration, family engagement is actively enhanced to promote child well-being both at home and at school. Evaluation of CBC has demonstrated its efficaciousness in reducing children’s mental and behavioral health concerns and enhancing family and school capacity to address such concerns collaboratively, including in rural schools (Holmes et al. 2017).

References Albers E, Evans W. Suicide ideation among a stratified sample of rural and urban adolescents. Child Adolesc Soc Work J [serial on the Internet]. 1994 [cited 2018 Jan 20];11(5):379–89. Available from: Social Work Abstracts. Albright A, Michael K, Massey C, Sale R, Kirk A, Egan T. An evaluation of an interdisciplinary rural school mental health programme in Appalachia. Adv School Ment Health Promot [serial on the Internet]. 2013 [cited 2018 Jan 20];6(3):189–202. Available from: ERIC. Anderson-Butcher D, Hoffman J, Rochman DM, Fuller M. General and specific competencies for school mental health in rural settings. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Benavides-Vaello S, Strode A, Sheeran B. Using Technology in the Delivery of Mental Health and Substance Abuse Treatment in Rural Communities: A Review. J Behav Health Ser R [Internet]. 2013 Jan [cited 2020 Jun 26];40(1):111–20. Available from: https://search-ebscohost-com.proxy. library.ohio.edu/login.aspx?direct=true&db=bth&AN=85385789&site=eds-live&scope=site Berry K, Hunt C. Evaluation of an intervention program for anxious adolescent boys who are bullied at school. J Adolesc Health [serial on the Internet]. 2009 [cited 2018 Jan 20];45(4):376– 82. Available from: PsycINFO. Burke B, Bynum A, Hall-Barrow J, Ott R, Albright M. Rural school-based telehealth: how to make it happen. Clin Pediatr [serial on the Internet]. 2008 [cited 2018 Jan 20];47(9):926–9. Available from: PsycINFO. Capps RE, Michael KD, Jameson JP. Lethal means and adolescent suicidal risk: An expansion of the peace protocol. J Rural Ment Health [Internet]. 2019 Jan [cited 2020 Jun 26];43(1):3–16. Available from: https://search-ebscohost-com.proxy.library.ohio.edu/login.aspx?direct=true& db=psyh&AN=2019-06780-002&site=eds-live&scope=site Carey TA. Why would teachers care? The value of rural school mental health from an educator’s standpoint. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Catron T, Weiss B. The Vanderbilt school-based counseling program: an interagency, primary-care model of mental health services. J Emot Behav Disorders [serial on the Internet]. 1994 [cited 2018 Jan 20];2(4):247. Available from: Academic Search Complete. Center for Health and Healthcare in Schools. School-Based Health Centers: Results From a 50 State Survey. School Year 1999–2000. Washington, DC: George Washington University; 2001 Crockett J. ‘There’s nothing the *@#! Wrong with me’: youth mental health and substance use in rural and remote Australia and the potential role of school-based interventions. Youth Stud Aust [Internet]. 2012 [cited 2017 Dec 16];31(1):53–9. Available from: PsycINFO. Curtin L, Massey C, Keefe SE. Intergenerational and familial influences on mental illness in rural settings and their relevance for school mental health. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Eagle J, Dowd-Eagle S, Snyder A, Holtzman E. Implementing a Multi-Tiered System of Support (MTSS): collaboration between school psychologists and administrators to promote systemslevel change. J Educ Psychol Consult [serial on the Internet]. 2015 [cited 2018 Jan 20];25: 160–77. Available from: Academic Search Complete. Eckert MD, Nishimura ST, Oka L, Barber S, Fleming L, Hishinuma ES, et al. A pilot school-based rural mental health consultation program utilizing an innovative stakeholder partnership at a

594

R. E. Capps et al.

diverse elementary school. J Rural Ment Health [Internet]. 2017 [cited 2017 Dec 16];41(4): 265–83. Available from: PsycINFO. Ellis A, Konrad T, Thomas K, Morrissey J. County-level estimates of mental health professional supply in the United States. Psychiatr Serv [serial on the Internet]. 2009 [cited 2018 Jan 31];60 (10):1315–22. Available from: PsycINFO. Fitzgerald C, Geraci L, Swanson M. Scaling up in rural schools using positive behavioral interventions and supports. Rural Special Educ Q [serial on the Internet]. 2014 [cited 2018 Jan 20];33 (1):18–22. Available from: CINAHL Complete. Flaherty L, Weist M, Warner B. School-based mental health services in the United States: history, current models and needs. Community Ment Health J [serial on the Internet]. 1996 [cited 2018 Jan 20];32(4):341–52. Available from: PsycINFO. Fontanella C, Hiance-Steelesmith D, Phillips G, Bridge J, Lester N, Campo J, et al. Widening ruralurban disparities in youth suicides, United States, 1996–2010. JAMA Pediatr [serial on the Internet]. 2015 [cited 2018 Jan 20];169(5):466–73. Available from: CINAHL Complete. Foster S, Rollefson M, Doksum T, Noonan D, Robinson G. Teich, School mental health services in the United States, 2002–2003 [Internet]. Rockville, MD: U.S. Department. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2005; 2005 [cited 2020 Jun 21]. (DHHS publication: no. (SMA) 054068). Available from: https://search-ebscohost-com.proxy.library.ohio.edu/login.aspx?direct= true&db=edsgpr&AN=edsgpr.000610117&site=eds-live&scope=site Fox N, Leone P, Rubin K, Oppenheim J, Miller M, Friedman K. Final report on the linkages to learning program and evaluation at broad acres elementary school [Internet]. College Park: University of Maryland; 1999 [cited 2018 Jan 20]. Available from: http://www.montgomer yschoolsmd.org/uploadedFiles/FinalReport-LTL-Program-and-Evaluation-atBroadAcresES.pdf Franklin CGS, Kim JS, Ryan TN, Kelly MS, Montgomery KL. Teacher involvement in school mental health interventions: A systematic review. Child Youth Serv Rev [Internet]. 2012 May 1 [cited 2020 Jun 26];34(5):973–82. Available from: https://search-ebscohost-com.proxy.library.ohio.edu/ login.aspx?direct=true&db=edselp&AN=S0190740912000503&site=eds-live&scope=site Franklin C, Kim JS, Beretvas TS, Zhang A, Guz S, Park S, et al. The Effectiveness of Psychosocial Interventions Delivered by Teachers in Schools: A Systematic Review and Meta-Analysis. Clin Child Fam Psychol Rev [Internet]. 2017 Sep [cited 2020 Jun 26];20(3):333–50. Available from: https://search-ebscohost-com.proxy.library.ohio.edu/login.aspx?direct=true&db=mnh& AN=28493176&site=eds-live&scope=site Frueh B. Solving mental healthcare access problems in the twenty-first century. Aust Psychol [serial on the Internet]. 2015 [cited 2018 Jan 20];50(4):304–6. Available from: PsycINFO. Gamm L, Stone S, Pittman S. Mental health and mental disorders: a rural challenge: a literature review. Rural healthy people 2010: a companion document to healthy people 2010, vol. 2. College Station: The Texas A & M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center; 2008. Grossman J, Laken M, Stevens J, Hughes-Joyner F, Sholar M, Gormley K. Use of psychiatric nurse practitioner students to provide services in rural school-based health clinics. J Child Adolesc Psychiatr Nurs [Internet]. 2007 [cited 2017 Dec 16];20(4):234–42. Available from PsycINFO. Hansel TC, Osofsky HJ, Osofsky JD, Costa RN, Kronenberg ME, Selby ML. Attention to process and clinical outcomes of implementing a rural school-based trauma treatment program. J Trauma Stress [Internet]. 2010 [cited 2017 Dec 16];23(6):708–15. Available from: PsycINFO. Health Resources & Services Administration. Telehealth programs [Internet]. USA: Health Resources & Services; 2015 [cited 2017 Dec 16]. Available from: https://www.hrsa.gov/ruralhealth/telehealth/index.html Holmes SR, Witte AL, Sheridan SM. Conjoint behavioral consultation in rural schools. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Horner R, Sugai G. School-wide PBIS: an example of applied behavior analysis implemented at a scale of social importance. Behav Anal Pract [serial on the Internet]. 2015 [cited 2018 Jan 8];

26

Providing School-Based Mental Health Services in Rural and Remote Settings

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8(1):80–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048248/pdf/ 40617_2015_Article_45.pdf Hyde P, Falls K, Morris J, Schoenwald S. Turning knowledge into practice: a manual for behavioral administrators and practitioners about understanding and implementing evidence-based practices. Boston: The Technical Assistance Collaborative; 2003. Inder KJ, Berry H, Kelly BJ. Using cohort studies to investigate rural and remote mental health. Aust J Rural Health [serial on the Internet]. 2011 [cited 2018 Jan 30];19(4): 171–8. Available from: PsycINFO. Jimerson L. The hobbit effect: why small works in public schools. Rural Trust Policy Brief Ser Rural Educ [Internet]. 2006 [cited 2018 Jan 8]. Available from: ERIC Kahn J, Kehle T, Jenson W, Clark E. Comparison of cognitive-behavioral, relaxation, and selfmodeling interventions for depression among middle-school students. School Psychol Rev [serial on the Internet]. 1990 [cited 2018 Jan 20];19(2):196–211. Available from: ERIC. Kirk A, Michael K, Bergman S, Schorr M, Jameson JP. Dose response of cognitive-behavioral therapy in a school mental health program. Cogn Behav Ther [Internet]. 2018 [cited 2020 June 26];1–20. Available from: https://doi.org/10.1080/16506073.2018.1550527 Lee YY, Barendregt JJ, Stockings EA, Ferrari AJ, Whiteford HA, Patton GA, Mihalopoulos C. The population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia. Epidemiol Psychiatr Sci [serial on the Internet]. 2017 [cited 2018 Jan 30];26(5):545–64. Available from: MEDLINE. Lyneham H, Rapee R. Childhood anxiety in rural and urban areas: presentation, impact and help seeking. Aust J Psychol [serial on the Internet]. 2007 [cited 2018 Jan 31];59(2):108–118. Available from: PsycINFO. Macgarvey A. Rural youth education and support program: the Casterton experience. Rural Soc [serial on the Internet]. 2005 [cited 2018 Jan 20];15(2):133–47. Available from: ERIC. Mack K, Jones C, Ballesteros M. Illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas – United States. Morb Mortal Wkly Rep Surveill Summ (Washington, DC: 2002) [serial on the Internet]. 2017 [cited 2018 Jan 20];66(19):1–12. Available from: MEDLINE. McDonnell K, Fronstin P. EBRI health benefits databook. Washington, DC: Employee Benefit Research Institute; 1999. Mellin E, Weist M. Exploring school mental health collaboration in an urban community: a social capital perspective. School Mental Health [serial on the Internet]. 2011 [cited 2018 Jan 20];3 (2):81–92. Available from: PsycINFO. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci [serial on the Internet]. 2009 [cited 2018 Jan 30];11 (1):7–20. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807642/pdf/Dia loguesClinNeurosci-11-7.pdf Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Michael KD, Renkert L, Wandler J, Stamey T. Cultivating a new harvest: rationale and preliminary results from a growing interdisciplinary rural school mental health program. Adv School Mental Health Promot [serial on the Internet]. 2009 [cited 2018 Jan 20]; 2(2):40–50. Available from: PsycINFO. Michael K, Albright A, Jameson J, Sale R, Massey C, Egan T, et al. Does cognitive behavioural therapy in the context of a rural school mental health programme have an impact on academic outcomes? Adv School Mental Health Promot [serial on the Internet]. 2013 [cited 2018 Jan 30];6(4):247–262. Available from: PsycINFO. Michael KD, Bernstein S, Owens JS, Albright A, Anderson-Butcher D. Preparing school mental health professionals: competencies in interdisciplinary and cross-system collaboration. In: Weist MD, Lever NA, Bradshaw CP, Owens JS, editors. Handbook of school mental health. 2nd ed. New York: Springer; 2014.

596

R. E. Capps et al.

Michael K, George M, Splett J, Jameson J, Sale R, Bode A, et al. Preliminary Outcomes of a Multisite, School-based Modular Intervention for Adolescents Experiencing Mood Difficulties. J Child Fam Stud [Internet]. 2016 [cited 2020 Jun 26];25(6):1903–15. Available from: https:// search-ebscohost-com.proxy.library.ohio.edu/login.aspx?direct=true&db=slh&AN=115197812& site=eds-live&scope=site Minke KM. Parent-teacher relationships. In: Bear GG, Minke KM, editors. Children’s needs III: development, prevention, and intervention. Washington, DC: National Association of School Psychologists; 2006. p. 73–85. Monnat S, Rigg K. Examining rural/urban differences in prescription opioid misuse among US adolescents. J Rural Health [serial on the Internet]. 2016 [cited 2018 Jan 20];32(2): 204–18. Available from: CINAHL Complete. Mufson L, Dorta, KP, Wickramaratne P, Nomura Y, Olfson M, Weissman MM. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Archiv Gen Psychiatr [Internet]. 2004 [cited 2017 Dec 16];6:577–84. Available from: https://msrc.fsu.edu/ system/files/Mufson%20et%20al%202004%20A%20randomized%20effectiveness%20trial%20of% 20interpersonal%20psychotherapy%20for%20depressed%20adolescents.pdf Murphy SM. Determinants of adolescent suicidal ideation: rural versus urban. J Rural Health [serial on the Internet]. 2014 [cited 2018 Jan 20];30(2):175–85. Available from: PsycINFO. National Assembly on School-Based Health Care. School-based health centers: a national definition. Washington, DC: Position Statement of the National Assembly on School Based Health Care; 2002. National Association of School Psychologists. The importance of school mental health services (Position statement). Bethesda: Author; 2008. National Research Council and Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Washington, DC: The National Academic Press; 2009. Nelson E, Bui T. Rural telepsychology services for children and adolescents. J Clin Psychol [serial on the Internet]. 2010 [cited 2018 Jan 20];66(5):490–501. Available from: PsycINFO. New Freedom Commission on Mental Health. Subcommittee on rural issues: background papers. DHHS publication No. SMA-04-2890. Rockville: Department of Health and Human Services; 2004. Owens JS, Murphy C. Effectiveness research in the context of school-based mental health. Clin Child Fam Psychol Rev [serial on the Internet]. 2004 [cited 2018 Jan 20];7(4):195–209. Available from: ERIC. Owens JS, Richerson L, Beilstein EA, Crane A, Murphy CE, Vancouver JB. School-based mental health programming for children with inattentive and disruptive behavior problems: first-year treatment outcome. J Atten Disord. 2005;9(1):261–74. Owens J, Richerson L, Murphy C, Jageleweski A, Rossi L. The parent perspective: informing the cultural sensitivity of parenting programs in rural communities. Child Youth Care Forum [serial on the Internet]. 2007 [cited 2018 Jan 20];36(5–6):179–94. Available from: PsycINFO. Owens JS, Murphy C, Richerson L, Girio E, Himawan L. Science to practice in underserved communities: the effectiveness of school mental health programming. J Clin Child Adolesc Psychol [serial on the Internet]. 2008 [cited 2018 Jan 20];37(2):434–47. Available from: MEDLINE. Owens JS, Andrews N, Collins J, Griffeth JC, Mahoney M. Finding common ground: university research guided by community needs for elementary school-aged youth. In: Harter L, HamelLambert J, Millesen J, editors. Participatory partnerships for social action and research. Dubuque: Kendall Hunt Publishers; 2011. p. 49–71. Owens JS, Watabe Y, Michael KD. Culturally responsive school mental health in rural communities. In: Clauss-Ehlers CS, Serpell ZN, Weist MD, editors. Handbook of culturally responsive school mental health: advancing research, training, practice, and policy. New York: Springer; 2013. p. 31–42. Polaha J, Williams SL, Heflinger CA, Studts CR. The perceived stigma of mental health services among rural parents of children with psychosocial concerns. J Pediatr Psychol [serial on the Internet]. 2015 [cited 2018 Jan 30];40(10):1095. Available from: Complementary Index.

26

Providing School-Based Mental Health Services in Rural and Remote Settings

597

Rones M, Hoagwood K. School-based mental health services: a research review. Clin Child Fam Psychol Rev [serial on the Internet]. 2000 [cited 2018 Jan 20];3(4):223–41. Available from: Education Source. Sander M, Everts J, Johnson J. Using data to inform program design and implementation and make the case for school mental health. Adv School Mental Health Promot [serial on the Internet]. 2011 [cited 2018 Jan 31];4(4):13–21. Available from: PsycINFO. Sheridan SM, Kratochwill TF. Conjoint behavioral consultations: promoting family-school connections and interventions. New York: Springer; 2008. Shirk SR, Kaplinski H, Gudmundsen G. School-based cognitive-behavioral therapy for adolescent depression: a benchmarking study. J Emot Behav Disord. 2009;17(2):106–17. Shochet IM, Dadds MR, Ham D, Montague R. School connectedness is an underemphasized parameter in adolescent mental health: results of a community prediction study. J Clin Child Adolesc Psychol. 2006;35(2):170–9. Siceloff ER, Barnes-Young C, Massey C, Yell M, Weist MD. Building policy support for school mental health in rural areas. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017. Strozer J, Juszczak L, Ammerman A. 2007–2008 national school-based health care census [Internet]. Washington, DC: National Assembly on School-Based Health Care; 2010 [cited 2017 Dec 16]. Available from: https://files.eric.ed.gov/fulltext/ED539818.pdf Sulkowski ML, Michael K. Meeting the mental health needs of homeless students in schools: a multi-tiered system of support framework. Child Youth Serv Rev [serial on the Internet]. 2014 [cited 2018 Feb 2];44:145–51. Available from: ScienceDirect. Waguespack A, Broussard C, Guilfou K. School- and home-based interventions in rural communities. In: Smalley KB, Warren JC, Rainer JP, editors. Rural mental health: issues, policies, and best practices. New York: Springer; 2012. p. 173–88. Weist M. Expanded school mental health services: a national movement in progress. Adv Clin Child Psychol [serial on the Internet]. 1997 [cited 2018 Jan 20];19:319–52. Available from: PsycINFO. Weist MD, Lever NA, Bradshaw CP, Owens JS. Further advancing the field of school mental health. In: Weist MD, Lever NA, Bradshaw CP, Owens JS, editors. Handbook of school mental health. 2nd ed. New York: Springer; 2014.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social and Emotional Well-Being: Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Strength-Based Approach for Aboriginal and Torres Strait Islander Social and Emotional Well-Being Service Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications of Using a Strength-Based SEWB Approach . . . . . . . . . . . . . . . . . . . . . . . Risk and Protective Factors for Healthy Social and Emotional Well-Being . . . . . . . . . . . . . . . . . . . Strengths-Based SEWB Approach for Working with Rural and Remote Communities . . . . . . Listen Respectfully to the Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Build Genuine Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Use Effective Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Critically Reflect on Australia’s Historical, Political, and Social Contexts . . . . . . . . . . . . . . . . . . . . Apply a Human Rights-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluate the Process and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

An understanding of the Aboriginal and Torres Strait Islander health discourse of social and emotional well-being (SEWB) is necessary for effective and culturally safe work in rural and remote communities. Composed of seven inter-connected domains of well-being – country, culture, spirituality, community, family and kinship, mind and emotions, and body – SEWB represents a cultural understanding of Aboriginal and Torres Strait Islander relationality, identity, and holistic individual, family, and community health. Risk and protective factors for SEWB are detailed, evidence which supports the connections between well-being and the domains is presented, and finally, the findings of a strengths-based SEWB inquiry with older people in a remote community are discussed. In total, this chapter provides a valuable guide to essential principles, concepts, and practices, for those working with Aboriginal and Torres Strait Islander in rural and remote areas.

Introduction Aboriginal and Torres Strait Islander peoples (herein referred to as Indigenous Australians) are two distinct cultural groups who make up 3.3% of the population of Australia. Indigenous Australians are the traditional custodians of the land now called Australia, one of the earth’s oldest, sustainable, harmonious, and equitable continuous cultures which are estimated to be between 60,000 and 70,000 years old (Rasmussen et al. 2011). Indigenous knowledge systems include sophisticated therapeutic epistemologies and practices, philosophy, governance and law, agriculture, environmental science, and astronomy. Prior to the invasion of their country by the British Empire in 1788, Indigenous Australians had few illnesses and harmonious social structures, cared for a complex and diverse ecosystem, and enjoyed a flourishing and rich culture in which Elders played a vital role in the guidance, healing, and governance of the community. Today Indigenous Australians have a medium age of only 23 years old, which is significantly younger than the non-Indigenous medium age of 38 (ABS 2016), and experience an unusually high burden of ill-health, social marginalization, and poverty, and these complex inequities are more pronounced for Indigenous people living in rural and remote areas (Senate Community Affairs Reference Committee 2018; Cairney et al. 2017). The health of Indigenous peoples in remote areas has often been characterized by “hardship, suffering and invisibility” (Gruen and Yee 2005, p. 182). Poverty within remote communities has long been recognized as a primary reason for ill-health, causing substantial “psychological and behavioral problems” which are “compounded by narrowly focused and inadequate mental health services, with children being particularly vulnerable” (Hunter 2007, p. 88). Homelessness, chronic overcrowding, extended periods of hunger due to poverty, and lack of access to nutritious food and medical services have deleterious effects on children’s well-being,

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including otitis media, skin infections, acute rheumatic fever, and rheumatic heart disease (Lowell et al. 2018). In the Northern Territory, “more than 38% of Aboriginal people live in crowded houses and most (92%) received that classification because they were living in severely crowded dwellings, defined as needing 4 or more extra bedrooms to accommodate the people who usually live there” (Lowell et al. 2018). In remote areas of Australian, two in five (41%) of Indigenous peoples live in overcrowded dwellings (AHMAC 2017), and their incomes are rapidly falling (Markham and Biddle 2018). Australia is one of the most wealthy countries in the world. Furthermore, entrenched racism “across urban and rural Australia and in the health-care system itself” (Hunter 2007, p. 91) has too often produced forms of institutionalized discrimination within settler-controlled remote communities such that adequate access to services and basic human needs (food, housing, sanitation, education, health care) has been repeatedly blocked and withdrawn. There are now decades of evidence about the chronically destructive physical and psychological impacts of racism (Williams et al. 2019), and racism has emerged as a strong determinant of mental health (Paradies et al. 2015). The grave state of health of remote communities continues to be a national “matter or equity and social justice” and requires “broad, transdisciplinary, health-affirming approaches that are attuned to the circumstances and priorities of remote communities and initiatives that support empowerment at individual, family, and community levels” (Hunter 2007, p. 91). Across the world, Indigenous communities have campaigned for and initiated just such health-affirming approaches (Foley 1991; Chandler and Dunlop 2018). Strength-based culturally safe comprehensive primary health care which is founded on holistic Indigenous understandings of health has now emerged as an evidence-based approach to the empowerment and healing of Indigenous individuals and their families and communities (Radford et al. 1990; McCoy 2007; Rowley et al. 2008; Bourke et al. 2018). Aboriginal and Torres Strait Islanderled holistic approaches which support the empowerment of individuals, families, and communities have existed since at least the 1970s when the self-determination movement successfully mobilized for Aboriginal Community Controlled Health Organisations (ACCHOs) (Foley 1991). As of 2018 there are roughly 150 such organizations across Australia. Importantly, a strength-based Aboriginal and Torres Strait health discourse, social and emotional well-being (SEWB), emerged from the self-determination movement and is now central to the practices and policies of numerous ACCHOs, as well as state and federal health policies. Indeed the vision of the National Aboriginal Community Controlled Health Organisation (NACCHO) reflects the centrality of SEWB: “Aboriginal people enjoy quality of life through whole-of-community self-determination and individual, spiritual, cultural, physical, social and emotional well-being. Aboriginal health in Aboriginal hands” (NACCHO 2019). Composed of seven interconnected domains of well-being – country, culture, spirituality, community family and kinship, mind and emotions, and body – SEWB is a core concept within Aboriginal and Torres Strait Islander psychology.

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The first part of this chapter offers a description of SEWB which can be understood as a distinctive feature of Indigenous health and health care. SEWB is a holistic strength-based model of health. Strength-based approaches to individual, family, and community well-being are becoming more prevalent with the primary health-care sector (Fogarty et al. 2018a). Aboriginal and Torres Strait Islander strength-based approaches uniquely draw on Aboriginal and Torres Strait Islander epistemologies of health (SEWB) and are as such an integral part of reclaiming Aboriginal and Torres Strait Islander knowledge systems for Aboriginal and Torres Strait Islander people. Further, there is a consensus in the Aboriginal and Torres Strait Islander health field that strength-based approaches enable the sustainable empowerment of individuals, families, and communities (NACCHO 2019). Second, this chapter explores the practice implications of understanding the centrality of SEWB for strengthening health and mental health and discusses the identified risk and protective factors for SEWB and the evidence-based benefits of using a SEWB approach across the rural health-care sector. The second section also focuses on strength-based SEWB research undertaken with Elders and older people in communities in New South Wales. To begin with, however, it is important to highlight key engagement principles relevant to all health professionals working in rural or remote areas with Aboriginal and Torres Strait Islander people. These principles embody a holistic and whole-of-life view of health held by Aboriginal and Torres Strait Islander peoples, were first identified by the 1989 National Aboriginal Health Strategy, later developed by the landmark Ways Forward (Swan and Raphael 1995), and contained in the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2004–2009. These principles underpin a central text in the field, Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing: Principles and Practice (Dudgeon et al. 2014). The revised 2017–2023 National SEWB Framework promotes these principles which are underpinned by a recognition that selfdetermination in the health sector is the solution to overcoming the complex burdens of colonization (Department of Prime Minister and Cabinet 2017; Dudgeon et al. 2017). 1 2 3

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Aboriginal and Torres Strait Islander health is viewed in a holistic context that encompasses mental health and physical, cultural, and spiritual health. That Land is central to well-being. Self-determination is central to the provision of Aboriginal and Torres Strait Islander health services. Culturally valid understandings must shape the provision of services and must guide assessment, care, and management of Aboriginal and Torres Strait islander peoples’ health problems generally and mental health problems, in particular. It must be recognized that the experiences of trauma and loss, present since European invasion, are a direct outcome of the disruption to cultural well-being. Trauma and loss of this magnitude continue to have intergenerational effects. Human rights of Aboriginal and Torres Strait islander peoples must be recognized and respected. Failure to respect these human rights constitutes continuous disruption to mental (continued)

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health (versus mental ill-health). Human rights relevant to mental illness must be specifically addressed. Racism, stigma, environmental adversity and social disadvantage constitute ongoing stressors and have negative impacts on Aboriginal and Torres Strait Islander peoples’ mental health and wellbeing. The centrality of Aboriginal and Torres Strait islander family and kinship must be recognized as well as the broader concepts of family and the bonds of reciprocal affection, responsibility, and sharing. There is no single Aboriginal or Torres Strait Islander culture or group, but numerous groupings, languages, kinships, and tribes, as well as ways of living. Furthermore, Aboriginal and Torres Strait Islander peoples may currently live in urban, rural, or remote settings, in urbanized, traditional, or other lifestyles, and frequently move between these ways of living. It must be recognized that Aboriginal and Torres Strait Islander peoples have great strengths, creativity, and endurance and a deep understanding of the relationships between human beings and their environment.

An understanding of these principles of engagement is vital to the practice of culturally safe work with Aboriginal and Torres Strait Islander peoples.

Social and Emotional Well-Being: Distinctive Features SEWB is a strength-based Aboriginal and Torres Strait Islander health discourse which is recognized across Australia (and internationally) as culturally unique and community created. An emerging health paradigm which informs policy, research, and therapeutic practices, SEWB is grounded in Aboriginal and Torres Strait Islander knowledge systems (Dudgeon and Walker 2015) and has been continually validated through comprehensive Aboriginal and Torres Strait Islander participatory feedback over the years and across the country. SEWB was reclaimed by the Indigenous mental health movement, specifically by the 1989 National Aboriginal Health Strategy Working Party (Swan and Raphael 1995) and then later in The Ways Forward Report (1995), the first national analysis of Aboriginal and Torres Strait Islander mental health and SEWB which supported the development of strength-based, culturally appropriate, community-led primary mental health and SEWB services and programs for Aboriginal and Torres Strait Islander peoples.1 SEWB was defined by the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2004–2009 as a holistic connection to “land, culture, spirituality, ancestry, family and community” (Social Health Reference Group 2004, p. 9). There are now seven recognized interconnected Aboriginal and Torres Strait Islander domains of SEWB: country, spirituality, culture, family and kinship, mind and emotions, and body (Gee et al. 2014; Dudgeon et al. 2014; Dudgeon and Walker 2015). The diagram below illustrates the SEWB concept and the influence of historical and social determinants on SEWB (Gee et al. 2014).

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Strong and dynamic relationships between the seven domains enables individuals, families, and communities to thrive. This model also recognizes that relationships between the domains vary within communities and across the life span (Dudgeon et al. 2014). Although SEWB is a national Aboriginal and Torres Strait Islander health discourse, specific cultural articulations can be found across the nation. For example, the term Ngarlu or Lian is used by the Yawuru people in the Kimberley to describe “a driver of emotional, spiritual and physical health [. . .] the connectedness of the individuals inner spirit and the collective grip, and shows how the connectedness between the inner spirit, body and country are one and the same” (Yap and Yu 2016, p. 28). The Yawuru concept for good life is Mabu Liyan (ibid.). There is also the central desert concept of Kurunpa: Kurunpa is the foundation of vitality and is critical to the physical, emotional, and spiritual well-being of Aboriginal men; it exits in physical, emotional, and spiritual form which can be injured, manipulated, moved, lost, felt, seen, found, and relaxed. Kurunpa goes beyond metaphor; it is not only a feeling, or a means of expressing distress, but it is the vessel of life force itself. (Brown et al. 2012 n.p.)

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Life force and well-being are also connected in other similar Aboriginal and Torres Strait Islander people’s concepts (Rose et al. 2003) but have yet to be researched in great depth. In Aboriginal and Torres Strait Islander communities, SEWB includes a strong sense of self- and cultural identity, which can provide meaning and resilience in times of adversity. Identifying, participating in, and engaging with cultural activities are essential to the development of strong and resilient children, young people, families, and communities. A positive cultural identity assists children and young people to navigate the challenges in Australia, such as the racial tensions and discrimination, including racism and oppressive policies (Manning et al. 2015; Yap and Yu 2016; Prince 2018). Elders and older people often hold special relationships with younger generations, particularly children. These relationships support the passing of cultural knowledge and connections, like kinship networks, language, culture, and cultural identity (Marmion et al. 2014; Rose et al. 2003; AHRC 2009; Yap and Yu 2016). Strong connections to culture serve as key protective factors that predict resilience in children (Prince 2018; Smith et al. 2017). When these domains and the connections between them are impaired – for example, by the loss of country due to the political and historical determinants of colonization – well-being suffers, and this suffering “may be manifested in a physical, social, emotional, mental, or spiritual manner” (Haswell-Elkins et al. 2009, p. 3). The forced removal of small children from families and communities, for example, disrupted the domain of family, kinship, and community creating forms of historical and intergenerational trauma: the 2004 Social Health Reference Group recognized this as a significant SEWB disruption (Social Health Reference Group 2004).

A Strength-Based Approach for Aboriginal and Torres Strait Islander Social and Emotional Well-Being Service Providers A strengths-based approach recognizes the resilience of individuals and communities. It focuses on abilities, knowledge, and capacities rather than a deficits-based approach, which focuses on what people do not know, or cannot do, problematizing the issue or victimizing people. It recognizes that the community is a rich source of resources; assumes that people are able to learn, grow, and change; encourages positive expectations of children as learners; and is characterized by collaborative relationships. It focuses on those attributes and resources that may enable adaptive functioning and positive outcomes. – National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2017–2023, 2017, p. 22

Why is a strength-based approach emerging within the field of Aboriginal and Torres Strait Islander health? In order to appreciate the importance of this

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conceptual shift, it is necessary to consider how a hegemonic “deficit discourse” about Aboriginal and Torres Strait Islander people legitimizes and popularizes a plethora of racist narratives which pivot around ideas about the essential incapacity of Aboriginal and Torres Strait Islander people. Two important Lowitija Institute reports – Deficit discourses and Indigenous health: how narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy (Fogarty et al. 2018b) and Deficit discourse and strengths-based approaches: changing the narrative of Aboriginal and Torres Strait Islander health and wellbeing (Fogarty et al. 2018a) – provide a comprehensive analysis of the deficit discourse and its multiple impacts on health policy and wider perceptions of Aboriginal and Torres Strait Islander people by the dominant non-Aboriginal and Torres Strait Islander culture and Aboriginal and Torres Strait Islander people themselves. “Assumptions of Aboriginal and Torres Strait Islander deficit have characterised relations between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander people since colonisation. Contemporary discourses of deficit have their origins in the race paradigm and subsequent colonial ideology” (Fogarty et al. 2018b, p. viii). There are numerous iterations of this discourse, and they are so common that they are familiar to most Australians: from the idea that Aboriginal and Torres Strait Islander people have lower IQs to assumptions that parents neglect and abuse their children, through beliefs that communities are unable to manage themselves, the deficit discourse has operated to pathologize and criminalize the dignity of Aboriginal and Torres Strait Islander people and justify the colonial control and surveillance of their lives. The deficit discourse can also be understood as opportunistic insofar as it masks the vast theft of Aboriginal and Torres Strait Islander land – the real “deficit,” as it were, which underlies the social, historical, and political determinants of Aboriginal and Torres Strait Islander health. The deficit discourse also operates to deflect critical attention from the deficiencies of the dominant colonial culture. For as the former Prime Minister Paul Keating admitted in his 1992 Redfern Park address: “[w]e took the traditional lands and smashed the traditional way of life. We brought the diseases, the alcohol. We committed the murders. We took the children from their mothers. We practiced discrimination and exclusion” (Keating 1992). In the light of all of this, it is important to respect the dignity of Aboriginal and Torres Strait Islander resilience. There are a number of strength-based approaches identified by Fogarty, Lovell, Langenberg, and Heron (2018a, p. 15) which are useful for culturally safe work with rural and remote communities. Strengths-based approaches 1 Asset-based

Key elements Utilizes existing positive attributes, characteristics and resources of a person and/or community

Example texts Priest et al. 2012, 2016; Brough et al. 2004 Grothaus et al. 2012 GCPH 2017 (continued)

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Strengths-based approaches 2 Resilience

Key elements The ability to withstand adverse circumstances through mental, emotional, social, and spiritual strength

3

Cultural appropriateness

The tailoring of programs, resources and health care to privilege cultural aspects of indigeneity

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Social determinants of health and ecological theories

Structural factors or conditions that influence health and well-being

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Protective factors

Non-physical and non-medical elements that counteract or mitigate the effects of adversity

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Empowerment

Focuses on self-determination and abilities rather than limiting factors, such as poor physical health

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Holistic approaches

Privilege indigenous ways of knowing and being

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Wellness and well-being

Measuring health in a wider range of metrics than physical illness or disease, usually including mental, social, emotional, spiritual, and communal wellness

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Strength-based counselling approaches and positive psychology

Prioritizes capabilities, talents, competencies, hope, resources, optimism, and autonomy of individuals and communities when remedying challenging circumstances

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Decolonization methodology

A broad methodology proactively shifting the Western and European worldview to the indigenous

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Example texts Jain and Cohen 2013 Payne et al. 2013 West et al. 2016 Thomas et al. 2012 Grothaus et al. 2012 Monchalin et al. 2016 Smith et al. 2010 Di Pietro and Illes 2016 Rowley et al. 2015 Neumayer 2013 Nelson et al. 2010 Henson et al. 2017 Tagalik 2009 Sweet et al. 2015 Nagel et al. 2012 Prillentesky 2005 Priest et al. 2012 Priest et al. 2016 Rowley et al. 2015 Hinton and Nagel 2012 Thomas et al. 2012 Day and Francisco 2013 Sweet et al. 2015 Tagalik 2009 Saleeby 1996 Grothaus et al. 2012 Craven et al. 2016 Sweet et al. 2015 Geia and Sweet 2015 Monchalin et al. 2016 (continued)

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Key elements Focuses on the assets and origins of health rather than the deficits of ill-health, to shift the pathologizing paradigm Prentice 2015

Example texts Antonovsky 1979, 1989 Mittlemark et al. 2017 IUHPE n.d.

Practice Implications of Using a Strength-Based SEWB Approach Cultural continuity is an important element of many SEWB community development programs. Among the identified protective benefits of cultural continuity are reductions in youth suicide, strengthening cultural identity and self-continuity, intergenerational communication and the transmission of cultural knowledge through the empowerment of Elders, the restoration of supportive peer relationships, family thriving, language reclamation, cultural revitalisation, and increased collective social and cultural capital (Busija et al. 2020; Chandler and Lalonde 1998; Dudgeon et al. 2016; Jongen et al. 2020; Prince 2018; Yap and Yu 2016). By extension, young people also conceive of themselves as having a future (as bearers of that culture). While the implications of cultural continuity as a concept are yet to be fully explored, including their application in Aboriginal and Torres Strait Islander settings, and in urban settings, support for cultural continuity is a highly productive line of policy development in relation to suicide prevention (and more broadly, Aboriginal and Torres Strait Islander peoples’ mental health and SEWB) based on cultural maintenance and, where necessary, reclamation. Chandler and Lalonde’s (1998, 2008) research across First Nations peoples in Canada should be considered for application to Australian Aboriginal and Torres Strait Islander settings. If thematic elements can be drawn from this work, the first is the importance of self-determination and community empowerment to individual well-being and mental health; and the second is the potential importance of what the researchers called “cultural continuity.” More broadly, the studies indicate that primordial prevention that incorporates these two themes has an important place in suicide prevention in Australian Aboriginal and Torres Strait Islander communities (Dudgeon et al. 2016). Chandler and Lalonde examined cases of suicide among young First Nations people of British Columbia and the potentially protective effects “cultural continuity” against suicide. In their first study (1987–1992), cultural continuity was defined according to six indicators of self-determination and cultural maintenance/ reclamation: • • • •

Measures of self-government Have litigated for Aboriginal title to traditional lands A measure of local control over health A measure of local control over education

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• A measure of local control over policing services • Community facilities for the preservation of culture Chandler and Lalonde mapped suicides in 197 communities or bands in British Columbia and found that those that had all six markers above had no or little cases of suicide among their younger people. Conversely, in communities where there were none or fewer of these markers, youth suicide rates were many times higher than the national average. A second study (1993–2000) identified two other markers and found similar results to those of the first study. The additional markers were a measure of local control over child welfare services and band councils that included equal numbers of women (Chandler and Lalonde 2008). Chandler’s research into cultural continuity provides compelling evidence for the multiple benefits of self-determination and is recognized within the Indigenous health-care sector to be aligned with NACCHO and the principles of supporting comprehensive primary health care. In terms of practice implications, support for community control of community issues can be understood as a guiding approach. The next section provides some further guide to culturally safe practices in the field.

Risk and Protective Factors for Healthy Social and Emotional Well-Being To reiterate, SEWB is fundamental to any understanding of individual, family, and community health. It is worth recalling the words of Swan and Raphael, who define SEWB as: holistic, encompassing mental health and physical, cultural and spiritual health. Land is central to well-being. This holistic concept does not merely refer to the “whole body” but in fact is steeped in the harmonised inter-relations which constitute cultural well-being. These interrelating factors can be categorised as largely spiritual, environmental, ideological, political, social, economic, mental and physical. Crucially, it must be understood that when the harmony of these interrelations is disrupted, Aboriginal ill health will persist. (1995, p. 19)

The protective and risk factors for the seven Aboriginal and Torres Strait Islander domains of SEW are identified by the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023 as follows. Domain Connection to body

Description Physical health – feeling strong and healthy and able to physically participate as fully as possible in life

Examples of risk factors Chronic and communicable diseases Poor diet Smoking

Examples of protective factors Access to good healthy food Exercise Access to culturally safe, culturally competent and effective health services and professionals (continued)

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Domain Connection to mind and emotions

Description Mental health – ability to manage thoughts and feelings.

Connection to family and kinship

Connections to family and kinship systems are central to the functioning of Aboriginal and Torres Strait Islander societies

Connection to community

Community can take many forms. A connection to community provides opportunities for individuals and families to connect with each other, support each other, and work together

Connection to culture

A connection to a culture provides a sense of continuity with the past and helps underpin a strong identity

Connection to country

Connection to country helps underpin identity and a sense of belonging Spirituality provides a sense of purpose and meaning

Connection to spirituality and ancestors

Examples of risk factors Developmental/ cognitive impairments and disability Racism Mental illness Unemployment Trauma including childhood trauma Absence of family members Family violence Child neglect and abuse Children in outof-home care Family feuding Lateral violence Lack of local services Isolation Disengagement from community Lack of opportunities for employment in community settings Elders passing on without full opportunities to transmit culture Services that are not culturally safe Languages under threat Restrictions on access to country No connection to the spiritual dimension of life

Examples of protective factors Education Agency: assertiveness, confidence and control over life Strong identity

Loving, stable accepting and supportive family Adequate income Culturally appropriate family- focused programs and services Support networks Community controlled services Self-governance

Contemporary expressions of culture Attending national and local cultural events Cultural institutions Cultural education Cultural involvement and participation Time spent on country

Opportunities to attend cultural events and ceremonies Contemporary expressions of spirituality

In many ways, SEWB reflects each of the important and interrelated aspects of cultural determinants. SEWB works to reduce psychological distress because it acts as a source of resilience that provides a “buffer” against the worst impacts of stressful life events. This is important because Aboriginal and Torres Strait Islander peoples

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experience stressful life events at higher rates than other Australians (Aboriginal and Torres Islander Health Survey, 2012–2013). Without SEWB/resilience, exposure to such events can leave individuals, families, and communities vulnerable to psychological distress and trauma.

Strengths-Based SEWB Approach for Working with Rural and Remote Communities The Aboriginal and Torres Strait Islander Social and Emotional Well-Being Framework introduced health professionals with a new way of practicing. The following strength-based approach will draw together this Aboriginal and Torres Strait Islander Framework, as well as the community contexts or rural and remote practitioners. The strength-based approach and philosophy for Aboriginal and Torres Strait Islander social and emotional well-being services was developed as a part of a research project (Gibson et al. 2018) which focused on working with Elders and older people in New South Wales. This strength-based approach includes six key dimensions. Strength-based approach for working in rural and remote communities Listen respectfully to the person Build genuine relationships Use appropriate communication skills Critically reflect on Australia’s political, historical, and social context Apply a human rights-based approach Evaluate the processes and outcomes

Each of the six dimensions are now explained and then followed by examples of how rural and remote practitioners could use each of these dimensions to deliver a social and emotional well-being service in rural and remote Australia.

Listen Respectfully to the Person Listen respectfully to the person, including their expressions and experiences of health, well-being, and quality of life. Listen and inquire about how the person understands and expresses their lived experience of social and emotional wellbeing. Listen and inquire about how the social and cultural determinants influence the person and their community. Rural and remote communities are more likely to experience social determinants that negatively influence health and wellbeing (Zubrick et al. 2014). Take the time to explore the social determinants, and do this by using the domains of social and emotional well-being, as illustrated above. Additionally, consider the nine guiding principles of social and emotional well-being and their relevance for the person, family, and/or community.

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Build Genuine Relationships It is important for the health professional to remember that their position or title does not guarantee the right to hear the person and/or community’s stories. Therefore, it is vital that health professionals build trusting relationships so that community members feel connected and open up about their social and emotional well-being experiences. Building relationships with the person and/or community requires appropriate communication skills, and as such, the communication strategies will support the relational development and/or maintenance. The rural and remote practitioner should also build relationships and work collaboratively with other service providers, including any Aboriginal organizations and/or networks, like Elders groups. For example, build relationships with service providers like housing organizations to take any affirmative actions to decrease the impact of broader social determinant issues. Build relationships with Aboriginal organizations, as they often hold close ties with communities and deliver services that meet health and/or health-related needs.

Use Effective Communication Rural and remote practitioners need to employ a number of communication strategies, which are strength-based, to support interventions, for example, connecting and working with local Aboriginal and Torres Strait Islander health service providers, who may share with the rural and remote practitioners any local communication and cultural communication strategies (Sheldon 2010). Rural and remote practitioners may need to negotiate where and how to conduct the initial interview with the person and/or community (Sheldon 2010), noting that some community members may not use or feel safe with certain services and/or buildings in the community. This may include negotiating the location of the interview (Sheldon 2012), such as in a park under the shade of a tree, in the clinic, or in the person’s home. Seek to understand who needs to be present for the interview (Sheldon 2010), such as consider conducting a joint visit with an Aboriginal Health Worker who knows the person or consider family members who may need or want to be present. Consider how gender might affect how and what information is shared. Furthermore, using a yarning style, which is relaxed and responsive to the person and their needs in the interview may help to develop rapport (Lin et al. 2016). Remaining mindful of culturally sensitive topics, such as bereavement, ceremonial business, sexual issues, and marital problems, is also essential (Sheldon 2010).

Critically Reflect on Australia’s Historical, Political, and Social Contexts Critically reflecting on Australia’s historical, political, and social contexts is essential. For example, the rural and remote practitioner should understand power and privilege and how it is enacted by the organization, the profession, and practitioner. Any form of institutional discrimination, perceived or real, effects the person and/or

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communities’ ongoing perceptions of an organization and its employees. Often professions, such as medicine, psychology, occupational therapy, and so on, are reflective of Western sciences, which can oppress and/or omit Aboriginal and Torres Strait Islander ways of knowing, being, and doing (Gilroy et al. 2018). Sometimes, rural and remote practitioners may be socialized into not seeing these contexts and therefore reflecting with other professionals may be useful. Furthermore, social contexts of Aboriginal and Torres Strait Islander communities are often overlooked during events (like drought) caused by climate adversity and, as such, should be considered by rural and remote practitioners.

Apply a Human Rights-Based Approach A human rights approach encompassed not only basic rights for individuals and communities accessing health-care services, but it also includes access to social determinants, which support good health and well-being. Although individual rural and remote practitioners are not responsible for delivering all services, being aware of what services are available and/or accessed is important. Furthermore, self-determination or the right to be in control of one’s own life is important (Gibson et al. 2015). Therefore, it is important for rural and remote practitioners to not only ensure that community voices and choices are privileged in service delivery but also more broadly in the community. Listening to the person and understanding their context is essential, so that the rural and remote practitioner can work with the person, to pursue personal goals and aspirations.

Evaluate the Process and Outcome In the absence of a formal evaluation tool for rural and remote practice in Aboriginal and Torres Strait Islander social and emotional well-being contexts, services should consider how individuals are encouraged to maintain cultural connections (Davy et al. 2016; Lindeman et al. 2016). Evaluating how services support independence and autonomy, including self-determining processes like being involved in the design, delivery, and evaluation of the program is also essential (Davy et al. 2016; Lindeman et al. 2016). Finally, services should be evaluated in terms of their culturally competency, such as not being discriminative and being inclusive of Aboriginal staff and incorporate local knowledge/culture into the program (Davy et al. 2016; Day and Francisco 2013; Day et al. 2015).

Concluding Comments and Recommendations In conclusion, SEWB is an emerging strength-based health discourse which is increasingly important to the restoration of resilience within rural and remote communities (Dudgeon et al. 2020). Australia, as a signatory to the UN Declaration

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of the Rights of Indigenous People, has a specific and historical human rights duty toward Aboriginal and Torres Strait Islander people and under obligation to ensure that the principle of self-determination is respected and upheld throughout the health sector (United Nations 2007). No other nation on earth has such a dramatic socioeconomic disparity between Indigenous and non-Indigenous people. It is a testament to the power of Aboriginal and Torres Strait Islander communities and leadership that despite the uniquely deleterious impact of Australian colonization, a strong Aboriginal and Torres Strait Islander health movement has risen up to protect and empower individuals, families and communities. Extensive national and international research has found that Indigenous selfdetermination in the health sector is linked to improved outcomes for vulnerable communities. The nine guiding principles of SEWB presented in this chapter are recognized as an ethical foundation of holistic Aboriginal and Torres Strait Islander health services. For example, the ninth principle – “It must be recognised that Aboriginal and Torres Strait Islander peoples have great strengths, creativity and endurance and a deep understanding of the relationships between human beings and their environment” – offers a useful corrective to the “deficit discourse” and the race-based shaming of Aboriginal and Torres Strait Islander people. The section on the risk and protective factors for SEWB further explores the complexity of this innovative Aboriginal and Torres Strait Islander health discourse and offers readers a general guide to identifying some of the core issues at stake in the field. Finally, this chapter explored the dynamic emergence of strengthbased approaches, highlighting Gibson’s work in rural and remote communities and the development of six key principles for empowering social and emotional well-being: listen respectfully; build genuine relationships; use culturally appropriate communication skills; critically reflect on Australia’s political, historical, and social context; apply a human rights-based approach; and evaluate the processes and outcomes.

Take-Home Messages • Racism is a significant determinant of mental health (Paradies et al. 2015) and has profoundly harmful impacts on health and mental health across the life span (Williams et al. 2019). Indigenous Australians endure the added burden of crossgenerational poverty, forms of trauma from colonization, and lack of access to culturally safe comprehensive primary health-care services, as well as secure food and accommodation. These social justice inequities are more pronounced in rural and remote regions. The nine engagement principles first identified by the 1989 National Aboriginal Health Strategy (see above) are crucial for any sustainable culturally safe work with rural and remote Indigenous peoples and are important in dismantling harmful racist narratives.

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• An in-depth understanding of the historical and cultural determinants of SEWB, the relational aspects of the seven connected domains of well-being – country, culture, spirituality, community, family and kinship, mind and emotions, and body – and the culturally unique risk and protective factors for each domain is essential for those working in the field. • The evidence-based around cultural-continuity supports the long-held knowledge of Indigenous Elders and their communities that self-determination improves the health of individuals, families, and communities. NACCHO recognizes that local Indigenous designed and delivered comprehensive primary health-care services are an expression of Indigenous self-determination in the field: Aboriginal health in Aboriginal hands. Upstream solutions from communities exist and should be empowered. • Gibson’s development of six key principles for empowering SEWB – listen respectfully; build genuine relationships; use culturally appropriate communication skills; critically reflect on Australia’s political, historical, and social context; apply a human-rights based approach; and evaluate the processes and outcomes – should be widely applied. Box 1. Case Study: Suicide Prevention Through Cultural-Continuity and SEWB

The Yarrabah (Queensland) and the Tiwi Islands (Northern Territory) communities have successfully reduced youth suicide over two decades by creating holistic forms of cultural continuity (Prince 2018). By enabling the “reconnection and transmission of cultural processes and traditions that had been lost” – engaging Elders as leaders, especially “Elders-driven on-country healing programs for young people to help them become stronger and think differently,” creating SEWB empowerment programs based on local Indigenous strengths-based cultural knowledge, strengthening the existing men and women’s groups – both communities began to heal from the traumatic impacts of colonization and drastically reduced youth suicide (Prince 2018, p. 33).

Box 2. Case Study: The National Empowerment Project (NEP) and SEWB

An Indigenous designed and led SEWB and suicide prevention research program begun in 2012, the NEP engaged 11 communities across Australia in the design and delivery of a complex SEWB program. Between 2014 and 2016 a Cultural and Social and Emotional Wellbeing (CSEWB) program which had evolved from the NEP was delivered in Kuranda and Cherbourg (Queensland) and qualitative evidence gathered from communities found that a significant positive SEWB change had occurred for the majority of participants and that their families and communities were also more empowered (Mia et al. 2017).

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Box 3. Case Study: The Back-to-Country Yiriman Project

Set in the West Kimberley region of Western Australia – the country of the Karajarri, Nyikina, Mangala, and Walmajarri peoples – the Yiriman Project is an Elder led “cultural maintenance project” and “a way to heal young people, heal country and heal community” (Palmer 2013, p. 10) which hosts cultural back-to-country trips for young people. The Yiriman Project has strengthened the SEWB of youth, as well as engaging them in community based land care, cultural education, economic and scientific development, fire management, and holistic community development.

Cross-References ▶ Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas ▶ Depression and Anxiety ▶ Future of Rural, Remote, and very Remote Mental Health ▶ Global Mental Health Perspectives on Rural and Remote Mental Health Provision ▶ Improving Access to Psychological Services in Remote Australia with a PatientLed Clinic ▶ Indigenous Mental Health in Remote Communities ▶ Professional Ethics in Rural Practice: Relational Territory ▶ Promotion and Prevention of Mental Health Problems in Rural and Remote Context ▶ Recovery in Mental Illness Among Rural Communities ▶ Rural and Remote Mental Health Practice: Nursing Roles ▶ Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts ▶ Suicide and Self-Harm: It’s Everyone’s Business ▶ Supporting Communities ▶ Working with Rural Families: Issues and Responses When a Family Member Has a Mental Illness

References Aboriginal and Torres Strait Islander Health Workforce Working Group. National Aboriginal and Torres Strait Islander health workforce strategic framework 2016–2023. Canberra: Department of Health; 2017. Antonovsky A. Health, stress, and coping. San Francisco: Jossey-bass; 1979. Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well, 1st edn. San Francisco: Jossey-Bass; 1987. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander social survey, 2014–15. Canberra: ABSABS4714.0; 2016.

27

Social and Emotional Well-Being: “Aboriginal Health in Aboriginal Hands”

617

Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander health performance framework 2017 report. Canberra: AHMAC; 2017. Australian Human Rights Commission. Annual report 2009–2010. Sydney: Australian Human Rights Commission; 2009. Bourke S, Wright A, Jill G, Russell L, Dunbar T, Lovett R. Evidence review of indigenous culture for health and wellbeing. Int J Health Wellness Soc. 2018;8(4):11–27. Brough M, Bond C, Hunt J. Strong in the city: towards a strength-based approach in Indigenous health promotion. Health Promot J Austr. 2004;15(3):215–220. Brown A, Scales U, Beaver W, Richards B, Rowley K, O’Dea K. Exploring the expression of depression and distress in Aboriginal men in Central Australia: a qualitative study. BMC Psychiatry. 2012;12:97. Cairney S, Abbott T, Quinn S, Yamaguchi J, Wilson B. Interplay wellbeing framework: a collaborative methodology ‘bringing together stories and numbers’ to quantify Aboriginal cultural values in remote Australia. Int J Equity Health. 2017;16(68):1–13. Chandler M, Dunlop WL. Cultural wounds demand cultural medicine. In: Greenwood M, De Leeuw S, Lindsay NM, editors. Determinants of indigenous peoples health: second edition: beyond the social; 2018. p. 147–60. Chandler MJ, Lalonde CE. Cultural continuity as a hedge against suicide in Canada’s first nations. Transcult Psychiatry. 1998;35(2):193–219. Chandler M, Lalonde CE. Cultural continuity as a protective factor against suicide in first nations youth. Horizons. 2008;10(1):68–72. Commonwealth of Australia (2018) Accessibility and quality of mental healthservices in rural and remote Austalia, The Senate, Community Affairs References Committee Senate Printing Unit, Parliament House, Canberra. Craven RG, Ryan RM, Mooney J, Vallerand RJ, Dillon A, Blacklock F, Magson N. Toward a positive psychology of indigenous thriving and reciprocal research partnership model. Contemp Educ Psychol. 2016;47:32–43. Davy C, Kite E, Aitken G, Dodd G, Rigney J, Hayes J, Van Emden J. What keeps you strong? A systematic review identifying how primary health-care and aged-care services can support the well-being of older indigenous peoples. Australas J Ageing. 2016;35(2):90–7. Day A, Francisco A. Social and emotional wellbeing in indigenous Australians: identifying promising interventions. Aust N Z J Public Health. 2013;37(4):350–355. Day A, Nakata V, Nakata M, Martin G. Indigenous students’ persistence in higher education in Australia: contextualising models of change from psychology to understand and aid students’ practices at a cultural interface. Higher Educ Res Develop. 2015;34(3):501–512. Department of Prime Minister and Cabinet. National strategic framework for Aboriginal and Torres Strait Islander peoples’ mental health and social and emotional wellbeing 2017–2023. Canberra: Australian Government; 2017. Di Pietro N, Illes J. Closing gaps: strength-based approaches to research with Aboriginal children with neurodevelopmental disorders. Neuroethics. 2016;9(3):243–252. Dudgeon P, Walker R. Decolonising Australian psychology: discourses, strategies, and practice. J Soc Polit Psychol. 2015;3(1):276–97. Dudgeon P, Cox A, Walker R, Scrine C, Kelly K, Blurton D, Bolardaras J, Brennan T, Butorac A, Charles A, Duffin W, Grogan G, Hams K, Hansen C, Holland C, Ingram D, Mascall C, Mia T, Miller D, McGuire V, Murray B, McGrady G, Peckham M, Riley B, Ryder A, Swift S, Taylor N. The voices of our people – national empowerment project promoting cultural, social and emotional wellbeing to reduce distress and suicide in Aboriginal and Torres Strait Islander communities: final report 2013. Perth: University of Western Australia; 2014. Dudgeon P, Milroy J, Calma T, Luxford Y, Ring I, Walker R, Cox S, Georgatos G, Holland C. Solutions that work – what the evidence and our people tell us, Aboriginal and Torres Strait Islander suicide prevention evaluation project report. Canberra: The Commonwealth Department of Prime Minister and Cabinet; 2016.

618

P. Dudgeon et al.

Dudgeon P, Bray A, D’Costa B, Walker R. Decolonising psychology: validating social and emotional wellbeing. Aust Psychol. 2017;52:316–25. Dudgeon P, Bray A, Darlaston-Jones D, Walker R. Aboriginal participatory action research: an indigenous research methodology strengthening decolonisation and social and emotional wellbeing, discussion paper. Melbourne: The Lowitja Institute; 2020. Fogarty W, Lovell M, Langenberg J, Heron M-J. Deficit discourse and strengths-based approaches: changing the narrative of Aboriginal and Torres Strait Islander health and wellbeing. Melbourne: The Lowitija Institute and the National Centre for Indigenous Studies, the Australian National University; 2018a. Fogarty W, Bulloch H, McDonnell S, Davis M. Deficit discourses and indigenous health: how narrative framing of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitija Institute; 2018b. Foley G. Redfern Aboriginal medical service 1971–1991 twenty years of community service. Redfern: Aboriginal Medical Service Cooperative; 1991. http://vuir.vu.edu.au/27033/1/ Redfern%20Aboriginal%20Medical%20Service%201971-1991.pdf Gee G, Dudgeon P, Schultz C, Hart A, Kelly K. Aboriginal and Torres Strait Islander social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, editors. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd ed. Canberra: Commonwealth of Australia; 2014. p. 55–68. Geia L, Sweet M. #IHMayDay: showcasing indigenous knowledge and innovation. Paper presented at 13th National Rural Health Conference, Darwin; 2015. Gibson C, Butler C, Henaway C, Dudgeon P, Michael Curtin M. Indigenous peoples and human rights: some considerations for the occupational therapy profession in Australia. Aust Occup Ther J. 2015;62(3):214–8. Gibson C, Crockett J, Dudgeon P, Bernoth M, Lincoln M. Sharing and valuing older Aboriginal people’s voices about social and emotional wellbeing services: a strength-based approach for service providers. Aging Ment Health. 2018; https://doi.org/10.1080/13607863.2018.1544220. Gilroy J, Uttjek M, Gibson C, Smiler K. Yuin, Kamilaroi, Sámi, and Maori people’s reflections on experiences as ‘indigenous scholars’ in ‘disability studies’ and ‘decolonisation’. Disabil Global South 2018;5(2):1344–1364. Glasgow Centre for Population Health. Asset-based approaches for health improvement; 2017. http://www.gcph.co.uk/work_themes/theme_4_assets_and_resilience/health_improvement_ asset_based_approaches. Accessed 26 July 2017. Grothaus TIM, McAuliffe G, Craigen L. Infusing cultural competence and advocacy Into strengthbased counseling. J Humanist Couns. 2012;51(1):51–65. https://doi.org/10.1002/j.21611939.2012.00005.x. Gruen RI, Yee TFM. Dreamtime and awakenings: facing realities o remote area Aboriginal health. Med J Aust. 2005;182:538–40. Haswell-Elkins M, Hunter E, Wargent R, Hall B, O’Higgins C, West R. Protocols for the delivery of social and emotional wellbeing and mental health services in Indigenous communities: guidelines for health workers, clinicians, consumers and carers. First Edition. Queensland Health, Cairns: Australian Integrated Mental Health Initiative, Indigenous Stream in North Queensland for Northern Area Health Services; 2009. Henson M, Sabo S, Trujillo A, Teufel-Shone N. Identifying protective factors to promote health in American Indian and Alaska native adolescents: a literature review. J Prim Prev. 2017;38(1–2): 5–26. Hinton R, Nagel T. Evaluation of a culturally adapted training in Indigenous mental health and wellbeing for the alcohol and other drug workforce. ISRN Public Health; 2012. Hunter E. Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote indigenous Australians. Aust J Rural Health. 2007;15:88–9. International Union for Health Promotion and Education (IUHPE) [n.d], Introduction. http://www. iuhpe.org/index.php/en/. Accessed 26 July 2017.

27

Social and Emotional Well-Being: “Aboriginal Health in Aboriginal Hands”

619

Jain S, Cohen AK. Fostering resilience among urban youth exposed to violence: a promising area for interdisciplinary research and practice. Health Educ Behav. 2013;40(6):651–662. Keating P. Redfern speech. 1992; 10th December. https://antar.org.au/sites/default/files/paul_keat ing_speech_transcript.pdf Lin I, Green C, Bessarab D. ‘Yarn with me:’ applying clinical yarning to improve clinician–patient communication in Aboriginal health care. Aust J Prim Health. 2016;22(5):377–82. Lindeman MA, Smith K, LoGiudice D, Elliott M. Community care for indigenous older people: an update. Australas J Ageing. 2016; https://doi.org/10.1111/ajag.12316. Lowell A, Maypilama L, Fasoli L, Guyula Y, Guyula A, Yunupiŋu M, Godwin-Thompson J, Gundjarranbuy R, Armstrong E, Garrutju J, McEldowney R. The ‘invisible homeless’ – challenges faced by families bringing up their children in a remote Australian Aboriginal community. BMC Public Health. 2018;18(1):1–14. https://doi.org/10.1186/s12889-018-6286-8. Manning M, Ambrey CL, Fleming CM. Indigenous wellbeing in Australia: evidence from HILDA. CAEPRE working paper no. 101. Canberra: Centre for Aboriginal Economic Policy Research; 2015. Markham F, Biddle N. Income, poverty and inequality. Canberra: Centre for Aboriginal Economic Policy Research; 2018. Marmion D, Obata K, Troy JF. Community, identity, wellbeing the report of the second national indigenous language survey. Canberra: Australian Institute of Aboriginal and Torres Strait Islander Studies; 2014. McCoy B. Suicide and desert men: the power and protection of kanyirninpa (holding). Australas Psychiatry. 2007;15(supplement):S63–7. Mia T, Dudgeon P, Mascall C, Grogan G, Murray B, Walker R. An evaluation of the national empowerment project cultural, social and emotional wellbeing program. J Indigenous Wellbeing. Te Mauri-Piatisiwin. 2017;2(2):33–48. Mittelmark MB, Bull T, Bouwman L. Emerging ideas relevant to the Salutogenic model of health. In The handbook of Salutogenesis (pp. 45–56). Springer, Cham; 2017. Monchalin R, Lesperance A, Flicker S, Logie C, Native Youth Sexual Health. Sexy Health Carnival on the Powwow Trail: HIV prevention by and for Indigenous youth. Int J Indig Health. 2016;11 (1):159–176. https://doi.org/10.18357/ijih111201616011. Nagel T, Hinton R, Griffin C. Yarning about Indigenous mental health: translation of a recovery paradigm to practice. Adv Mental Health. 2012;10(3):216–223. National Aboriginal Community Controlled Health Organisation. NACCHO vision; 2019. Available at https://www.naccho.org.au/about-nacho/naccho-vision/ National Aboriginal Health Strategy Working Party. A national Aboriginal health strategy. Canberra: National Aboriginal Health Strategy Working Party; 1989. Nelson A, Abbott R, Macdonald D. Indigenous Austalians and physical activity: using a social– ecological model to review the literature. Health Educ Res. 2010;25(3):498–509. Neumayer H. Changing the conversation: strengthening a rights-based holistic approach to Aboriginal and Torres Strait Islander health and wellbeing. Indig Allied Health Austr Canberra; 2013. Palmer D. ‘We know they healthy cos they on country with old people’: demonstrating the value of the Yiriman Project 2010–2013; 2013. Available from http://kalacc.org/wp-content/uploads/ 2018/06/yiriman-project-11_12_2013.pdf Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511. https://doi.org/ 10.1371/journal.pone.0138511. Payne D, Olson K, Parrish JW. Pathway to hope: an indigenous approach to healing child sexual abuse. Int J Circumpolar Health. 2013;72:534–540. Priest N, Mackean T, Davis E, Briggs L, Waters E. Aboriginal perspectives of child health and wellbeing in an urban setting: developing a conceptual framework. Health Sociol Rev. 2012; 21(2):180–195.

620

P. Dudgeon et al.

Priest N, Thompson L, Mackean T, Baker A, Waters E. “Yarning up with Koori kids” – Hearing the voices of Australian urban Indigenous children about their health and well-being. Ethn Health. 2016;1–17. https://doi.org/10.1080/13557858.2016.1246418. Prilleltensky I. Promoting well-being: time for a paradigm shift in health and human services. Scand J Public Health. 2005;33(66_suppl):53–60. Prentice T. Visioning health: using the arts to understand culture and gender as determinants of health for HIV-positive Aboriginal women (PAW) (Doctoral dissertation, Université d’Ottawa/ University of Ottawa); 2015. Prince D. Stories from community: how suicide rates fell in two indigenous communities. Sydney: Healing Foundation; 2018. Radford AJ, Harris RD, Brice GA, van der Byl M, Monten H, Matters D, Neeson M, Bryan L, Hassan RJ. Taking control: a joint study of Aboriginal social health in Adelaide with particular reference to stress and destructive behaviours, 1989–1989, Monograph 7. Adelaide: Department of Primary Health Care, Flinders University, South Australia; 1990. Rasmussen M, Guo X, Wang Y, Lohmueller KE, Rasmussen S, Albrechtsen A, …, Kivisild T. An Aboriginal Australian genome reveals separate human dispersals into Asia. Sci. 2011;334 (6052):94–98. Rose D, James D, Watson C. Indigenous kinship with the natural world in New South Wales. Huntsville: NSW National Parks and Wildlife Service; 2003. Rowley KG, et al. Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow up in a decentralised community. Med J Aust. 2008;188(5):283–7. Rowley K, Doyle J, Johnston L, Reilly R, McCarthy L, Marika M, Riley T, Atkinson P, Firebrace B, Calleja J, Cargo M. Strengths and limitations of a tool for monitoring and evaluating First Peoples’ health promotion from an ecological perspective. BMC Public Health. 2015;15:1215. https://doi.org/10.1186/s12889-015-2550-3. Saleeby D. The strengths based perspective in social work: extensions and cautions. Soc Work. 1996;41(3):296–305. Sheldon M. Reviewing psychiatric assessment in remote Aboriginal communities. In: Purdie I, Dudgeon P, Walker R, editors. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice; 2010. p. 211–22. Sheldon I. Globalization and the rural–urban divide. J Agric Econ. 2012;63(2):487–489. Smith K, Grundy JJ, Nelson HJ. Culture at the centre of community based aged care in a remote Australian Indigenous setting: a case study of the development of Yuendumu Old People’s Programme. Rural Remote Health. 2010;10(4):1422. Smith S, O’Grady L, Cubillo C, Cavanagh S. Using culturally appropriate approaches to the development of kids matter resources to support the social and emotional wellbeing of Aboriginal children. Aust Psychol. 2017;52:299–305. Social Health Reference Group. Social and emotional well being framework: a national strategic framework for Aboriginal and Torres Strait Islander mental health and social and emotional well being. Canberra: Department of Health and Ageing; 2004. Swan P, Raphael B. Ways forward: National Aboriginal and Torres Strait Islander mental health policy national consultancy report. Canberra: Department of Health and Ageing; 1995. Sweet M, Geia L, Dudgeon P, McCallum K. # IHMayDay: tweeting for empowerment and social and emotional wellbeing. Austr Psychiatry. 2015;23(6):636–640. Tagalik S. A framework for indigenous school health: foundations in cultural principles. Prince George, BC: The National Collaborating Centre for Aboriginal Health; 2009. Thomas Y, Gray MA, McGinty S. An exploration of subjective wellbeing among people experiencing homelessness: a strengths-based approach. Soc Work Health Care. 2012;51(9):780–797. United Nations. United Nations declaration on the rights of indigenous people. New York: United Nations; 2007. http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf. Accessed June 2010.

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West R, Foster K, Stewart L, Usher K. Creating walking tracks to success: a narrative analysis of Australian Aboriginal and Torres Strait Islander nursing students’ stories of success. Collegian. 2016;23(4):349–354. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:14.1–14.21. Yap M, Yu E. Community wellbeing from the ground up: a Yawuru example. Perth: Bankwest Curtin Economics Centre Research Report 3/16 August; 2016. Zubrick SR, Shepherd C, Dudgeon P, Gee G, Paradies Y, Scrine C, Walker R. Social determinants of social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, editors. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing. Canberra: Commonwealth of Australia; 2014. p. 93–112.

Working with Rural Families: Issues and Responses When a Family Member Has a Mental Illness

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Andrea Reupert, Rochelle Hine, and Darryl Maybery

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protective Factors and Stressors for Families Living in Rural and Remote Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to Support and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burden of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Particularly at-Risk Family Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aboriginal and Torres Strait Islander Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culturally and Linguistically Different (CALD) Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Families Where a Parent Has a Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lesbian, Gay, Bisexual, Trans/Gender Diverse, and Intersex (LGBTI) Individuals and Their Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Systems Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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A. Reupert (*) Krongold Clinic, Faculty of Education, Monash University, Clayton, VIC, Australia e-mail: [email protected] R. Hine · D. Maybery Monash University School of Rural Health, Warragul, VIC, Australia e-mail: [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_29

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Abstract

Mental illness impacts on more than the individual – family members, including children, are inevitably impacted by their relative’s illness. Moreover, the issues for families living with mental illness in rural and remote communities are considerable and often result in an overreliance on families for practical and emotional support. The subsequent burden of care alongside a lack of dedicated and timely services requires a specialized practitioner and systems response. The stigma associated with increased visibility of mental illness in rural and remote areas is another issue that impacts help-seeking and mental health outcomes. While the mental health issues for those living in rural and remote communities are a feature of much research, this chapter provides a new perspective by discussing the specific needs of families living with mental illness in these communities. Particularly at-risk groups including Aboriginal and Torres Strait families, culturally and linguistically different families, and others will also be presented. Implications for practice, services, and professional and resource development conclude the chapter. Structural, organizational, and practice change is required to identify family members and to effectively recognize and address the needs of those with a mental illness and their families.

Introduction Mental illness is a family affair. When an individual is unwell, his or her family are often profoundly impacted. This chapter reviews the literature on families where a member has a mental illness but presents this in a new way, namely, through the lens of living in rural or remote communities. To appreciate the requirements of rural and remote living, it is necessary to understand rural communities and their health service needs. The parameters of “rural realities,” in particular, geography and demography, rural culture, and workforce constraints, are all important considerations when discussing rural health (Strasser and Neusy 2010), though often not considered through the lives of the families living with, or caring for, someone with a mental illness. We employ Osher’s and Osher’s (2002) concept of family, which involves a usercentred definition of who is in one’s “family.” This definition incorporates diverse biological and nonbiological relationships that may not necessarily resemble a traditional nuclear family. In this chapter we explore some of the issues confronted by families who live in rural or remote communities, who have a family member with a mental illness, and some of the supports they turn to along with additional resources they may need. The strategies and approaches that practitioners working with families may employ will also be outlined, alongside the necessary systems responses. Though there is little data about the prevalence of mental illness among people who live in rural and remote Australia, those who live outside of urban areas have

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higher rates of illness, disability, and mortality (Australian Institute of Health and Welfare [AIHW] 2008). Each year 3.6 million Australian adults experience a mental health problem, and approximately 65,000 will attempt, and 2500 people will die, by suicide (National Review of Mental Health Programs and Services 2014). Less than half of those experiencing a mental illness each year will seek treatment. Moreover, all of those with a mental illness will have families who may be a source of trauma and/or a source of healing (Bouverie Centre 2016). Effective rural and remote mental health practice requires an understanding of those who use services, in the context of their particular communities. It is important to note that rural and remote communities are not homogeneous and each community will have a unique set of factors that contribute to the well-being of its members (Wainer and Chesters 2000). Notwithstanding this diversity, some of the common issues and responses are outlined here. Overall, health policy and service planning increasingly focus on providing care for individuals in their home environment. Invariably, this means there is an increased role for family in the treatment of the individual. It is within these circumstances that the following chapter is framed.

Protective Factors and Stressors for Families Living in Rural and Remote Environments Historically, there is a romanticized view of rural communities as homogenous, slow-paced, and close-knit (Wainer and Chesters 2000). Indeed, there are benefits to living in rural areas that contribute to the resilience of individuals, families, and whole communities (Maybery et al. 2009a). Rural communities are known for their high levels of cohesive community support and tend to offer more opportunities for social connection, than urban centres (Hoolahan 2002). In North America, Berry and Okulicz-Kozaryn (2011) found that happiness or well-being was lowest in large central cities and highest in small towns and on the periphery of rural communities. Likewise, in Australia, life in rural settings, particularly country towns, is associated with higher levels of well-being than in urban locations (Cummins et al. 2005). The reasons for these differences vary but may be related to commuting time, access to green spaces, and a sense of community. Notwithstanding these benefits, living in rural or remote communities brings specific stressors to families, not normally experienced by those residing in urban areas. In recent times, Australian families living in rural areas have been adversely impacted by financial insecurity resulting from years of drought and global competitive markets (Maybery et al. 2010). Likewise, unreliable and expensive communications, rising fuel prices, and a lack of access to fresh food, safe housing, and adequate educational services add further pressures to families (McMurry and Clendon 2014). Due to a lack of educational opportunities in remote areas, some young people leave home to study in urban settings. When the family business is farming, their departure can create additional work pressures for those left behind (McMurry and Clendon 2014). Overall, those living in rural areas have higher rates

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of unemployment, lower income, and lower rates of secondary school completion, than those living in urban areas (McMurry and Clendon 2014). Other issues for rural families pertain to inadequate access to mental health treatment, the stigma associated with mental illness, and the overreliance on the family for support, resulting in a burden of care for families who care for, or live with, someone with a mental illness. Each of these issues is further explored below. Particularly vulnerable families in rural and remote communities are then described, followed by strategies that practitioners might employ.

Access to Support and Treatment People with a mental illness and their families have various needs and accordingly require a range of supports. For many living in rural or remote areas, the general practitioner (GP) is the primary or only source of continuing care for people who have experienced a mental illness (AIHW 2004). However, waiting lists for GPs are long, and there are often low rates of bulk billing in rural areas (Rickwood 2006). Additionally, given the low numbers of available GPs, their focus is inevitably on crisis management rather than prevention, continuing care, and/or relapse prevention. Similarly, in terms of their expertise in assessment and treatment of those with a mental illness, Fleury et al. (2012) found that GPs primarily employed clinical intuition with few clinical tools and described limited access to specialist systems and underdeveloped shared care models. In the face of constrained and often stretched services, the family is often left to respond to and care for those with severe and/or chronic mental illnesses. Additionally, rarely do GPs address the psychological needs of families caring for their ill relative even though many consider it important to do so. One Australian study found that GPs regarded mental health consultations as an opportunity to engage with individuals about their family. For example, one GP stated, “I am often the first port of call and the health professional who raises and discusses mental health issues within the family” (Reupert et al. 2017, p. 332). However, in the same study, a major issue for GPs when working with families was how their client base was defined, with many pointing out that they were not paid to work with family members (Reupert et al. 2017). Moreover, many GPs were not aware of the services that might be offered to families and acknowledged the lack of specialized mental health services for those with a mental illness and their families (Reupert et al. 2017). Additionally, working with families requires a dedicated interdisciplinary and interagency stance. However, some GPs regard the case management and coordination of patient’s mental illness and the needs of their families as burdensome because it requires time, flexibility, and emotional investment and must be provided in addition to already busy workloads (Fleury et al. 2012; Reupert et al. 2017). Given the lack of other services, many rural people make greater use, than their urban counterparts, of hospital emergency departments (AIHW 2008). Additionally, many communities have no resident specialist mental health service and instead rely on visiting services (Rickwood 2006). This means that individuals have to travel to

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regional or urban areas where the services they require are available (Rickwood 2006), often leaving their family and friends behind. For families with children, such separations may be especially traumatic (Foster et al. 2016). Meeting the costs of accommodation as well as missing school or work is an issue for those who have to travel for services, including their family (Rickwood 2006). Given the low number of specialized mental health professionals in rural and remote areas, the importance of social, education, and community agencies is critical. Sources of support might be drawn from schools, the police, publicans, nurses, and community groups such as playgroups or sporting clubs. Hence, these groups may require professional development, resourcing, and support in terms of how they might promote inclusion and connectedness, support mental health and well-being, and learn to identify and respond proactively to the early warning signs of mental illness. Notwithstanding the many access issues for families, there are positives for mental health practitioners practicing in rural and remote areas. Given the limited availability of services in these settings, health professionals and service providers often work closely together as they may know each other well (Hoolahan 2002). This means that various services who work with different family members (e.g., adult mental health services and child and adolescent mental health services) have the opportunity to collaborate and share information.

Stigma A common barrier to seeking help in rural and remote communities is stigma. Stigma has been defined as an “attribute that is deeply discrediting” and one which reduces the bearer of the attribute “from a whole and usual person to a tainted, discounted one” (Goffman 1963, p. 3). For many, stigma is as distressing as the mental illness symptoms themselves (Phelan 2005). Stigma does not only impact on the individual, however, as family members may also be adversely affected due to their association with someone with a mental illness (Hinshaw 2005). In this way, a child whose parent has a mental illness might be considered to be contaminated by their parent, either genetically or by association (Corrigan and Miller 2004). Similarly, family members might be blamed for their relative’s illness (Karnieli-Miller et al. 2013; Reupert and Maybery 2015). The ways in which others within the local community (both service providers and community members) respond to people with mental illness can be indicative of negative views toward mental illness, which may lead to discrimination and exclusion (Wilkinson and Marmot 2003). Cremers, Cogan, and Twamley (2014) found that mothers with mental illness living in rural areas were subjected to stigma and experienced a sense of inclusion. Stevens (1998, cited in Welch 2000) argued that within rural communities, strong social rules exist which limit people’s behavior and may close opportunities for further support. There are several consequences of stigma for those with a mental illness and their families in rural areas, who in the first instance might withdraw, rather than seek

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support, from appropriate mental health and support services (Hoolahan 2002). The shame associated with a mental illness may lead family members to avoid social contact or avoid being seen in public with their ill relative. Family members may spend energy and resources hiding the secret from others (Larson and Corrigan 2008). Accordingly, many families learn the “art of selective disclosure” in terms of what, and to whom they share information with, or alternatively, decide not to share information with anyone (Karnieli-Miller et al. 2013). Dealing with the discriminatory behavior resulting from stigmatizing beliefs around mental illness is a major issue for those living in rural and remote areas. For instance, one of the rural parents with a mental illness interviewed by Reupert, Jones, Sutton, and Maybery (2015b, p. 11) stated that because “everyone knew everyone’s business,” it was hard to seek help or to “make a fresh start.” Accordingly, episodes of illness and use of treatment services may be more visible in rural areas, having ramifications for the relationships, housing, employment, and inclusion, not only for the individual with the mental illness but also for the family. Likewise, privacy is an issue in relation to accessing services in small communities and their families. People may be concerned about being recognized in public venues such as doctor’s surgeries and chemists. Stigma may be especially pronounced in rural and remote communities because visibility and informal communication channels (i.e., gossip) may lead to an increased likelihood of community members finding out about someone’s illness. For example, teachers in rural schools learnt that a student had a parent with a mental illness by informal chats with other teachers in the staff room or in the community (Reupert and Maybery 2007a). The second way of identifying these at-risk children was from the student himself or herself, and the third was from the school counsellor or principal. Such results highlight the lack of a formal, systematic system of identifying at-risk families in rural and remote schools. Similarly, in a study with a small cohort of mothers residing in rural Ireland, Cremers et al. (2014) found concerns regarding the “close-knittedness” of their communities, resulting in fears about being observed and negatively judged by others (p. 100). Participants stated that this occurred both in a social context and in interactions with healthcare professionals. For rural grandmothers who are primary carers for their grandchildren, social exclusion exacerbated other challenges such as poverty, stress, and ill-health (Thomas 2011). Men who have a mental illness, especially fathers living in rural and remote locations, face particular forms of stigma because they may be seen as not living up to masculine ideals of strength, self-sufficiency, and control (Price-Robertson et al. 2015). Galasinski (2013) reiterated this theme when he highlighted some of the issues for fathers with a mental illness: . . .Expectations of what it means to be a man: active, enterprising, tough and powerful. But on the other hand, mental illness undermines all this. Social perceptions of mental illness are precisely the opposite of what it is to be a role model, while the illnesses often prevent men from being “manly.” (p. 1)

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In rural areas, a stoic exterior is the dominant cultural norm for many men, with seeking help for a mental health concern being interpreted as a personal weakness by both the men themselves (self-stigma) and from the broader community (public stigma). Accordingly, men may not talk to, nor ask for help from, their family or others, including mental health practitioners. Rural fathers with a mental illness may face other issues, e.g., men who have a mental illness have reported that because of their illness, they were automatically seen as a risk to their children and so were “under observation” (Price-Robertson et al. 2015, p. 4). Joe and His Family

At 18 years of age, Joe experienced a psychotic episode. He was subsequently hospitalized in a large regional centre. His mother, a single parent, did not understand his mental illness, although she experienced guilt associated with Joe witnessing family violence as a child, perpetrated by an ex-partner. She made sure that Joe’s diagnosis and treatment was “kept quiet” and told no one. Joe’s friends and other family members did not know that he had been hospitalized. How Services Might Help Services need to ask Joe what involvement he wants his family to play in his treatment planning, how services might communicate with them, and possible constraints around confidentiality (what can be released to his mother). His mother should be provided with psychoeducation about the nature of the illness, local service options, and strategies for how they can best support him and her. As his closest family member, his mother needs to be actively engaged in his discharge and follow-up treatment options. While in hospital, Joe’s mother needs to be informed about his progress; this might be via videoconferencing or some other online medium. In the longer term, carer respite might need to be arranged. To promote community understanding, a mental health first-aid course for the local community might be delivered, including participants from Joe’s Football Club Football-Netball Club and local employers.

Burden of Care Not all people with a mental illness require hospitalization nor can access timely support; instead many will receive support and care from their family. In rural areas, the burden of caring for someone with a mental illness may be more pronounced than in urban areas. As services and resources are scarce, individuals with a mental illness may rely on family members more so than formal and qualified mental health professionals (Hunsucker et al. 1999). Caring for someone with a mental illness often results in a disproportionate burden on women with

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nurturing others traditionally viewed as women’s work (Wuest 1998). Children, particularly in single-parent families, may be required to shoulder a burden of care beyond the familial obligations usually associated with childhood. Reliance on others within the family may be compounded for indigenous and migrant families living in rural and remote areas which may have few culturally sensitive resources to assist them. Those assuming a caring role may experience sustained emotional, physical, and financial hardship. Burdens may be objective, for example, a drop or loss in income and constraints in leisure, social, and work activities which may in turn contribute to ill-health. The burden of care may also be subjective, defined in terms of how caregivers feel about being a carer, e.g., exhaustion, shame, embarrassment, feelings of guilt, and self-blame (Saunders 2003). Notable issues for caregivers include the lack of respite and constantly being “on call.” While temporary caring responsibilities may offer rich emotional rewards, promote close family ties, and promote skill development, in the long term, carers often find that their own resources, including time, energy, finances, and autonomy, are diminished. Family members who provide care also lack specialized services and support that they might otherwise access if they lived in urban areas, such as carer support groups or respite programs. Without large numbers of carers requiring service at one time, rural areas often lack the demand or critical mass required to make such services feasible.

Particularly at-Risk Family Groups As well as the generic issues highlighted above, some particularly at-risk family groups experience additional challenges.

Intimate Partner Violence Rural life might be especially problematic for people exposed to intimate partner violence, as their isolation may further amplify their loneliness and reliance on the perpetuator (McMurry and Clendon 2014) as well as reduced access to support from others. Some rural women become trapped in violent relationships through “financial insecurity, dependency, and stress; and stigma attached to the public disclosure of violence” (Wendt 2009, p. 175). A number of factors place people who live in rural and remote areas at particular physical and psychological risk. These include the distance from services (including police), high levels of gun ownership in country areas, and a lack of public transport (Wainer and Chesters 2000). The culture of rural communities where traditional gender stereotypes prevail may harbor violence supporting attitudes and behavior toward women (Flood and Pease 2009).

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Aboriginal and Torres Strait Islander Families Many rural and remote communities are home to significant populations of people from Aboriginal and Torres Strait Islander backgrounds (Australian Bureau of Statistics [ABS] 2002). Although some Aboriginal and Torres Strait Islander adults access community mental health services (AIHW 2011), there is evidence to suggest that this represents an underutilization. For Aboriginal and Torres Strait families, issues around a lack of privacy and confidentiality are amplified due to not only small communities but also because an individual may be well-known or related to the service provider. This means that those employed within Aboriginal and Torres Strait Islander health care have nowhere to attend where their anonymity can be assured (if this is their preference). Additionally, Aboriginal and Torres Strait families may experience extreme difficulty in maintaining professional boundaries when service users are close relatives or friends, who seek assistance outside of “office hours.” Family and kinship networks are paramount in Aboriginal and Torres Strait Islander communities, and the term may have broader interpretations than in nonindigenous contexts, incorporating extended family, community, and cultural connections and involving specific reciprocal roles and responsibilities (Pascoe 2012). Historic and contemporary issues including economic disadvantage, the gap in health outcomes, child custody loss resulting in stolen generations, high imprisonment rates, family violence, and ongoing discrimination continue to have a profound impact on the mental health and well-being of Aboriginal and Torres Strait Islander families (Holland 2016).

Culturally and Linguistically Different (CALD) Families In rural communities there are significantly smaller populations of families from non-English-speaking and culturally diverse backgrounds as 82% of people born overseas reside in Australia’s capital cities (ABS 2012). This means that there is a dearth of specialist CALD services in rural and remote locations and an increased likelihood of social marginalization. As rural communities can comprise stable populations with long-term social relationships that sometimes span generations, newcomers to the location may experience obstacles to social connection (Wainer and Chesters 2000), and language or cultural barriers can exacerbate these difficulties. Racism can be prevalent in rural communities (Wainer and Chesters 2000), meaning that people from CALD backgrounds may face discrimination in their attempts to gain employment, education, social supports, and health services. Language and cultural barriers create difficulties in accessing appropriate services for those experiencing mental illness and those in caring roles. While health and community services are legally obliged to use interpreters when individuals are not proficient in English, a lack of practitioner experience may compromise access to

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this service as well as the quality of the experience. Although the practice is prohibited (Victorian Government Department of Health, Rural and Regional Health and Aged Care Services 2009), there are occasions when family members are used as interpreters, and this can result in inaccurate interpretations, a silencing of the consumer, diminished trust in the healthcare system, and the breaching of confidentiality within the family. Family obligations may be placed upon children for such tasks as communication and negotiating service access, as they are often the first in their family to learn the new language and customs.

Families Where a Parent Has a Mental Illness It has been estimated that between 21% and 23% of families have a parent with a mental illness (Maybery et al. 2009b). Children whose parents have a mental illness are more likely than other children to acquire their own mental health difficulties, behavioral disorders, and to drop out of school (Reupert and Maybery 2007b). These adverse outcomes arise from both genetic and environmental sources (Reupert et al. 2012b). While there is widespread policy recognition that services need to support the children in these families, several studies have shown that mental health professionals do not know how to engage and support the children of their service users (Maybery and Reupert 2009; Reupert et al. 2012b). Various e-learning resources are available for professional development in this area, which rural practitioners have found to be of use (Reupert et al. 2011, 2015d; Tchernegovski et al. 2015). However, there is a lack of monitoring and service evaluation in this area, and it is often up to the individual practitioner to decide whether and how to work with a consumer’s children. Some youth in these families find peer support from other youth living in similar families to be useful (Reupert et al. 2012a). Peer support groups provide safe opportunities for young people to socialize and normalize the issues facing their families, in conjunction with psychoeducation and respite. There are few such programs in rural and remote areas however because of the difficulties in assembling a sufficient number of eligible children in one location and ensuring facilitators are adequately trained (Reupert et al. 2012a, b). For rural and remote youth, online support might be especially advantageous. Most online interventions for these youth are available in the Netherlands (see, e.g., Drost et al. 2011) with another having been recently developed in Australia (Reupert et al. 2018). There are also issues regarding the burden of care. Children growing up with a parent with mental illness may need to provide physical care for the parent, younger siblings, assume household responsibilities such as cooking and shopping, and provide emotional support to their parent (Reupert and Maybery 2007b). Excessive caring may result in dropping out of school and less opportunities for social opportunities. In rural locations, the social and political context of families, including the roles and responsibilities of each member and how these may be ascribed according to age, gender, and culture, will impact on the resources and supports they have at their disposal.

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Case Study: The Thompson Family

Philippa and Steve have three children, aged 5, 9, and 12. Philippa and Steve ran a family carpentry business in a small country town, but times have been tough, and they have been working long hours to make ends meet. Their youngest child has just started school and is not coping well with the transition. Philippa has a history of the “baby blues” after the birth of each of her children but lately has been feeling much worse. She is increasingly irritable with her family, struggles to get out of bed, and is feeling increasingly hopeless. She was prescribed antidepressants from her local GP though negative thoughts, especially around suicide, remain. Once she disclosed her suicidal thoughts, Philippa was hospitalized in a psychiatric ward in a large regional town some 200 kms. away. How Services Might Help the Family Someone (preferably within the family) needs to talk with the children about what is happening to Philippa, why she is away, and answer any questions or concerns they might have. Such conversations need to be provided in a child-centred, age-appropriate, and sensitive way (see Reupert et al. 2015a). If Steve talks with his children, he may need some support in doing this. Philippa and her children need an opportunity to remain in contact, for example, by telephone, email, facetiming, or visiting. Staff need to encourage this contact while Philippa is in hospital; if a visit is organized, family-friendly facilities should be available so the family can safely meet. While Philippa is away, the family might need support for various domestic issues in terms of transport and running the household. The children may assume some of the responsibilities, but this needs to be monitored. Steve also needs to be supported, offered respite as required, and, if needed, provided with psychoeducation about his wife’s illness. Current follow-up treatment to Philippa needs to incorporate her parenting role. Together with the family, services might need to monitor how the children are progressing.

Lesbian, Gay, Bisexual, Trans/Gender Diverse, and Intersex (LGBTI) Individuals and Their Families In a national wide survey of same-sex partnered families, the Bouverie Centre (2012) found that just over 40% of the same-sex parented families surveyed lived in the inner metropolitan area, while 35% lived in the outer metropolitan area, 16% of participants lived in regional areas, and 7% lived in rural/remote areas. Confidentiality is particularly important for these families living in rural and remote areas. As well, same-sex parented families in rural and remote parts of Australia may not be as well connected to other same-sex parented families as those living in inner-city locations.

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Other issues occur in families when a youth is identified as LGBTI. Young people residing in rural Australia who identify their sexual identity as other than heterosexual have highlighted key issues around health, well-being, and safety. Hillier et al. (2010) found that rates of “self-harm, suicidal ideation and suicide attempts were higher in rural areas” (p. 96) compared to same-sex attracted young people living in metropolitan areas. Many young people who are exploring their sexual and gender identity move to urban settings where their anonymity is possible and they can build connections with a “gay community” (Hillier et al. 2010, p. 96). There are few resources or peer networks for parents or carers in rural and remote areas, in terms of how they might support their child’s exploration of their sexual identity, and negative responses may exacerbate the young person’s mental distress.

Practice Implications Notwithstanding the isolation, stigma, and lack of specialist services, there is still much that practitioners located in rural and remote areas can do, to support those with a mental illness and their families. As outlined in the next section, for practitioners to deliver family-focused practices, adequate infrastructure and systems support is required. It is critical that practitioners move away from individualized treatment services and instead acknowledge that those with a mental illness may hold multiple family roles such as caring for dependent children. Hence, it is essential that practitioners ask all consumers about their family roles in the past, currently, and as a future aspiration, such as their dreams of being in a relationship or having children. Consumers’ parenting status needs to be identified, regardless of custody status (Maybery and Reupert 2009). Acknowledging and celebrating these family roles can assist in recovery and provide opportunities to facilitate a strengths-based approach that might be missing in individually focused treatment. Additionally, practitioners need to acknowledge that family members contribute in many ways to a consumer’s recovery journey. This means that practitioners need to ascertain how the consumer defines his or her family and what involvement they want them to play in their care and treatment. Identifying an individual’s family allows practitioners to decide whether and/or how to draw on an individual’s family as a potential source of practical and emotional support for an individual. Some studies have highlighted the need to provide family members (including children) with psychoeducation (Grove et al. 2015; Reupert and Maybery 2007b; Reupert et al. 2015c) which includes information about the consumer’s mental illness diagnosis and prognosis. Additional information might provide an orientation to what different services could offer the family and their ill relative. How to manage potentially volatile or stressful times might also be included if there are concerns about violence or suicide. Overall, the opportunity to talk “with” rather than “to” family members is critical so that the family has the opportunity to ask questions, process their experiences of their relative’s illness, and contribute their knowledge to treatment planning, including medication. Understanding more about their relative’s

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illness may alleviate the guilt and shame that families may associate with their relative’s illness, normalize what is happening, and empower families to seek help for their own needs. Practitioners also need to collaborate with other services to address the family’s own needs. This might, for example, include respite for excessive caring or arranging for transport to visit their ill relative in hospital. There are multiple benefits associated in supporting a consumer’s family, where enhancing the well-being of carers leads to a reduction in household tension which in turn is conducive to an environment in which the consumer may cope better, thereby reducing the risk of relapse (Lakeman 2008). Finally, there is some debate in the literature as to whether to, and how to, release consumers’ treatment information to their family (Marsh and Johnson 1997; Stanbridge et al. 2009). Marsh and Johnson (1997) argued that if the release form is presented at the right time, namely, when the consumer is well enough to provide informed consent and when explained carefully by the practitioner as a means of enhancing treatment, most consumers are willing to authorize the release of relevant information to their families. The release of information to the family is especially important to harness the support of families in the care of their ill relative and respect their input in ongoing care. Consent is an ongoing conversation rather than a single event, and the barriers to, as well as benefits of, providing consent need to be explored. Likewise, the right of consumers to withdraw consent for the release of information to family members needs to be respected.

Systems Change As mental health outcomes in families are driven by a complex interplay of various factors, a public health approach is needed that focuses on social justice outcomes. This means funding and resources need to be directed to the economic, housing, employment, and health inequities of Aboriginal and other communities. Additionally, public health initiatives need to be designed to prevent violence and address homophobia, within the context of rural and remote communities. Such efforts will reduce the prevalence and burden of mental illness in future generations. There are several other service initiatives that might be provided. Telemental health provides an innovative way of delivering services to those with a mental illness and their families in rural and remote areas, by allowing them to participate in consultations with a mental health provider. Similarly, the Internet provides families with access to psychoeducational information about mental illness and creates opportunities to connect people with others living with mental illness (Christensen et al. 2002). Mental health systems need to promote such services and ensure that there is adequate organizational support to not only develop these sites in the first instance but also to fund ongoing staff to deliver synchronous support online. Services need to ensure that there is adequate infrastructure to support the identification of a consumer’s family status and the presence of dependent children and other family members, for example, on intake forms when a consumer is

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hospitalized or otherwise enters a service. Likewise, there need to be clear procedures for supporting and working with the family members of those with a mental illness, across the continuum of services, namely, from intake, screening, and referral, negotiating a treatment or recovery plan, delivery of treatment, evaluation, and, finally, discharge (Goodyear et al. 2015). Respite services should be made available for family members who assume a major caring role. Waiting rooms need to be family friendly, where, for example, toys are available and there are safe spaces in psychiatric wards for children to visit their parents. Psychoeducational resources should be actively offered to family members along with local information about services that might be useful for their relative as well as for themselves. Working with consumers and their families requires adequate time as well as opportunities for professional development and supervision, both of which needs to be provided at a systems level. Additional time is also needed for initiating and delivering inter-professional shared care models among different services, a key factor when supporting the complex needs of families. Given the lack of specialized services in rural and remote areas, training and supervision need to be provided to nonmental health community and volunteer groups in this area, for example, Mental Health First Aid (Kitchener and Jorm 2002) or specific to working with families, such as the online resource, Keeping Families and Children in Mind (Reupert et al. 2011).

Concluding Comments and Recommendations An individual’s mental illness impacts other family members’ well-being; at the same time, family functioning may impact the individual with the illness. The informal care provided by family members to an individual with a mental illness is especially pronounced in rural and remote areas where services are limited and there is a high level of stigma associated with mental illness and help-seeking behavior. Not all families will have the same experiences, and there are particular at-risk families that require special attention. Notwithstanding these issues, there is much that practitioners and services might do, to identify and address the needs of families and their ill relative. A substantial investment in time and funding is recommended in rural and remote areas to ensure that innovative services such as telehealth are provided and that services no longer focus on the consumer only but instead support and care for the consumer within the context of his or family.

Take-Home Messages • Mental health outcomes for individuals and their families are influenced by a complex interplay of various social determinants of health. • Promoting mental health of individuals and families is the responsibility of mental health services and others, e.g., local government and education.

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• Stigma is a significant barrier to service access. Racism, homophobia, and other types of discrimination exacerbate mental illness stigma and increase the vulnerability of particular population groups. • A whole systems response is required to identify and adequately meet the needs of those with a mental illness and their families.

Cross-References ▶ Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas ▶ General Practitioners ▶ Rural and Remote Mental Health Practice: Nursing Roles ▶ Rural and Remote Psychiatry ▶ Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand

References Australian Bureau of Statistics. Australian Capital Territory in focus 2002. Cat. no. 1307.8. Canberra: ABS; 2002. Australian Bureau of Statistics. Cultural diversity in Australia: reflecting a nation, stories from the 2011 census. Cat. no. 2071.0.4. Canberra: ABS; 2012. Australian Institute of Health and Welfare. Australia’s health 2004. Australia’s health no. 9. Cat. no. AUS 44. Canberra: AIHW; 2004. Australian Institute of Health and Welfare. Australia’s health 2008. Cat. no. AUS 99. Canberra: AIHW; 2008. Australian Institute of Health and Welfare. Australia’s welfare 2011. Cat. no. AUS 142. Canberra: AIHW; 2011. Berry BJ, Okulicz-Kozaryn A. An urban-rural happiness gradient. Urban Geogr. 2011;32(6):871–33. Bouverie Centre. Guidelines for healthcare providers working with same-sex parented families. Melbourne: La Trobe University; 2012. Retrieved October 24, 2016, from http://www.bouverie. org.au/images/uploads/Bouverie_Centre_Guidelines_for_working_with_Same_Sex_Parented_ Families.pdf Bouverie Centre. From individuals to families: a client-centred framework for involving families. Melbourne: La Trobe University; 2016. Retrieved June 17, 2016, from http://www.bouverie. org.au/images/uploads/Bouverie_Centre_Framework.pdf Christensen H, Griffiths KM, Evans K. E-mental health in Australia: implications of the internet and related technologies for policy. ISC discussion paper no. 3. Canberra: Commonwealth Department of Health and Ageing; 2002. Retrieved October 25, 2016, from http://unpan1.un.org/ intradoc/groups/public/documents/apcity/unpan046316.pdf Corrigan PW, Miller FE. Shame, blame, and contamination: a review of the impact of mental illness stigma on family members. J Ment Health. 2004;13:537–48. Cremers GE, Cogan NA, Twamley I. Mental health and parenting in rural areas: an exploration of parental experiences and current needs. J Ment Health. 2014;23(2):99–104. https://doi.org/ 10.3109/09638237.2014.889283. Cummins RA, Davern M, Okerstrom E, Lo SK, Eckersley R. Australian unity wellbeing index: special report on city and country living. Melbourne: Deakin University; 2005. Retrieved October 25, 2016, from http://www.acqol.com.au/reports/survey-reports/survey-012-1-report.pdf Drost LM, Cuijpers P, Schippers GM. Developing an interactive website for adolescents with a mentally ill family member. Clin Child Psychol Psychiatry. 2011;16:351–64.

638

A. Reupert et al.

Fleury M, Imboua A, Aube D, Farand L, Lambert Y. General practitioners’ management of mental disorders: a rewarding practice with considerable obstacles. BMC Fam Pract. 2012;13:19. Flood M, Pease B. Factors influencing attitudes to violence against women. Trauma Violence Abuse. 2009;10(2):125–42. https://doi.org/10.1177/1524838009334131. Foster K, Maybery D, Reupert A, Gladstone B, Grant A, Ruud T, Falkov, A.,& Kowalenko, N. Family-focused practice in mental health care: an integrative review. Child Youth Serv. 2016;37 (2):129–55. Galasinski D. Fathers, fatherhood and mental illness: a discourse analysis of rejection. Hampshire: Palgrave Macmillan; 2013. Goffman E. Stigma: notes on the management of spoiled identity. London: Penguin; 1963. Goodyear M, Hill TL, Allchin B, McCormick F, Hine R, Cuff R, O’Hanlon B. Standards of practice for the adult mental health workforce: meeting the needs of families where a parent has a mental illness. Int J Ment Health Nurs. 2015;24:169–80. https://doi.org/10.1111/inm.12120. Grove C, Melrose H, Reupert A, Maybery D, Morgan B. When your parent has a mental illness: children’s experiences of a psycho-educational intervention. Adv Ment Health. 2015;13(2): 127–38. Hillier L, Jones T, Monagle M, Overton N, Gahan L, Blackman J, Mitchell A. Writing themselves in 3: the third national study on the sexual health and wellbeing of same sex attracted and gender questioning young people. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University; 2010. Retrieved October 25, 2016, from http://www.glhv.org.au/files/ wti3_web_sml.pdf Hinshaw SP. The stigmatization of mental illness in children and parents: developmental issues, family concerns, and research needs. J Child Psychol Psychiatry. 2005;46(7):714–34. https:// doi.org/10.1111/j.1469-7610.2005.01456.x. Holland C. Progress and priorities report 2016. The close the gap campaign steering committee for Indigenous health equality; 2016. Retrieved October 25, 2016, from https://www.humanrights. gov.au/sites/default/files/document/publication/Progress_priorities_report_CTG_2016_0.pdf Hoolahan B. The tyranny of distance. In: Issues that impact on mental health care in rural NSW. Orange: NSW Centre for Rural and Remote Mental Health; 2002. Hunsucker SC, Frank D, Flannery J. Meeting the needs of rural families during critical illness: the APN’s role. Dimens Crit Care Nurs. 1999;18:24–32. Karnieli-Miller O, Perlick D, Nelson A, Mattias K, Corrigan P, Roe D. Family members’ of persons living with a serious mental illness: experiences and efforts to cope with stigma. J Ment Health. 2013;22(3):254–62. Kitchener BA, Jorm AF. Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behaviour. BMC Psychiatry. 2002;2(10) Kramer JL. Bachelor farmers and spinsters: gay and lesbian identities and communities in rural North Dakota. In: Bell D, Valentine G, editors. Mapping desire: geographies of sexualities. London: Routledge; 1995. p. 200–13. Lakeman R. Practice standards to improve the quality of family and carer participation in adult mental health care: an overview and evaluation. Int J Ment Health Nurs. 2008;17:44–56. Larson JE, Corrigan P. The stigma of families with mental illness. Acad Psychiatry. 2008;32:87–91. Marsh DT, Johnson DL. The family experience of mental illness: implications for intervention. Prof Psychol Res Pract. 1997;28(3):229–37. Maybery DJ, Reupert AE. Parental mental illness: a review of barriers and issues for working with families and children. J Psychiatr Ment Health Nurs. 2009;16(9):784–91. Maybery DJ, Pope RP, Hodgins GA, Hitchenor Y, Shepherd A. Resilience and wellbeing of small inland communities: community assets as key determinants. Rural Soc. 2009a;19 (4):326–39. Maybery D, Reupert A, Patrick K, Goodyear M, Crase L. Prevalence of children whose parents have a mental illness. Psychiatr Bull. 2009b;33(1):22–6. Maybery DJ, Pope RP, Hodgins GA, Hitchenor Y. Fostering resilient responses to hardship in rural communities. Gateways. 2010;3:55–69.

28

Working with Rural Families: Issues and Responses When a Family Member Has. . .

639

McMurry A, Clendon J. Community health and wellness: primary health care in practice. 5th ed. Chatswood: Elsevier; 2014. National Review of Mental Health Programs and Services. The national review of mental health programmes and services. Sydney: NMHC; 2014. Retrieved October 25, 2016, from http:// www.mentalhealthcommission.gov.au/our-reports/contributing-lives,-thriving-communitiesreview-of-mental-health-programmes-and-services.aspx Osher TW, Osher DM. The paradigm shift to true collaboration with families. J Child Fam Stud. 2002;11:47–60. Pascoe B. The little red, yellow, black book: an introduction to indigenous Australia. Canberra: AIATSIS, Aboriginal Studies Press; 2012. Phelan JC. Geneticization of deviant behaviour and consequences of stigma: the case of mental illness. J Health Soc Behav. 2005;46:307–22. Price-Robertson R, Reupert A, Maybery D. Fathers’ experiences of mental illness stigma: scoping review and implications for prevention. Adv Ment Health. 2015;13(2):100–12. Reupert AE, Maybery DJ. Strategies and issues in supporting children whose parents have a mental illness within the school system. Sch Psychol Int. 2007a;28(2):195–205. Reupert AE, Maybery D. Families affected by parental mental illness: a multiperspective account of issues and interventions. Am J Orthopsychiatry. 2007b;77(3):362–9. Reupert AE, Maybery DJ. Stigma and families where a parent has a mental illness. In: Reupert A, Maybery D, Nicholson J, Gopfert M, Seeman M, editors. Parental psychiatric disorder: distressed parents and their families. Cambridge, UK: Cambridge University Press; 2015. p. 51–60. Reupert A, Foster K, Maybery D, Eddy K, Fudge E. “Keeping families and children in mind”: an evaluation of a web based workforce resource. Child Fam Soc Work. 2011;16(2):192–200. Reupert A, Cuff R, Drost L, Foster K, van Doesum K, van Santvoort F. Intervention programs for children whose parents have a mental illness: a review. Med J Aust. 2012a;16:18–22. Reupert A, Maybery D, Kowalenko N. Children whose parents have a mental illness: prevalence, need and treatment. Med J Aust. 2012b;16:7–9. Reupert A, Cuff R, Maybery D. Helping children understand their parent’s mental illness. In: Reupert A, Maybery D, Nicholson J, Gopfert M, Seeman M, editors. Parental psychiatric disorder: distressed parents and their families. Cambridge, UK: Cambridge University Press; 2015a. p. 201–9. Reupert AE, Jones RW, Sutton K, Maybery DJ. ‘Everyone knew everyone’s business’: being a parent with housing issues in rural areas. J Sociol. 2015b;52(4):677–692. Reupert AE, Maybery DJ, Cox M, Scott Stokes E. Place of family in recovery models for those with a mental illness. Int J Ment Health Nurs. 2015c;24(6):495–506. Reupert AE, Maybery DJ, Morgan B. E-learning professional development resources for families where a parent has a mental illness. In: Reupert A, Maybery D, Nicholson J, Gopfert M, Seeman M, editors. Parental psychiatric disorder: distressed parents and their families. Cambridge, UK: Cambridge University Press; 2015d. p. 288–300. Reupert A, Willilamson C, Maybery D. How family orientated are family care physicians? J Child Fam Stud. 2017;26(1):329–35. Reupert A, Bartholomew C, Cuff R, Foster K, Matar J, Maybery DJ, Pettenuzzo L. An online intervention to promote mental health and wellbeing for young adults whose parents have mental illness and/or substance use problems: theoretical basis and intervention description. Front Psych. 2018;20(10):e10158. Rickwood D. Pathways of recovery: preventing further episodes of mental illness (Monograph). Canberra: Commonwealth of Australia; 2006. Retrieved October 25, 2016, from https://www. health.gov.au/internet/main/publishing.nsf/Content/85A27F4558113287CA257BF00021207D/$ File/mono.pdf Saunders J. Families living with severe mental illness: a literature review. Issues Ment Health Nurs. 2003;24(2):175–98. Stanbridge R, Burbach F, Leftwich S. Establishing family inclusive acute inpatient mental health services: a staff training programme in Somerset. J Fam Ther. 2009;31:233–49.

640

A. Reupert et al.

Strasser R, Neusy AJ. Context counts: training health workers in and for rural and remote areas. Bull World Health Organ. 2010;88(10):777–82. Tchernegovski P, Reupert A, Maybery D. “Let’s talk about children”: an evaluation of an e-learning resource for mental health clinicians. Clin Psychol. 2015;9(1):49–58. Thomas EA. Cushioning, weathering, place, and community in rural grandmother-mothering. Issues Ment Health Nurs. 2011;32(5):291–300. https://doi.org/10.3109/01612840.2011.557177. Victorian Government Department of Health, Rural and Regional Health and Aged Care Services. Cultural responsiveness framework: guidelines for Victorian health services; Melbourne, Victoria; 2009. Retrieved October 25, 2016, from http://www.health.vic.gov.au/__data/assets/pdf_ file/0008/381068/cultural_responsiveness.pdf Wainer J, Chesters J. Rural mental health: neither romanticism nor despair. Aust J Rural Health. 2000;8:141–7. https://doi.org/10.1046/j.1440-1584.2000.00304.x/epdf. Welch N. Understanding of the determinants of rural health. National Rural Health Alliance; 2000. Retrieved October 25, 2016, from http://ruralhealth.org.au/sites/default/files/documents/nrhapolicy-document/policy-development/dev-determinants-rural-health-01-feb-2000_0.pdf Wendt S. Constructions of local culture and impacts on domestic violence in an Australian rural community. J Rural Stud. 2009;25(2):175–84. Wilkinson RG, Marmot M. Social determinants of health: the solid facts. Denmark: World Health Organization; 2003. Retrieved October 25, 2016, from http://www.euro.who.int/__data/assets/ pdf_file/0005/98438/e81384.pdf Wuest J. Setting boundaries: a strategy for precarious ordering of women’s caring demands. Res Nurs Health. 1998;21:39–49.

Supporting Communities

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gender Differences and Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Support and Rural Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Groups as Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Building Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Support Groups as Formal Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Media and Mobile Phones for Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financial Counselors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implications for Rural Mental Health Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Social support is essential for psychological well-being. Those in rural areas are especially prone to social isolation despite high levels of community focus and interdependence. Social support can be provided through informal and formal groups, illness or situationally based support groups which meet in person or virtually, through social media and mobile phone usage, and by connection with rural financial counselors. Rural mental health providers must be connected to their communities to assist with recognizing those who are socially isolated as well as to provide education and resources to build social support.

S. Letvak (*) Adult Health Nursing, The University of North Carolina at Greensboro, Greensboro, NC, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_31

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Introduction The relationship between social support and psychological well-being is wellestablished in the literature. A recent meta-analysis of 64 research studies conducted between 1996 and 2015 found a high effect size of the correlation between social support and mental health (Harandi et al. 2017). More attention to the effects of social isolation on those in rural areas has recently increased due to continued reports of poorer health in rural residents compared to those in urban areas (Tittman et al. 2016). However, while membership in social and community groups provides social support for rural community members, those with mental illness may be reluctant to join or participate due to anxiety, depression, or other mental health disorders which isolate them from other members of the community (Sheridan et al. 2015). Often those with mental illness have socially unacceptable behaviors that lead to avoidance by others in a community, leading to further social isolation and a worsening of mental health and psychological well-being (Wang et al. 2017). Additionally, there is often a lack of awareness of what community supports may be available. This chapter provides an overview of the importance of social support as well as specific strategies that can be utilized to assist rural mental health providers with enhancing community social support and engagement for rural residents with mental health problems.

Social Support Social support is conceptualized and measured in different ways. Hupcey (1998) summarized the five major theoretical definitions. The first is defining social support by the type of support provided. This includes the specific resources provided to a person. The second category is related to an individual’s perception. It is the belief by individuals to which they believe support has been provided to them. The third category focuses on the provider of the support and their intentions or behaviors. The fourth category requires reciprocity between a provider and the recipient of support, that is, there is a giving, receiving, and exchange of support. The fifth, and final category, focuses on social networks and is the social ties to other individuals, groups, or the community. Regardless which definition is drawn from, it is important to note that social support is intended by the sender to be beneficial and is universally considered to be important for physical and psychological well-being (Reblin and Uchino 2009). Heaney and Israel (2011) categorize social support into four types of behaviors. These behaviors can be considered to be emotional, instrumental, and informative or used for appraisal. Examples of emotional support include expressions of love, care, empathy, and friendship. Instrumental support includes tangible services such as care provision and financial support. Informative support includes education, advice, and sharing of individual experiences. Finally, appraisal support is those activities that allow for self-evaluation or self-improvement. Support groups would be an example of appraisal support.

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Reis and Collins (2004) argue there is extensive evidence on the importance of relationships, including our own evolution as humans. The belongingness hypothesis purports that humans are motivated to form and maintain interpersonal bonds and to have supportive and satisfying relationships with others (Baumeister and Leary 2005). Indeed, research has demonstrated that social support protects individuals from mental health problems, ranging from mild depression to suicide (Cohen et al. 2000). Cohen (2004) proposes there are two main models that examine how social support impacts health: a stress-buffering model and a main or direct effect model. The stress-buffering model proposes that social connections provide both psychological and material resources to buffer stress. The model predicts social support is beneficial only for those with high stress demands and does not have an impact on health otherwise. Stress influences health by promoting negative behavioral coping responses to health (such as drinking alcohol or drug use) as well as by activating physiological body systems, such as the sympathetic nervous system and hypothalamic-pituitary-adrenocortical axis (Cohen 2004). Prolonged activation of these system places individuals at higher risk for mental health disorders. Social support acts as a stress buffer due to the perception that others will provide needed assistance and also bolsters the perceived ability to cope with stress. Social support is only effective if the available assistance matches needed demands. Receiving support, versus simple perception of available support, also buffers stress. The receipt of adequate support is especially problematic for those living in rural areas due to geographic isolation and lack of resources. The main-effect model proposes that social support is beneficial even for those who are not under stress (Cohen and Willis 1985). Beneficial effects of social support are received because social networks provide regular positive experiences and socially rewarded roles in the community. Being with others provides emotional regulation which increases positive affect and helps limit the intensity and duration of negative affective states. These social networks also help individuals avoid negative experiences that can lead to psychological disorders (Cohen and Willis 1985). Numerous theories have also been developed to explain how social support influences health. The three most dominant examples of theories are life-span theory, relational-regulation theory, and stress and coping social support theory. Life-span theory explains social support as having developed through the life span, and the critical period of development is during childhood with attachment to parents. Uchino (2009) argues that individuals with positive early family situations develop “positive psychosocial profiles” which allow them to cope more effectively with life stressors (p. 55). Relational regulation theory was developed to be a coherent theory to synthesize research findings on social support and health and to understand mechanisms of social support based on interpersonal regulation of emotions (Marroquin 2011). This theory argues that social support is a relational construct and individuals gain support through interaction and shared activities and relationships.

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The theory supports the main and direct effects model of social support. The relationship between perceived support and psychological well-being comes from the regulation of emotions through conversations and shared activities. An influential theory utilized in research on mental health and social support is the stress and coping social support theory. This theory supports the stress-buffering model of social support. Social support provides direct protection (buffering) from the negative effects of stress and also influences how people cope with stressful events (Cohen and Willis 1985). While there is currently no one theory that fully helps us understand how social support influences mental health, an understanding of theories helps us consider different viewpoints in how social support can be utilized to improve the mental health of those living in rural areas.

Gender Differences and Social Support Gender differences are known to exist related to social support, including the effects of gender and mental health (Milner et al. 2016). It is well-recognized that men utilize social support far less than women during times of stress, despite receiving just as much health benefit, if not more from support, than women (Taylor et al. 2003). This is especially important since men residing in rural and remote areas are known to have poorer mental health outcomes than those in urban areas (Ricciardelli et al. 2012) due to a lack of resources and transportation problems (Berry et al. 2008). Additionally, when studying social connection as a variable, researchers have found that levels of social connection vary more between men and women than any other demographic characteristic, with woman having not only larger but also more varied social networks and friends than men (Caetano et al. 2013). Wymer (2012) summarizes that this is likely due to socialization in childhood, where girls are taught to express emotion, which encourages mutually supportive relationship building, and boys are taught to repress emotions and be more independent. Women are also socialized into being caregivers and desiring of intimate relationships with others, while men are taught to seek dominance and be more competitive with others. Additionally, women are taught to value altruistic, reciprocal relationships, while men value power and affirmation of their social status. Alston and Kent (2008) purport that the dominant form of hegemonic masculinity found in men in rural areas in times of stress prevents men from seeking help during times of stress. Thus, mental health providers must be inherently aware that rural-dwelling men must retain their feelings of having power if they are to be successful in providing needed mental health services. It well-known that married men have more positive health outcomes than single men. Meta-analysis studies that investigate marital status and quality on health consistently demonstrate that single men have the poorest health (Djundeva 2018). These findings are consistent across cultures and countries (Tatangelo et al. 2017). In countries such as China, rural men have great

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difficulty with finding a spouse which weakens their social support networks and is negatively impacting their quality of life (Wang et al. 2018). The positive effects of marriage on mental health are attributed to intimacy and mutual care, emotional reward, social support, and engagement in healthier lifestyles (Musick and Bumpass 2012). Rural healthcare providers need to consider marital status of men to assist with identifying community groups that will fulfill social support needs.

Social Support and Rural Communities Worldwide, rural residents are faced with geographic isolation, higher rates of poverty, and a lack of health resources, especially focused on mental health (Morling and Boxall 2014; Strasser 2003). However, rural residents are known to have greater connectedness to community than those in urban communities as evidenced by more community volunteering and participation in community groups such as charities, sports, clubs, and hobby groups (Hyett et al. 2014). Rural residents are known to be highly self-reliant and are often distrustful of outsiders (Best Start Resource Center 2010; Hawley et al. 2014). This has strong implications for rural healthcare providers who must work to integrate into a community to provide the highest quality service. Cultural sensitivity is needed to gain trust; cultural insensitivity can exacerbate mistrust; and this perspective may be shared with other locals via the community grapevine (Molinari and Bushy 2012). Bushy (2000) views social support from a rural perspective as three-tiered. The first tier is support of families and friends. The second tier consists of local emergency services and community and religious organizations. The third tier is composed of formal services. These tiers have significant implications for rural mental health providers as many rural dwellers believe that psychological problems should be handled within the family or church first (Glenna 2003). Efforts must be made to educate families and church clergy about the importance of formal services for those with mental health problems to help break down these tiers.

Community Groups as Social Support Social support in rural areas can also be considered informal versus formal (Orpin et al. 2014). Informal groups are usually defined as those consisting of family, friends, and faith. Formal groups are those provided by organizations with paid professional workers. Whole both are important for providing social support for rural residents, providers of rural mental health services must be especially concerned with the stress of rural caregivers who are less likely to use formal services such as home healthcare services, transportation services, and caregiver social support groups (Hicken et al. 2014). Additionally, Kutek et al. (2011)

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highlight that informal support may be especially important to rural men, who are less likely to use formal support services. Rural mental health providers must work especially hard with connecting rural men to formal support services. Community groups are an important form of social support in rural communities. These would be considered informal groups. Community groups vary with regard to group type, size, and membership. In a review of multiple research studies of community groups, Lickel and colleagues (Lickel et al. 2000) identified four common group types: task-focused groups, intimacy or social-focused groups, social categories, and loose associations. Task-focused groups are groups that bring people together around a common interest, such as charity groups and gardening and fishing clubs. Intimacy and social-focused groups consist of family and friends. Social categories relate to gender, ethnicity, and nationality. Loose associations are just that social affiliations without structure. Intimacy or social-focused groups hold the highest self-importance for individuals. Lyons et al. (2016) researched the relationship between psychological well-being and resilience to participating in different rural community groups. Group types ranged from sports groups to support groups and were described as highly organized with a fixed hierarchical structure to relatively relaxed and casual with no fixed rules. Psychological well-being was measured by the Short Warwick-Edinburgh Mental Well-Being Scale. Resilience was measured using the Brief Resilience Scale. While group type was not significant for psychological well-being or resilience, participants with the highest psychological well-being belonged to groups without hierarchies. The groups without hierarchies were more often socially focused than task-focused. Thus, when working to build community groups in rural and remote settings, mental health providers should assist groups in building groups that do not have formal hierarchies.

Building Community One way to assure rural community members have access to social support is through building community. Poole (2005) defines rural community building as “the process of developing and sustaining partnerships between groups of citizens and practitioners to bring about planned change for the public good in rural communities” (p. 125). Planned change is the systematic efforts to alter any conditions that may harm those living in the community. Examples may include the use of rural land for the building of mental health clinics and even improved roads and infrastructure. Importantly, planned changes are done at the group versus the individual level, so community inclusion is essential. Gamble and Weil (2010) offer eight specific strategies to assist with rural community building. These strategies would be especially beneficial in working with rural communities to address mental illness as a health concern. 1. Develop capacity of residents to organize and direct the impact of regional planning and external development to improve quality of life. The focus is on

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improving social, economic, and environmental conditions. For example rural and remote mental health providers can assist with organization community groups to assist with developing policies to reduce exposure to pollutants and toxins in the environment, as well as developing formal emergency plans to deal with natural disasters such as drought and wildfires. Assistance can also be provided to assist community groups in regional planning for development of rural lands to support industry which will lead to employment opportunities. Organize community members for action concerning social justice focused on advocacy and on changing attitudes and behaviors. Advocacy should focus on particular issues of the rural population. Rural and remote mental health providers can specifically work to decrease stigma and increase knowledge concerning mental health issues. Promote grassroots plans and prepare community members to use social and economic resources without harming environments. Rural and remote mental health providers can assist community members with building hiking trails and parks that maximize natural environments. The focus should be on lowincome and marginalized groups in the area who are most vulnerable to exploitation. Use participatory engagement with community members to assist with planning service development for specific populations. Specifically rural and remote mental health providers must always partner with community members as peers versus authority figures with planning, implementing, and evaluating all mental healthcare services. Assist with social planning with neighborhood groups as well as elected bodies. Focus on integrating social, economic, and environmental needs into public planning. Rural and remote mental health providers must be aware that resources needed to improve the health of rural dwellers is often based on funding and support, especially from the government. Meetings of community members and elected officials together can be coordinated to increase awareness of the urgency of mental healthcare resources and support for rural communities. Organize coalitions to build a multi-organizational power base to advocate for standards and programs. The focus would be to improve social, economic, and environmental conditions and to support human rights. There is power in numbers. Rural and remote mental healthcare providers must seek multiple groups and organizations, especially those of influence, if they are to effectively assist with improving quality of life and healthcare services for those in rural areas. Organize and advocate for political and social action focused on changing polices or policymakers. Development expert Albert Hirschman (1972) famously stated that those who live in impoverished areas have three choices, exit, loyalty, or voice. Rural and remote mental health providers must give voice to those who are underrepresented and underserved, especially in relation to mental healthcare services.

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8. Assist with action for progressive change, developing new paradigms for the healthy development of people and the planet. Again, the focus should be on social justice. An example of advocacy might be assisting rural residents with developing ecotourism which will allow for healthy development of both residents and the environment. As stated earlier, men are less likely to utilize formal support services. An example of how to involve men is through the example of The Invisible Men Project which was developed by the United Kingdom (Johal et al. 2012) to engage more men into community projects. These suggestions they offer based on research can also assist rural healthcare providers with establishing socially supportive community groups: – Utilize a hook to incentivize engagement in a group. An example of a hook is free food. – Consult with targeted rural residents to determine what their specific needs and areas of interest are. – Conduct targeted outreach. Instead of advertising to the community as a whole, target recruitment efforts for those you are specifically looking to increase social connection in. – Acknowledge differences. To increase engagement with the community group, a wide range of needs must be met by the group. A successful community group must meet a variety of individuals’ needs. – Build trust. Rural healthcare providers must build relationships with community members so trust can be developed. Without the trust of the community, any community program development will likely be unsuccessful. Rural and remote mental healthcare providers can also assist men in the community with attending or organizing a Men’s Shed. The Australian Men’s Shed Association (n.d.) defines a Med Shed as any community based, nonprofit organization that is accessible to all men who want a safe and friendly environment to work on meaningful projects at their own pace in the company of other men with the purpose of advancing the well-being and health of their male members. Importantly, Men’s Sheds may be especially beneficial for men’s mental health. Research has demonstrated that participation in a Men’s Shed group can provide a sense of purpose, increased self-confidence, social connectedness and informal support (Ayres et al. 2018), as well as decrease self-reported symptoms of depression (Culph et al. 2015). While Men’s Sheds are more common in Australia, they can be increasingly found in Europe and the United States.

Support Groups as Formal Social Support Support groups bring together individuals facing similar life problems or illnesses, including mental health problems. Talking with others experiencing similar situations can allow an individual to feel less isolated as well as gain practical advice and

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anticipatory guidance. While any individual can start a support group, many support groups are developed and moderated by a healthcare professional. Research has demonstrated the benefits of support group attendance for those with mental illness (Markowitz 2015; World Health Organization (WHO) 2017). One study of 73 men and women aged 18 to 73 with mental illness attended support groups over a yearlong period in England (Crabtree et al. 2010). Participants had increased resistance to the stigma attached with mental illness and increased perceived social support from nonfamily friends. A limitation to support group attendance for those in rural areas, however, is concerns about confidentiality. In small communities there are limited places to hold formal meetings making support groups more “exposed” than in more urban areas. Participants may also know each other – therefore anonymity is far less likely. Indeed, rural residents are known to recognize each other by the vehicles they drive (Hastings and Cohn 2013). Additionally, rural dwellers have limited access to a large variety of support groups. Long drives to urban centres may prevent regular attendance. In order to address the access issue, rural mental health providers can assist with the start -up of support groups. The Self-Help Network of Kansas (2012) offers the following tips: 1. Think creatively about the meeting place and name for the group. Rotating meeting places can assist with protecting anonymity. The importance of confidentiality must be stressed at every meeting. 2. Share responsibility with other professionals in the community and even group members. Shared leadership builds self-confidence and self-esteem. 3. Have realistic expectations. Rural support groups may take longer to fully develop due to the sparse population and need to earn trust from the community. 4. Respond to group members’ needs. A suggestion is to have an educational workshop on a topic of interest to create interest in the group at the first meeting and repeat as needed. 5. Reach out to the community. Word of mouth is most likely the best way to spread word about the group or postings in a rural newspaper or newsletter. Inform other established organizations in the community about the new group. 6. Promote self-help. Informing the community about the benefits of support groups to strengthen the entire community is important. 7. Have options. It is better to have lots of small groups throughout a large sparsely populated area than only one. Online, or virtual, support groups offer rural dwellers an option for social support. Joining an online support group can provide confidentiality as well as offer a wider range of group options for those with mental illness (Mehta and Atreja 2015). However, some clinicians believe that online support groups only perpetuate “avoidance” with confronting stigmas. Most developed countries have a plethora of online chat and support groups for individuals to join. Australians have Beyond Blue for those suffering from anxiety and depression, for example. In addition to providing education on anxiety, depression, and suicide prevention, Beyond Blue offers professional resources and online support groups. Large mental

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health organizations, such as the National Alliance on Mental Illness (NAMI) in the United States, heavily promote a large variety of online support groups for those with mental health conditions ranging from anxiety to eating disorders to psychosis.

Social Media and Mobile Phones for Social Support Another area is the use of social media and mobile phones for social support. With the growth of the Internet in most rural areas in developed countries, individuals with mental illness now have the ability to stay connected with family and friends through social media and use of mobile phones. Research suggests that social media sites provide social support and enhance psychological well-being when used appropriately (Kim 2014), including for those in rural areas (Weinert 2000). Programs such as “Skype” allow individuals to not just connect in voice or text but also in real-time video. Mobile phones have become widespread even in rural areas in most developed areas of the world. Mobile phones have allowed those living in rural areas to have improved access with family and friends. While some research has documented some detrimental effects of mobile phones, especially on sleep and addictive behaviors (Takao et al. 2009), mobile phones have been found to improve health outcomes in rural areas (Chib et al. 2012). Cognitive behavioral therapy can be provided over mobile phones (Norris et al. 2013). Video phones can be used to directly visualize individuals to assess their level of distress. Importantly, mobile phones may have the most beneficial impact for those in poor, rural regions of the world. Indeed, research has demonstrated that mobile phone ownership improves mental health well-being in sub-Saharan African countries (Pearson et al. 2017). Specifically, mobile phone ownership was associated with an increased level of peace for those without nearby family. Mobile phone applications such as Facetime, Tango, and Viber also allow for real-time video conversation for those in rural and remote areas allowing for increased connectedness.

Financial Counselors Financial counselors play a significant role for those in rural areas and especially for those with mental health problems. In addition to providing needed financial advice and assistance for rural residents, these counselors are an important referral source to mental health teams, personal counseling, and health and welfare organizations (Fuller and Broadbent 2006). Some countries, including Australia, have entire agencies focused on financial counseling for those in rural areas. In Australia, the Rural Financial Counselling Service is housed under the Department of Agriculture and Water Services. In the United States, the US Department of Agriculture Development agency provides services. Europe has the European Agricultural Fund for Rural Development program.

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Case Study

Mr. Anderson is a recently widowed 72-year-old farmer who has lived in his rural community his entire life. His three grown children and grandchildren live in an urban city many hours away. Mr. Anderson has never been a “joiner” – he was happy to just work the farm during the day and sit and listen to music with his wife in the evenings. A neighbor recently visited him and noticed that he had lost a lot of weight and did not seem to be himself. She convinced him to see his healthcare provider for a checkup. Mr. Anderson admitted to not sleeping well and having a poor appetite since he never liked eating alone. The PHQ-9 was administered and documented mild depression; however, Mr. Anderson refused any medication. No other medical conditions were diagnosed. Mr. Anderson refused to schedule an appointment with the counselor located in the clinic, but he did agree to a home visit since he could “use some company.” Later that week the counselor did a home visit with Mr. Anderson. After a complete assessment, the counselor quickly recognized that social isolation was likely underpinning his depression. Together they developed a plan to help Mr. Anderson get more social support from his family and community members. Mr. Anderson refused to purchase an Internet plan because of the high cost, but he did agree to purchase a “smart” mobile phone with Internet connectivity so he could video chat with his children and grandchildren at least weekly. After being given a list of active social groups in his community, Mr. Anderson chose a “Men Shed” focused on woodworking – a hobby he used to enjoy but had neglected over the years. Mr. Anderson also agreed to have the counselor visit monthly to “check on things.” One month later, Mr. Anderson was visibly more upbeat. He had purchased the mobile phone and had attended two Men Shed meetings. After 3 months, Mr. Anderson’s PHQ-9 score had returned to the normal range. He had gained weight and stated he was sleeping well. Mr. Anderson told the counselor he didn’t need future visits since his schedule was “full,” and she could better spend her time helping others.

Implications for Rural Mental Health Providers Rural mental health providers must be deeply informed and connected with their communities to be aware of all available resources to assist residents with social connection and support. Indeed, the Center for Rural Health (2016) declares that “you need to be engaged to survive” and rural health care providers and organizations cannot operate in isolation. Rural mental health providers can work with community leaders to develop community support systems, especially for those who have difficulty in making and keeping social bonds. Counselors and providers

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must assist rural residents with building and enhancing informal group connections with family and friends. As needed, they should connect rural residents with formal groups that exist in the community, including support groups focused on specific individual needs – in person or virtually. Counselors and providers can provide lists of social media sites specific to individual needs. They also can advocate for and assist with purchasing mobile phones. Rural healthcare providers must continually work to educate policymakers and governmental agencies on the unique challenges and needs of assuring social connection for rural residents. They must collaborate and advice established regional and national organizations to educate them on rural resident social support needs. Finally, rural healthcare providers must advocate for more formal education for counselors on working in rural and remote locations. Breen and Drew (2012) conducted a study of rural health counselors. While the counselors were attracted to a rural health position by more independence, less crime, and more time for outdoor leisurely activities, they also had to make many personal compromises, including lower pay, less opportunities for professional development, and working in a “fish bowl” since the entire community knows them as one of the few mental health providers. These counselors made recommendations for counselor education: 1. A need for overall education on rural counseling and specific attributes. 2. The need to prepare students for more broad roles. Rural counselors do not have a referral base and must provide more services. A high level of self-efficacy must be developed. 3. A need to educate on rural culture. This includes understanding of values, geography, isolation, connections, and lifestyle. 4. The offering of more interns. 5. Hips in rural areas.

Take-Home Messages 1. Members of rural communities are at risk for social isolation. 2. Social support is essential for psychological well-being and can be especially beneficial for those with mental illness. 3. There are gender differences in social support. Socially isolated men are an especially vulnerable group. 4. Rural mental health providers are instrumental in building community and social support systems. 5. Social support systems can be both informal and formal.

Concluding Comments and Recommendations Social connection is important for mental health. Social support has been identified as significant for physical and psychological well-being. Rural residents are vulnerable to social isolation and lack the support resources more available in urban

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settings. Rural mental healthcare providers are essential for identifying those at risk for social isolation and assisting with building social support systems. Understanding available resources, building social support systems, and advocating for rural residents are critical for assuring rural residents optimal psychological well-being.

Cross-References ▶ Future of Rural, Remote, and very Remote Mental Health ▶ Rural, Remote, and very Remote Mental Health

References Alston M, Kent J. The big dry: the link between rural masculinities and poor health outcomes for farming men. J Sociol. 2008;44(2):133–47. Australian Men’s Shed Association. (n.d.). https://mensshed.org/. Accessed 26 Aug 2018. Ayres L, Patrick R, Capetola T. Health and environmental impacts of a regional Australian Men’s Shed program. Aust J Rural Health. 2018;26(1):65–7. Baumeister RF, Leary MR. The need to belong: desire for interpersonal attachment as a fundamental human motivation. Psychol Bull. 2005;117(3):497–529. Berry HL, Kelly BJ, Hanigan IC, Coates JH, McMichael AJ, Welsh JA, et al. Rural mental health impacts of climate change. Garnaut Clim Change Rev. 2008. Retrieved August 25, 2018 from http://garnautreview.org.au/CA25734E0016A131/WebObj/03-DMentalhealth/$File/03-D% 20Mental%20health.pdf Best Start Resource Center. How to reach rural populations. Toronto: Author; 2010. Breen DJ, Drew DL. Voices of rural counselors: implications for counselor education and supervision. Ideas and Information You Can Use: Vistas 2012. 2012;1, Article 28. Bushy A. Orientation to nursing in the rural community. Thousand Oaks: Sage; 2000. Caetano SC, Silva CMFP, Vettore V. Gender differences in the association of perceived social support and social network with self-related health status among older adults: a populationbased study in Brazil. BMC Geriatr. 2013;13:122. https://doi.org/10.1186/1471-2318-13-122. Center for Rural Health. The importance of community in rural health. Grand Forks: The University of North Dakota School of Medicine and Health Sciences; 2016. Chib A, Cheong YJ, Lee LCL, Ng CHC, Tan CK, VLV K. The hope of mobile phones in rural Indian rural healthcare. J Health Inform Dev Ctries. 2012;6(1):406–21. Cohen S. Social relationships and health. Am Psychol. 2004;59(8):676–84. Cohen S, Willis TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98:310–57. Cohen S, Gottlieb B, Underwood L. Social relationships and health. In: Cohen S, Underwood L, Gottlieb B, editors. Measuring and intervening in social support. New York: Oxford University Press; 2000. p. 3–25. Crabtree JW, Haslam AS, Postmes T, Hasla C. Mental health support groups, stigma, and selfesteem: positive and negative implications of group identification. J Soc Issues. 2010;66 (3):553–69. Culph JS, Wilson NJ, Cordier R, Stancliff RJ. Men’s Sheds and the experience of depression in older Australian men. Aust Occup Ther J. 2015;62(5):306–15. Djundeva M. Partnership trajectories and cardiovascular health in late life of older adults in England and Germany. SSM Popul Health. 2018;6:26–35. Fuller J, Broadbent J. Mental health referral role of rural financial counsellors. Aust J Rural Health. 2006;14(2):79–85.

654

S. Letvak

Gamble DM, Weil M. Conceptual frameworks and models for community practice. In: Community practice skills: local to governmental perspectives. New York: Columbia University Press; 2010. p. 24–46. Glenna L. Religion. In: Brown DL, Swanson LE, editors. Challenges for Rural America in the 21st century. University Park: The Pennsylvania State University Press; 2003. p. 262–72. Harandi TF, Taghinasab MM, Nayeri TD. The correlation of social support with mental health: a meta-analysis. Electron Physician. 2017;9(9):5212–22. Hastings SL, Cohn TJ. Challenges and opportunities associated with rural mental health practice. J Rural Ment Health. 2013;37(1):37–49. Hawley SR, Orr SA, St Romain T. Public health workforce issues in rural areas. In: Warren JC, Smalley KB, editors. Rural public health: best practices and preventive models. New York: Springer; 2014. p. 46–58. Heaney CA, Israel BA. Social networks and social support. In: Glanz K, Rimer BK, Viswanath KV, editors. Health behavior and health education: theory research and practice. 4th ed. Hoboken: John Wiley and Sons Inc.; 2011. p. 189–210. Hicken BL, Smith D, Luptak M, Hill RD. Health and aging in rural America. In: Warren JC, Smalley KB, editors. Rural public health: best practices and preventive models. New York: Springer; 2014. p. 241–54. Hirschman A. Exit, loyalty or voice: responses to decline in forms, organizations and states. Cambridge: Harvard University Press; 1972. Hupcey JE. Clarifying the social support theory-research linkage. J Adv Nurs. 1998;27:1231–41. Hyett N, Scholar D, Kenny A, Dickson-Swift V, Farmer J. How can rural health be improved through community participation? Deeble Institutes Brief No. 2. Canberra: Debble Institute; 2014. Johal A, Shelupanov A, Norman W. Invisible men: engaging more men in social projects. London: Young Foundation; 2012. Kim H. Enacted social support on social media and subjective well-being. Int J Commun. 2014;8:2340–2. Kutek SM, Turnbull D, Fairweather-Schmidt AK. Rural men’s subjective well-being and the role of social support and sense of community: evidence for the potential benefit of enhancing informal networks. Aust J Rural Health. 2011;19:20–6. Lickel B, Hamilton DL, Wieczorkowska G, Lesia A, Sherman SJ, Uhles AN. Varieties of groups and the perception of group entitativity. J Perspect Sociol. 2000;78(2):223–46. Lyons A, Fletcher G, Farmer J, Kenny A, Bourke L, Carra K, Bariola E. Participation in rural community groups and links with psychological well-being and resilience: a cross-sectional community-based study. BMC Psychol. 2016;4:16. Markowitz FE. Involvement in mental health self-help groups and recovery. Health Sociol Rev. 2015;24(2):199–212. Marroquin B. Interpersonal emotion regulation and as a mechanism of social support in depression. Clin Psychol Rev. 2011;31:1276–90. Mehta N, Atreja A. Online social support networks. Int Rev Psychiatry. 2015;27(2):118–23. Milner A, Krnjacki L, LaMontagne AD. Age and gender differences in the influence of social support on mental health: a longitudinal fixed-effects analysis using 13 annual waves of the HILDA cohort. Public Health. 2016;140:172–8. Molinari D, Bushy A. The rural nurse: transition to practice. New York: Springer; 2012. Morling D, Boxall AM. Rural mental health matters. Aust J Rural Health. 2014;22(6):340–1. Musick K, Bumpass L. Re-examining the case for marriage: union formation and changes in wellbeing. J Marriage Fam. 2012;74:1–18. Norris L, Swartz L, Tomlinson M. Mobile phone technology for improved mental health care in South Africa: possibilities and challenges. S Afr J Psychol. 2013;43(3):379–88. Orpin P, Stirling C, Hetherington S, Robinson A. Rural dementia carers: formal and informal sources of support. Ageing Soc. 2014;34(2):185–208. Pearson AL, Mack E, Namanya J. Mobile phones and mental well-being: initial evidence suggesting the importance of staying connected to family in rural, remote communities in Uganda. Plos One. 2017; https://doi.org/10.1371/journal.pone.0169819.

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Poole D. Rural community-building strategies. In Lohmann N, Lohmann R, editors. Rural Social Work Practice. New York: Columbia University Press; 2005. pp. 124–143. https://doi.org/ 10.7312/lohm12932.10. Reblin M, Uchino BN. Social and emotional support and its implications for health. Curr Opin Psychiatry. 2009;21(2):201–5. Reis HT, Collins WA. Relationships, human behavior, and psychological science. Curr Dir Psychol Sci. 2004;13(6):233–7. Ricciardelli L, Mellor D, McCabe M. The quiet crisis: changes for men’s health in Australia. InPsych. 2012;34(4). Retrieved August 22, 2018 from https://www.psychology.org.au/inpsych/ 2012/august/ricciardelli/#. Self-Help Network of Kansas. Tips for starting rural self-help groups. Lawrence: The University of Kansas; 2012. Sheridan AJ, Drennan J, Coughlan B, et al. Improving social functioning and reducing social isolation and loneliness among people with enduring mental illness: report of a randomised controlled trial of supported socialization. Int J Soc Psychiatry. 2015;61(3):241–50. Strasser R. Rural health around the world: challenges and solutions. Fam Pract. 2003;20(4):457–63. Takao M, Takahashi S, Kitamura M. Addictive personality and problematic mobile phone use. Cyberpsychol Behav. 2009;12(5):501–7. Tatangelo G, McCabe M, Campbell S, Szoeke C. Gender, marital status and longevity. Maturitas. 2017;100:64–9. Taylor SE, Klein LC, Gruenewald TL, Gurung RA, Taylor SF. Affiliation, social support, and biobehavioral responses to stress. In: Suls JM, Wallston KA, editors. Social psychological foundations of health and illness. Boston: Blackwell Publishing; 2003. p. 314–32. Tittman SM, Harteau C, Beyer KMM. The effects of geographic isolation and social support on the health of Wisconsin women. West Med J. 2016;115(2):65–9. Uchino BN. What a lifespan approach might tell us about why distinct measures of social support have differential links to physical health. J Soc Pers Relat. 2009;26(1):53–62. Wang J, Lloyd-Evans B, Giacco D, et al. Social isolation in mental health: a conceptual and methodological review. Soc Psychiatry Psychiatr Epidemiol. 2017;52(12):1451–61. Wang S, Yang X, Attane I. Social support networks and quality of life of rural men in a context of marriage squeeze in China. Am J Mens Health. 2018;12(4):706–19. Weinert C. Social support in cyberspace for women with chronic illness. Rehabil Nurs. 2000;25 (4):129–35. World Health Organization. Creating peer support groups in mental health and related areas – WHO Quality Rights training to act, unite and empower for mental health (pilot version). Geneva: World Health Organization; 2017. http://apps.who.int/iris/bitstream/handle/10665/254813/ WHO-MSD-MHP-17.13-eng.pdf;jsessionid¼CD17EB2F1593949C57C0734A187B8014? sequence¼1. Accessed 26 Aug 2018. Wymer W. Gender differences in social support and the decision to volunteer. Int Rev Public Nonprofit Mark. 2012;9:19–26.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Environmental Problems and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Related Environmental Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Impacts of Climate Change and Related Environmental Threats . . . . . . . . . . . . . . . . . . . Mental Health Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact on Rural and Remote Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gradual or Indirect Causes of Climate Change on Mental Health and Psychosocial Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impacts on Rural and Remote Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Climate Change Impacts on Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vicarious Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implications for Rural and Remote Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Building Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

While the social, economic, and environmental determinants of mental health have long been recognized, an emerging awareness over recent years has been the particular impacts of climate change and related environmental threats on mental health. Climate change is regarded as the most serious global health threat of the twenty-first century. As well as physical health impacts, climate change also affects people’s mental health and psychosocial well-being via the S. E. L. Burke (*) Australian Psychological Society, Melbourne, VIC, Australia © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_32

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direct effects of extreme weather events or the flow-on effects of its gradual or indirect impacts on the livability of places, disruptions, and even as an existential threat to civilization as we know it. Rural and regional communities are disproportionately affected by the impacts of climate change, because it both presents additional problems and exacerbates existing vulnerabilities and risks, including increased climatic variability and extreme events such as droughts, floods, heat waves, and bushfires. The multiple health threats posed by climate change mean that an increased demand for services from the health-care system is very likely. For rural and remote communities, climate change may compound the difficulties and inequities that they already face in their health systems. In addition, rural and remote practitioners also experience the challenge of often being one of a small number of practitioners in a community and personally impacted by the environmental threats as well. Rural and remote mental health practitioners need to anticipate the impact that climate change and related environmental threats will have in their communities and in their own lives.

Introduction Mental health starts – long before illness – where we live, learn, work, play, and age. It begins in our families, our “place,” our communities, our jobs, in the parks and gardens that we live near, in the active ways we get around, in the air we breathe, and in the food we eat. While these social, economic, and environmental determinants of mental health have long been recognized (World Health Organization 2003), an emerging awareness over recent years has been the particular impacts of climate change and other environmental threats on mental health (Hayes et al. 2018; Clayton et al. 2017; Dodgen et al. 2016). Health itself is a very broad and complex topic, and so is climate change. Put together, they bring even more aspects to consider, concepts to grasp, and knowledge to master. Thousands of reports, articles, and books have been published on those topics. In this chapter, the core climate change and health knowledge that is important for people to know about will be covered. In particular, the direct, indirect, and gradual/vicarious impacts of climate change and other environmental threats on the mental health of individuals, communities, and societies, and particularly on those living in rural and remote areas, will be considered. Firstly, the direct impacts of climate change, such as extreme weather events, are likely to have immediate impacts on mental health concerns and outcomes. Secondly, vulnerable communities are beginning to experience disruptions to the social, economic, and environmental determinants that promote mental health. Finally, there is an emerging understanding of the ways in which climate change as a global environmental threat, and perceptions of loss of biodiversity, may create emotional distress and anxiety about the future.

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In the following chapter, the practice implications of environmental threats like climate change are discussed. Rural and remote mental health practitioners can make important changes not just with their clients and in their workplaces but also as active advocates for, and participants in, urgent mitigation and adaption measures to address the escalating threat of climate change and associated threats in their communities and all around the world.

Distinctive Features Environmental Problems and Health Climate change and other environmental problems threaten people’s health and wellbeing wherever they live on the globe. Specific groups of people are at higher risk for distress and other adverse mental health consequences from exposure to climate change, and this particularly includes people living in rural and remote areas. According to a recent major report on climate change and health (Dodgen et al. 2016), groups especially at risk include communities that rely on the natural environment for sustenance and livelihood and populations living in areas most susceptible to specific climate change events. This includes people living in rural and remote areas. A report by the Climate Council (Hughes et al. 2016) shows how rural and regional communities are disproportionately affected by the impacts of climate change, because it both presents additional problems and exacerbates existing vulnerabilities and risks, including increased climatic variability and extreme events such as droughts, floods, heat waves, and bushfires. Further at-risk groups include the economically disadvantaged, children, the elderly, women (especially pregnant and postpartum women), people with pre-existing mental illness, the homeless, and first responders (Dodgen et al. 2016). For this reason, understanding the impacts that these environmental threats have on people’s mental health and well-being, as well as what to do to reduce these threats (mitigation) and adapt to these threats (adaptation), is an incredibly important part of rural and remote mental health practitioners’ work.

Climate Change Climate change is caused by an excess of carbon dioxide and other greenhouse gases that are trapping additional heat in the lower atmosphere and causing a rise in global average temperatures and subsequent instability in global weather patterns. An overwhelming majority (97%) of climate scientists agree that climate change is caused by human behavior (Cook et al. 2013) largely through the burning of fossil fuels and deforestation. Climate change is one of the principal threats to quality – and equality – of life on our planet. Beyond environmental problems, the changing climate poses substantial

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and escalating risks for food security, water availability, health, housing, infrastructure, agriculture, and natural ecosystems. The evidence is very clear that climate change is a real, urgent, and increasing threat (IPCC 2014). World leaders from 195 nations, in a historic agreement at climate talks in Paris, 2015, acknowledged the threat and agreed to urgent changes to reduce human contributions to greenhouse gas emissions in an attempt to limit the rise in global average temperatures to below 2° (preferably below 1.5°) (IPCC 2014; UN 2016). Despite this, however, and despite knowing that climate change is a problem, and that urgent changes are needed in human behavior at all levels of society to reduce greenhouse gas emissions and adapt to unavoidable changes in climate stability, this awareness has not yet led to actions around the world that are commensurate with the threat. Emissions are still rising. If global emissions continue to rise on a businessas-usual basis, global temperature will rise between 3.7 and 4.8 °C above preindustrial levels by 2100. This level of temperature increase would be catastrophic (IPCC 2018). This would be a world of unprecedented heat waves, severe drought, bushfires, flooding, and major storms in many regions, with serious impacts on all human systems and ecosystems.

Related Environmental Threats Climate change exacerbates a number of other environmental threats on human health and well-being, for example, air pollution; water and food contamination; food insecurity; vector-borne diseases; extreme weather events like cyclones, floods, and bushfires; soil degradation; and toxic waste. While each of these environmental threats has proven impacts on people’s physical health and well-being independent of a rise in global average temperatures, the likelihood of them worsening, and having even more of a negative impact, in a warmer, unstable climate, is well documented (Dodgen et al. 2016; WHO 2003). One of the best ways of understanding climate change is as a risk amplifier. The interactions between climate and non-climate factors increase human vulnerability to climate change in a variety of ways, and these will be elaborated on in the following section.

Health Impacts of Climate Change and Related Environmental Threats Climate change has been described as the most serious global health threat of the twenty-first century (Dodgen et al. 2016; Costello et al. 2009; Watts et al. 2015). It dramatically disrupts some of life’s basic essential requirements for health – water, air, and food. The literature on proven and plausible health impacts of global climate change now covers virtually every organ system in the human body (Sheffield and

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Landrigan 2010). Wherever you live, climate change threatens your health. Threats to physical health include higher incidence/exacerbation of: • Injuries and fatalities related to heat waves and other severe weather events • Spread of some infectious diseases from rising temperatures and changes in rainfall, like malaria • Higher incidence of food- and water-borne diseases from rising temperatures and extreme weather events • Heat-related illness • Malnutrition from food insecurity • Exacerbated respiratory allergies from increased allergens (pollens and spores) in the air • Exacerbated respiratory and heart diseases in response to increases in some air pollutants

Mental Health Impacts Climate change also impacts on our psychological and mental health (Hayes et al. 2018; Clayton et al. 2017). Psychological and mental health impacts of climate change are among some of the most potentially devastating effects in terms of human suffering and among the most difficult to quantify and address. Psychological impacts of climate change result from both direct and indirect or gradual causes of climate change (Clayton et al. 2017; Doherty and Clayton 2011), as well as vicarious causes. In the following sections, we will look at each of these causes in turn, looking in particular at the special vulnerabilities of people living in rural and remote areas. Direct causes are things like climate-related extreme weather events –wildfires/ bushfires, cyclones/hurricanes, floods, severe storms, and heat waves. These are all expected to worsen in severity and/or frequency as a result of climate change. Extreme weather events that become natural disasters can have devastating consequences for individuals and communities. People can die; lose family members, friends, or neighbors; be injured; and lose pets, livestock, livelihoods, homes, properties, all their possessions, schools, workplaces, and familiar and favorite places. They may have to suffer significant financial losses and accrue substantial debt and subsequent financial stress. They may have to move away from their community to find new homes; they may have to find new jobs and start over. There is a significant risk of mental health problems following extreme climaterelated disasters. The most common are post-traumatic stress disorder (PTSD), depression, and complicated grief, followed by substance use and anxiety disorders. Approximately 30% of people affected by a disaster are at risk (Kaniasty and Norris 1999; Norris et al. 2002). Additionally, there can also be psychosocial impacts. Many more people who do not end up with a diagnosis of depression or PTSD nonetheless end up with

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heightened distress, grief, stress, and strain that are directly related to the extreme weather event. These strains have flow-on effects on relationships, families, work competence, parenting capacity, and overall quality of life and account for a significant amount of the human suffering following extreme weather events (Norris et al. 2002; Bonanno et al. 2010). As well as acute extreme weather events like fires and storms, heat waves are also a major concern for mental health and well-being. Prolonged heat events can create chronic stress situations that may initiate or exacerbate health problems in populations already suffering from mental illness and stress-related disorders. Hospital admissions for mental and behavioral disorders in both rural and urban areas rise once ambient temperatures go above a benchmark of approximately 27 °C (Hansen et al. 2008; Nitschke et al. 2007). Even deaths attributed to mental and behavioral disorders increase slightly during heat waves among the elderly (Nitschke et al. 2007). In addition, psychotropic drugs interfere with the body’s ability to regulate temperature; individuals being treated with these drugs could be at increased risk of heat-related illness during extreme heat events (Martin-Latry et al. 2007).

Impact on Rural and Remote Populations People in rural and remote areas are not only more at risk from extreme weather events and heat waves because of their geographical location, but they have additional vulnerabilities. They are usually more physically and socially isolated because of sparse populations, large distances, and a lack of public transport. There is a higher prevalence of chronic conditions in people living in rural and remote areas (AIHW 2015; Wilkins 2015). The aging of the population is also often more marked in rural and remote areas. Both chronic conditions and aging are factors which render people less mobile personally. Poorer physical and personal mobility makes people more vulnerable to injury and death from fires, drought, cyclone, flooding, and excessive heat waves. Such events also disproportionately affect rural communities’ health and emergency services, many of which are already under pressure (Bi and Parton 2008; Horton et al. 2010; Loughnan et al. 2010). The predicted increasing severity and/or frequency of extreme events will impose greater demands on many rural health support and emergency services that are already overstretched and hampered by poor infrastructure such as unreliable access to the Internet (Blashki et al. 2010). These impacts are going to be even greater in the least developed countries around the world.

Gradual or Indirect Causes of Climate Change on Mental Health and Psychosocial Well-Being The next major way in which climate change affects mental health and well-being is via climate change’s more gradual or indirect impacts on the environment, human

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systems and infrastructure (Fritze et al. 2008). These include such things as changes in average temperature, rise in sea levels, spread of disease, changes in agricultural conditions, drought, changes in natural landscapes, ecosystem disruptions, increased air pollution, decreased fresh water, and greater wear and tear on infrastructure. These all have a range of flow-on effects, like changes in land use/habitation, increases in food insecurity, increases in displaced people, loss of livability, increases in disruptions to transport, energy supply, increases in cost of living, economic insecurity, increased workload, and financial stress. These can also often mean a loss of choices and loss of freedom for people. The notion of having choices available irrespective of whether any of them will be actually picked is an essential constituent of the freedom aspect of well-being. And these environmental, social, and economic impacts can then result in psychosocial and mental health impacts, like increased stress, distress, family stress, anxiety, depression, substance use, violence, family breakdown, grief, loss of autonomy, loss of identity, increased rates of suicide, reduced social participation, etc. Environmental psychologists Susan Clayton and colleagues also talk about climate change impacts on community health. These types of impacts are understudied but may include things like a diminishment in community cohesion, the loss of community identity, and threats to a sense of continuity and sense of belonging as people are forced to move in and out of communities because of environmental stressors, an undermining of cultural integrity if people have to leave their homelands. Migration challenges the identity, sovereignty, and heritage of people who have to leave their homelands. It also challenges the integrity and continuity of people’s traditional ways of life. Threats to community health also include an increased likelihood of criminal behavior, violence, and aggression as community members experience various stressors related to climate change (Clayton et al. 2017).

Impacts on Rural and Remote Populations These impacts are all especially true for rural and remote residents who rely on the land for their livelihood and also for whom the land often provides a strong sense of place (Stayner 1997). The greater reliance of rural, regional, and remote communities on the environment makes them especially vulnerable to both the direct (previous section) and indirect impacts of climate change. The least developed countries (LDCs) are some of the most vulnerable to these indirect impacts of climate change as well (IPCC 2014). Not only are they least able to recover from climate stressors, but their economic growth is highly dependent on climate-sensitive sectors. Climate change threatens to undo decades of progress towards reducing poverty (UN 2019). There is a growing body of literature documenting the mental health impacts of prolonged drought and other climaterelated disasters in developing countries. Padhy, Sarkar, Panigrahi, and Paul (2015), for example, show how drought in India can lead to farmers and their families getting caught in debt, then becoming further impacted by a rise in expenses of food and

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other goods in the region. Inability to make basic purchases can lead to malnutrition and the risk of other infections. Prolonged droughts may result in people migrating to another region and/or pursuing another vocation, which may lead to acculturation stress. The combination of these stressors then increases the risk of mental health problems and, at worse, increased suicide attempts in the rural farmer population. The impacts of prolonged drought on mental health are better documented in developed countries. There, the links between drought, socioeconomic hardship, and declining mental health have been long established (Stanke et al. 2013). In rural Australia, for example, the experience of drought and associated loss of income, changes to social roles, and changes to the environment were found to be associated with anxiety, stress, and, tragically, suicidal thoughts and acts for people living in these rural communities (McMichael 2011). One study even quantified these increased risks. Nicholls, Butler et al. (2006) in a study in New South Wales found that a decrease in annual rainfall by about 300 mm would lead to increases in the suicide rate by about 8% of the long-term average suicide rate. Rural and remote communities that rely heavily on fishing and forestry are also vulnerable to the impacts of climate change. For those communities whose economic foundations are deeply embedded in agricultural production, the substantial risks posed to farming by climate change equate to risks to the whole community (Hughes et al. 2016). When agriculture suffers, the flow-on impacts affect everyone. Hughes et al. make the point that climate change should be thought of as a threat multiplier – exacerbating existing stressors on rural industries and communities as well as adding new ones. Many indigenous people living in remote and very remote areas also suffer a disproportionate negative impact from climate change for a number of reasons. Remote indigenous communities are particularly vulnerable to increasing severity and frequency of extreme events such as glacial melts (e.g., Himalayas); drought and deforestation (e.g., Amazon); loss of sea ice and diminished traditional food supply (e.g., Arctic); heat waves, combined with water shortages, and decreases in traditional plant and animal resources (e.g., Africa); and rising sea levels and associated coastal inundation (e.g., Australia). These changes all have significant cultural and economic consequences (McNamara et al. 2012; Beer et al. 2014; Green et al. 2009). Climate change also exacerbates the difficulties already faced by vulnerable indigenous communities, including political and economic marginalization, loss of land and resources, human rights violations, discrimination, and unemployment. Indigenous people in remote areas also have a heightened sensitivity to ecosystem change due to the close connections between the health of their “country,” their mental well-being, and the maintenance of their cultural practices. Major biophysical change therefore has the potential to affect their mental health (Hughes et al. 2016). Extensive research into the importance of an individual’s understanding of place and community to their sense of belonging and identity illustrates how ecosystem changes can disrupt pre-existing emotional attachments and threaten place-related identity processes (Fullilove 1996). Many cultures attach great importance to ecosystems or their components, either for religious, spiritual, recreational, or aesthetic

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reasons. Loss of diversity and change in the ecosystem can result in the loss of “sense of place” in local residents and indigenous people. Both place attachment (the process of attaching oneself to a place and a positive emotional connection with familiar locations) and place identity (the ways in which physical and symbolic attributes of certain locations contribute to an individual’s sense of self or identity) are important considerations here. People who are attached to their home environment or familiar landscape enjoy positive emotions from this attachment, as well as feelings of belonging, comfort, and security. Change to this familiar environment can threaten all of these and result in fear, anxiety, and considerable distress (Fried 2000, cited in Devine-Wright 2009).

Climate Change Impacts on Health Systems Climate change also poses significant threats to health systems (Walter et al. 2014). While in general health systems around the world have already established ways of planning for, and responding to, unusual events like extreme weather disasters and epidemics through risk and disaster management strategies, needs after a disaster will almost always outweigh existing services. In every disaster, local leaders are working to capacity to design a proper psychosocial response. And climate change is likely to exacerbate the threats and amplify current public health problems even further. Climate change presents impacts and challenges which are quite different from previous challenges (Ebi 2011). In most places, countries’ current public health approaches do not fully take into account the profound implications and consequences of the connections between climate change and human health (McMichael et al. 2009). The multiple health threats posed by climate change mean that an increased demand for services from the health-care system is very likely. Climate change may increase the demand for physical health care as well as social support and mental health services and, at the same time, make these services harder to sustain because of the disruptions that extreme weather and climate variability put on infrastructure, access, rising costs, etc. The impacts of future climate change on public health also have the potential to generate very large health-care costs (Frumkin et al. 2008; Campbell-Lendrum et al. 2009). For rural and remote communities, climate change may compound the difficulties and inequities that they already face in their health systems (Berry et al. 2011). For example, many communities already find it hard to recruit dedicated health-care and social service professionals. And of course, these difficulties are even further compounded in rural and remote areas in the least developed countries that are already lacking health services compared to the population need.

Vicarious Causes The third broad category of climate change and other environmental threats is that of vicarious threats in the future (either of the next disaster season or further into the

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future), or other places, or as an existential threat to civilization as we know it, that we hear about in the media (Fritze et al. 2008). For many people living in the developed world, this is largely how climate change is experienced – not as a direct threat but as a global threat, often distant in time and place, or as a threat to our very way of life. Qualitative research finds evidence of some people being deeply affected by feelings of loss, helplessness, and frustration as they engage with the problems of global climate change (Moser 2013). This distress is variously referred to as “eco-anxiety” or “climate change anxiety” and describes the growing angst around knowing about loss of biodiversity, species extinction, and dwindling natural resources, as well as the bigger issues of climate change, even if you are not yet directly impacted. Even the perception of loss of biodiversity can lead to considerable concern, anxiety, guilt, anger, helplessness, dread, and pessimism (e.g., Bohm 2003; Edelstein 2002; Doherty and Clayton 2011). The biodiversity of healthy natural environments and ecosystems is integral to human health and well-being and of profound importance to people’s everyday lives and connection with the natural world. This importance goes well beyond human requirements for “healthy,” life-supporting, ecosystems and uncontaminated air, water, food ecosystem services, though these are of course fundamental to human health and well-being. Biodiversity is also of profound importance for meeting psychological needs of hope and inspiration, connection to the natural world, restoration, recreation, and identity (Bentrupperbäumer and Reser 2008). Overall, healthy ecosystems make an essential contribution to our quality of life. The existence and flourishing of natural environments constitute a very meaningful symbolic message, even more so in a troubled and changing world. They convey the message that we live in a naturally ordered world of beauty, peace, inspiration, hope, and transcendence. The availability of natural environments for humans affords us a personal connection with a coherent and meaningful world (e.g., Hartig and Staats 2003; Uzzell and Moser 2006). Further, biodiversity, or the health of natural environments, communicates powerful messages about the fate of our planet and its survival. Biodiversity has always been a “miner’s canary” for individuals and human communities, a signboard for how the natural environment and natural systems are faring. For example, the health and well-being of natural environments within urban or peri-urban environments is often the “window” for many urban dwellers on the well-being of the larger natural world (e.g., Kaplan et al. 1998). Loss of biodiversity therefore has significant psychosocial impacts on individuals and communities.

Protective Factors It is important to note that climate change and other environmental threats are not only or always bad for people’s health and well-being, and nor are rural and remote populations without their own pre-existing strengths and resilience for coping with these threats.

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There is also much that has been written about the resilience of rural and remote communities and their capacity to grow strong in the face of adversity (Hegney et al. 2007). For example, rural communities are strong in connectedness, community spirit, and “being a part of a community,” hard-working, and connection to land. Of course, these are both protective and risk factors, because if environmental stressors require people to leave their much loved land and break their community ties, or prevent them from working, these consequences can become additional sources of significant stress. And our understanding of resilience in individuals is best understood as a continuum, with individuals who are highly resilient at one end, and individuals who are not, at the other. Rutter (1987) argues that individuals may move along this continuum during their lifetime, often in response to changing environmental circumstances. Whereas individuals may respond well to a particular stressor, they may succumb to another. The threat, of course, with climate change is the cumulative impact of increasingly frequent and intense environmental stressors, which risks even the most resilient individuals becoming undone at various stages of their life.

Practice Implications Implications for Rural and Remote Practitioners Mental health practitioners living and working in rural and remote regions have a special set of challenges to cope with because of climate change and related environmental threats. As well as the increased burdens on community members’ health and well-being outlined in the previous sections, there are also unique challenges that befall practitioners because of the realities of working as one of only a small number (or sometimes the only) health professional caring for a distressed community. For example, some particular challenges that the rural and remote mental health practitioner might face in responding to loss and damage caused by extreme weather events are summarised by the Australian Psychological Society tip sheet ‘Psychologistsliving in small, remote or rural communities affected by a disaster’ (Australian Psychological Society 2016), and include: • Being seen as the trauma expert, even if you’re not, and asked to respond, give information and advice, and intervene in communities. • Having to examine the limits of your competence in the face of a great pressure to be a trauma expert. Knowing when to refer on or when to seek additional supervision when referring on is not possible. • Having to draw from your other competencies to address the crisis. • Being required to work in new venues, e.g., speaking at community meetings or talking to the local media or Internet forums. • Feeling traumatized yourself at the same time as having to respond to other people’s trauma as a helping professional.

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• Experiencing secondary traumatization by witnessing the distress of people with whom you have close or intimate relationships, such as family members, colleagues, friends, and neighbors. • Risking vicarious traumatization as a result of listening to other people’s distressing stories of the disaster in the context of a therapeutic relationship. • Having to provide a higher level of care to distressed clients at a time when you are also managing your own personal reactions to a tragedy. • Finding your own anxieties mirrored or increased by the needs and concerns expressed by the people you are working with. • Being tempted to wear your professional hat first and neglecting to look after yourself. • Finding yourself working beyond the call of duty because the perceived need is so great. • Struggling to balance demands placed on you in your work with a traumatized community against the demands in your own life, particularly if you and your family and close friends were personally impacted by the disaster. • Working as a helping professional in a situation in which your clients know that you too have experienced an extremely stressful event and having no choice about this initial disclosure. Many of the circumstances listed above increase professional demands and stress on psychologists at a time of personal distress. The extraordinary demands that can be placed on a mental health practitioner during a disaster within his or her own community intensify the need for self-monitoring with an eye to self-care strategies that can help bolster professional and personal resilience. Increased stress is a natural response to these circumstances, and the first step in managing this stress is careful attention to self-care, including recognizing and paying attention to early warning signs.

Building Resilience Rural and remote practitioners’ resilience can be enhanced in many and varied ways including through their personal and professional social supports and increased selfawareness and self-care. Social support is always the mainstay of building resilience. Practitioners benefit from connecting with their peers for professional and collegial support, either face to face, phone, or electronically. Practitioners can also endeavor to access a mentor who can help them think through their work, give strategic advice, and be a good sounding board. Friends and family are also an important part of practitioners’ social support. Practitioners can also develop a good self-awareness, becoming familiar with their own stress signals and warning signs, talking about their needs with others, knowing when to ask for help for themselves, and developing insight in what helps

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them cope. Useful self-care includes trying to keep reasonable working hours, taking deliberate regular breaks for hours or even days at a time, maintaining healthy routines like taking time to do physical exercise, preparing and eating healthy meals, getting enough sleep, and spending time on things that give a sense of meaning in life. Case Study

Natalie was a psychologist working in a small town in the tropics. When the cyclones hit the area earlier in the year, Natalie was among the many residents who had to evacuate to a larger town 100 km inland to escape the full force of the cyclonic winds. Natalie and her family were lucky to have friends who they could shelter with, but many of the people she knew, and families who she worked with, sought refuge in the large new evacuation centre, built after the cyclones that devastated the same region only 5 years earlier. When the storm had passed, Natalie and the rest of the community returned home to assess the damage. Natalie’s family home was intact, but the roof of the hotel that her parents owned had been partially damaged, much to the township’s dismay! The power and telecommunications were unavailable for several days, and the community health centre where she worked part-time wasn’t able to access the online appointment diary and client records. When the centre did re-open, they were inundated with calls in the coming weeks for support from families struggling to deal with their own losses. Some people had just rebuilt their homes and got back on their feet after the last cyclone 5 years earlier and hadn’t expected to have to deal with another one so soon. Some families had returned to their homes and were living in the one dry room that remained and were not coping with the strain of the whole family living on top of each other in the weeks of heavy rain that followed the cyclone. Others were struggling to cope with the ruin of crops and the worry of how they were going to make ends meet. One staff member took extended leave because her own home was significantly damaged and she had to find temporary accommodation with family out of the area, so the centre found themselves understaffed at a time of great need. Natalie found herself working long hours, and she found herself becoming increasingly irritated by the incessant rain. She and her husband tried to help out at her parents’ hotel on Friday and Saturday nights, but that made it even harder to have some time away from hearing people’s stories of the storm. People would also sometimes stop her in the street to ask about her parents and how they were managing or to ask her advice about their children. Sometimes it felt hard living and working in the same community. Like other people in the town, she started to dread the next cyclone season. Luckily, some of Natalie’s colleagues in the wider region set up a telephone peer support group after the cyclone to provide support for each other. It was here that she was able to discuss the stress and strains of living and working in a disaster(continued)

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affected community. She realized that looking after herself was just as important as looking after everyone else. She started to set aside times each day when she would switch off her phone for a few hours and have a proper meal with her husband or friends, or read a good book, or put on her gumboots and go for a walk. She found that these mini breaks gave her a lot more energy to cope with her work and be a part of the community’s long recovery.

Concluding Comments and Recommendations Environmental threats like climate change, increased global average temperatures, altered rainfall patterns, changed agricultural systems, and extreme weather events, plus all the flow-on effects these changes have on human systems, infrastructure, the economy, and communities, all have serious consequences for people’s health and well-being. There are mental health impacts, psychosocial impacts, community health impacts, and existential impacts. This is especially true for rural and remote residents. People living in rural and remote settings are more likely to be impacted by extreme weather events. Those who rely on the land for their livelihood are more likely to suffer economic losses from changing climatic conditions. Those for whom the land provides a strong sense of place are vulnerable to grief and loss when these places are altered or when they are forced to move away from their homelands because of extreme weather disaster or in search of new livelihoods. People living in rural and remote areas are also more likely to have existing vulnerabilities, like being older, higher rates of chronic illness, and lower social economic status, all of which mean that their capacity to cope with adversity, protect themselves from disaster, or bounce back is not as great as others. The health system is also particularly vulnerable to climate impacts in rural and remote areas because it is already under pressure, especially for mental health services. The increased demand for these services as the impact of climate change continues to rise will currently be met with serious shortfalls. The implications of these environmental threats for rural and remote mental health practitioners living and working in these areas are significant. Not only are their communities especially vulnerable to climate change impacts, it is often also the case that the rural and remote practitioner is one of only a small group of health workers trying to meet the needs of a community, at the same time as having to cope personally with the extreme weather event or flow-on effects of climate change that is impacting their community. Good self-care to build resilience for the health practitioner is vitally important. Climate change is an ongoing and escalating threat, as this chapter has illustrated. In the following chapter, many more strategies are explored for coping with the impacts of climate change and related environmental threats.

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Take Home Messages • Climate change has been described as the most serious global health threat of the twenty-first century. • Rural and regional communities are disproportionately affected by the impacts of climate change. • Climate change exacerbates existing vulnerabilities and risks in rural and regional communities. It is a threat multiplier. • Psychological impacts of climate change result from: – Direct causes of climate change – Indirect or gradual causes of climate change – Vicarious threats in the future or other places – Existential threats to civilization • The multiple health threats posed by climate change mean that an increased demand for services from the health-care system is very likely. • Public health approaches around the world do not fully take into account the profound implications and consequences of the connections between climate change and human health. • For rural and remote communities, climate change may compound the difficulties and inequities that they already face in their health systems. • Practitioners need to anticipate the threat that climate change places on their own roles within their community and organizations. • Practitioners need to employ suitable self-care strategies to cope with the additional stressors of living in a rural and remote community.

Cross-References ▶ Addressing Climate Change

References Australian Psychological Society. Psychologists living in small, remote, rural communities affected by a disaster - Information Sheet. Melbourne: Australian Psychological Society; 2016. AIHW. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. Catalogue number IHW 147. Canberra: AIHW; 2015. Beer A, Tually S, Kroehn M, et al. Climate change and the future of Australia’s country towns. In: Palutikoff JP, Boulter SL, Barnett J, Rissik D, editors. Applied studies in climate adaptation: New York: Wiley; 2014. Bentrupperbäumer JM, Reser JP. Encountering a world heritage landscape: community and visitor perspectives and experiences. In: Stork N, Turton S, editors. Living in a dynamic tropical forest landscape: lessons from Australia. Oxford, UK: Blackwell; 2008. Berry HL, Hogan A, Owen J, Rickwood D, Fragar L. Climate change and farmers’ mental health: risks and responses. Asia Pac J Public Health. 2011;23:119S–32.

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Bi P, Parton KA. Effect of climate change on Australian rural and remote regions: what do we know and what do we need to know? Aust J Rural Health. 2008;16:2–4. Blashki G, Armstrong G, Berry H, Weaver HJ, Hanna EG, Bi P. et al. Implications of climate change for health services in Australia. State of the science and policy 2010. Discussion paper no. 3. Canberra. 2010. Bohm G. Emotional reactions to environmental risks: consequentialist versus ethical evaluation. J Environ Psychol. 2003;23(2):199–212. Bonanno GA, et al. Weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities. Psychol Sci Public Interest. 2010;1(11):1–49. Campbell-Lendrum D, Bertollini R, Neira M, Ebi K, McMichael A. Health and climate change: a roadmap for applied research. Lancet. 2009;373(9676):1663–5. Clayton S, Manning CM, Krygsman K, Speiser M. Mental health and our changing climate: impacts, implications, and guidance. Washington, DC: American Psychological Association and ecoAmerica; 2017. Cook J, Nuccitelli D, et al. Quantifying the consensus on anthropogenic global warming in the scientific literature. Environ Res Lett. 2013;8(2):024024. Costello A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009;373:1693–733. https://doi.org/ 10.1016/S0140-6736(09)60935-1. Devine-Wright P. Rethinking NIMBYism: the role of place attachment and place identity in explaining place-protective action. J Community Appl Soc Psychol. 2009;19(6):393–520. Dodgen D, Donato N, Kelly A, La Greca J, Morganstein J, Reser J, Ruzek S, Schweitzer MM, Shimamoto K, Thigpen T, Ursano R. Ch. 8: Mental health and well-being. In: The impacts of climate change on human health in the United States: a scientific assessment. Washington, DC: U.S. Global Change Research Program; 2016. https://doi.org/10.7930/J0TX3C9H. Doherty TJ, Clayton S. The psychological impacts of global climate change. Am Psychol. 2011;66 (4):265–76. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/21553952 Ebi K. Climate change and health risks: assessing and responding to them through ‘adaptive management’. Health Aff. 2011;30(5):924–30. Edelstein MR. Contamination: the invisible built environment. In: Bechtel RB, Churchman A, editors. Handbook of environmental psychology. New York: Wiley; 2002. Fritze JG, Blashki GA, Burke S, Wiseman J. Hope, despair and transformation: climate change and the promotion of mental health and wellbeing. Int J Ment Heal Syst. 2008;2:2008. Available from http://www.ijmhs.com/content/pdf/1752-4458-2-13.pdf Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health response. Am J Public Health. 2008;98(3):435–45. Fullilove M (1996) Psychiatric implications of displacement: contributions from the psychology of place. Am J Psychiatry 1996;153(12):1516–23. Green D, King U, Morrison J. Disproportionate burdens: the multidimensional impacts of climate change on the health of indigenous Australians. Med J Aust. 2009;190:4–5. Hansen A, Bi P, Nitschke M, Ryan P, Pisaniello D, Tucker G. The effect of heat waves on mental health in a temperate Australian city. Environ Health Perspect. 2008;116:1369–75. https://doi. org/10.1289/ehp.11339. Hartig T, Staats H. Restorative environments: part special issue. J Environ Psychol. 2003; 23:103–70. Hayes K, Blashki G, Wiseman J, Burke S, Reifels L. Climate change and mental health: risks, impacts and priority actions. Int J Ment Heal Syst. 2018;12(28). https://doi.org/10.1186/s13033018-0210-6 Hegney D, Buikstra E, Baker P, Rogers-Clarke C, Pearce S, Ross H, King C, Watson-Luke A. Individual resilience in rural people: a Queensland study, Australia. Rural Remote Health. 2007;7(620). www.rrh.org.au/journal/article/620 Horton G, Hanna L, Kelly B. Drought, drying and climate change: emerging health issues for ageing Australians in rural areas. Australas J Ageing. 2010;29:2–7.

30

Environmental Impacts on Mental Health

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Hughes L, Rickards L, Steffen W, Stock P, Rice M. On the frontline: climate change & rural communities. Sydney: Climate Council of Australia; 2016. IPCC. Climate change 2014: synthesis report. Contribution of working groups I, II and III to the fifth assessment report of the intergovernmental panel on climate change [Core writing team, Pachauri RK, Meyer LA, editors]. Geneva: IPCC. 151 pp. 2014. IPCC. 2018: summary for policymakers. In: Masson-Delmotte V, Zhai P, Pörtner H-O, Roberts D, Skea J, Shukla PR, Pirani A, Moufouma-Okia W, Péan C, Pidcock R, Connors S, Matthews JBR, Chen Y, Zhou X, Gomis MI, Lonnoy E, Maycock T, Tignor M, Waterfield T, editors. Global warming of 1.5°C. an IPCC special report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. Geneva: World Meteorological Organization; 2018. Kaniasty K, Norris F. The experience of disaster: individuals and communities sharing trauma. In: Gist R, Lubin B, editors. Response to disaster: psychosocial, community, and ecological approaches. Ann Arbor: Brunner/Mazel; 1999. Kaplan R, Kaplan S, Ryan RL. With people in mind: design and management of everyday nature. Washington, DC: Island Press; 1998. Loughnan M, Nicholls N, Tapper N. Mortality– temperature thresholds for ten major population centres in rural Victoria, Australia. Health Place. 2010;16:1287–90. Martin-Latry K, Goumy MP, Latrye P, Gabinski C, Bégaud B, Faure I, Verdoux H. Psychotropic drugs use and risk of heat-related hospitalisation. Eur Psychiatry. 2007;22(6):335–8. McMichael AJ. Drought, drying and mental health: lessons from recent experiences for future risklessening policies. Aust J Rural Health. 2011;19:227–8. McMichael A, Neira M, Bertollini R, Campbell-Lendrum D, Hales S. Climate change: a time of need and opportunity for the health sector. Lancet. 2009;374(9707):2123–5. McNamara KE, Smithers SG, Westoby R, Parnell K. Limits to climate change adaptation for lowlying communities in the Torres Strait. Gold Coast: National Climate Change Adaptation Research Facility; 2012. Moser SC. Navigating the political and emotional terrain of adaptation: community engagement when climate change comes home. In: Moser SC, Boykoff MT, editors. Successful adaptation to climate change: linking science and policy in a rapidly changing world. New York: Routledge; 2013. p. 289–305. Nicholls N, Butler CD, Hanigan I. Interannual rainfall variations and suicide in New South Wales, Australia, 1964–2001. Int J Biometeorol. 2006;50:139–43. Nitschke M, Tucker G, Bi P. Morbidity and mortality during heatwaves in metropolitan Adelaide. Med J Aust. 2007;187(11–12):662–5. Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: part I. an empirical review of the empirical literature, 1981–2001. Psychiatry. 2002;65(3): 207–39. Padhy S, Sarkar S, Panigrahi M, Paul S. Mental health effects of climate change. Indian J Occup Environ Med. 2015;19(1):3. Rutter M. Psychosocial resilience and protective mechanisms. Am J Orthopsychiatry. 1987;57: 316–31. Sheffield PE, Landrigan PJ. Global climate change and children’s health: threats and strategies for prevention. Environ Health Perspect. 2010;119:291–8. Stanke C, Kerac M, Prudhomme C, et al. Health effects of drought: a systematic review of the evidence. PLoS Curr. 2013;5 https://doi.org/10.1371/currents.dis.7a2cee9e980f91ad769 7b570bcc4b004. Stayner R. Sense of place, social capital and rural development. In: Proceedings, rural Australia: toward 2000 conference; 4 July 1997. Wagga Wagga, Australia. United Nations. Paris agreement. United Nations Treaty Collection. 8 July 2016. [cited 2017 Sep 19]. Available from https://treaties.un.org/pages/ViewDetails.aspx?src¼TREATY&mtdsg_ no¼XXVII-7-d&chapter¼27&clang¼_en

674

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United Nations. The sustainable development goals report. 2019. Available from https://unstats.un. org/sdgs/report/2019/The-Sustainable-Development-Goals-Report-2019.pdf Uzzell DL, Moser G. Environment and quality of life. Eur Rev Appl Psychol. 2006;56:1–4. Walter T, Stevens P, Verhoeven A, Boxall A-M. Impacts of climate change on public health in Australia. Recommendations for new policies and practices for adaptation within the public health sector. Deeble institute issues brief. 2014; 7. [Cited 2017 Sep 19]. Available from http:// ahha.asn.au/publication/issue-briefs/impacts-climate-change-public-health-australia-recommen dations-new-policies Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. The Lancet. 2015;386(10006):1861–914. Wilkins R. The household, income and labour dynamics in Australia survey: selected findings from waves 1 to 12. Melbourne: Melbourne Institute of Applied Economic and Social Research; 2015. World Health Organization. Climate change and human health: risks and responses. McMichael AJ, Campbell-Lendrum DH, Corvalán CF, Ebi KL, Githeko AK, Scheraga JD, Woodward A, editors. Geneva: WHO; 2003.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Responding to Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mitigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coping with Loss and Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Climate change and other environmental problems threaten people’s health and wellbeing wherever they live on the globe, but specific groups of people are at higher risk for distress and other adverse mental health consequences from exposure to climate change, and this particularly includes people living in rural and remote areas. Understanding what to do to reduce these threats (mitigation) and adapt to these threats (climate adaptation, disaster preparedness), as well as how to care for people who are adversely affected by climate change impacts, are an essential part of rural and remote mental health practitioners’ work. Practitioners have a responsibility to participate in national and global efforts to mitigate the threat of climate change by reducing the greenhouse gas emissions of their sector, workplaces, and organizations, even more so because it is a problem which is caused by human behavior and which threatens human health and wellbeing. Practitioners can use their respected positions as health practitioners, as well as the communication techniques identified by climate change communication experts, to raise the importance of climate change action within their profession as well as with leaders and decision-makers. Attention must also be paid to urgent adaptation and disaster preparedness in face of the escalating S. E. L. Burke (*) Australian Psychological Society, Melbourne, VIC, Australia © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_40

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threat of increased frequency and intensity of extreme weather events in rural and remote communities around the world.

Introduction Environmental threats like climate change are already having, and will continue to have, enormous impacts on people’s health and wellbeing. As well as the direct effects of extreme weather event disasters on individuals and communities, and the resulting losses, damage, and ensuing mental health problems, there are also indirect or gradual flow-on effects of environmental impacts. These include things like changes in land use, loss of liveability in particular regions, increased disruptions to transport and energy, and increased economic hardship. These environmental, social, and economic impacts in turn can then result in psychosocial and mental health impacts, like increased stress, distress, family stress, anxiety, depression, substance use, violence, family breakdown, grief, loss of autonomy, loss of identity, increased rates of suicide, reduced social participation, etc. Finally, there are also the vicarious impacts of climate change on people’s health and wellbeing resulting from the existential threat that climate change poses to civilization and our very way of life. These impacts on mental health were detailed in the previous chapter. This chapter picks up the story of what needs to be done in response to the enormous threat of climate change. It looks at the practice implications for rural and remote mental health practitioners, not just with their clients, and in their workplaces, but also as active advocates for, and participants in, urgent mitigation and adaption measures to address the escalating threat of climate change in their communities and all around the world. Climate change and other environmental problems threaten people’s health and wellbeing wherever they live on the globe, but specific groups of people are at higher risk for distress and other adverse mental health consequences from exposure to climate change, and this particularly includes people living in rural and remote areas (Hughes et al. 2016). For this reason, understanding what to do to reduce these threats (mitigation) and adapt to these threats (climate adaptation, disaster preparedness), as well as how to care for people who are adversely affected by climate change impacts, is an incredibly important part of rural and remote mental health practitioners’ work.

Distinctive Features Responding to Climate Change Helping people to address and deal with the impacts of climate change is a multifaceted task. For many years, responding to climate change has required two wide areas of focus: mitigation (reducing the threat) and adaptation (managing the impacts

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that cannot be avoided). More recently, following the 2015 Paris Agreement (UN 2016), a third area of action on climate change has been discussed: loss and damage. Loss and damage refers to the consequences of climate change that we are unable to mitigate or adequately adapt to. So in this section, practice implications for rural and remote mental health practitioners dealing with climate change will include the need for climate change mitigation and adaptation in their workplaces, the community, and the healthcare sector, as well as assisting people to deal with change, loss, and suffering and the ensuing sequelae of psychosocial and mental health issues caused when climate change impacts on them personally. The many and various considerations that come into rural and remote mental health practitioners’ practice will be outlined, under these three areas: mitigation, adaptation, and loss and damage.

Mitigation Mitigation is a term used to refer to the things that we do to reduce the threat of climate change. Largely this is about reducing carbon emissions which are driving increased global temperatures. Around the world, the ultimate goal is “de-carbonizing” the economy, making a transition to 100% renewable energy, getting off coal and gas, decoupling our financial systems from the fossil fuel industry, removing excess CO2 from the atmosphere, electrifying transport systems, refurbishing and redesigning buildings, changing agricultural production systems, adopting new industrial processes, adapting lifestyles, and doing all this before 2050 in order to have a reasonable chance of keeping global average temperature rise to below 1.5 °C and trying to avoid catastrophic runaway climate change (IPCC 2014; ClimateWorks 2014). On a local scale, the same tasks are needed in order to mitigate (reduce) the threat of climate change. So mitigation includes behaviors like reducing the carbon footprint of our own workplaces, organizations, homes, and activities, reducing waste, investing in energy efficiency and clean energy, promoting sustainable transport and resource consumption, etc. It is increasingly part of any responsible organizational practice to reduce its environmental impacts. The environmental impact of healthcare is significant. If the American healthcare system were a country, it would rank 13th in the world for greenhouse gas emissions (Eckelman and Sherman 2016). The environmental cost in Australia is not as well quantified, but we know something about its carbon footprint, with early estimates suggesting the health sector is responsible for seven percent of carbon emissions from all buildings (Armstrong 2014). There is substantial scope to “green” the healthcare sector, reducing emissions, energy consumption, and overall operating costs. Arguably, too, health professionals have an even greater moral and ethical responsibility to take leadership on climate change mitigation to address an issue which is caused by human behavior and which threatens human health and wellbeing.

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There is much, therefore, that rural and remote mental health practitioners can do within their workplaces, within their organizations, and as advocates in the healthcare sector, to reduce emissions, encourage others to do the same, and take a leadership role on the importance of reducing environmental harms in health care, as well as engaging in effective action to curb climate change.

Reducing Your Environmental Footprint Within the Rural and Remote Mental Health Practitioners’ Workplace Reducing your environmental footprint within your hospital or health clinic or practice includes things like: • • • • • • • • • • • • •

Auditing the carbon footprint of your workplace Developing sustainability policies for your workplace Setting emission reduction targets Purchasing renewable energy Reducing waste Increasing energy efficiency Buying safer and more sustainable products Reducing water consumption Promoting sustainable transportation, like encouraging bike commuting and public transport, and reducing work-related air travel through increased video conferencing Purchasing and serving sustainably grown, healthy food Supporting green and healthy building design and construction Educating staff about climate change (and particularly the health impacts) Encouraging staff to reduce their own carbon footprint at home

Health Care Without Harm is a global network of health practitioners advocating for environmentally responsible healthcare. They aim to reduce the environmental impact of health care over a range of services including medical waste, toxic materials, safer chemicals, green building and energy, healthy food, pharmaceuticals, green purchasing, transportation, and water. They have health partners around the world achieving reductions in emissions and improvements in sustainability. For example, a Global Green and Healthy Hospitals (GGHH) initiative helps health organizations from around the world to connect, learn, and collaborate with each other to support their efforts toward reducing the environmental footprint of the health sector and promote environmental health (http://www.greenhospitals.net/sus tainability-goals/). There are a few notable examples of substantial or green hospital building and design. One example is the Patrick Dollard Discovery Health Center in upstate New York. It is a residential facility for developmentally disabled children and adults, and the medical staff has a keen interest in the impact of the environment on developmental disabilities. The Dollard Health Center was built using local and regional recycled-content low-emitting materials. By using ground source heat pumps, energy demand was reduced by 42 percent, and onsite fossil fuel combustion was

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eliminated. The facility runs on green power. In Australia, the Kooweerup Regional Health Service (KRHS) is another example of a sustainable hospital. The KRHS is a small acute hospital (12 beds), residential care, and community care comprising district nursing and allied health services which also acts as a local sustainability hub that supports healthy and sustainable lifestyles across the community (Armstrong 2014). Adopting environmentally sustainable practices within workplaces is not just a nice thing to do, but an essential part of worldwide efforts to restore a safe climate. While “greening the clinic” might not seem to be directly related to mental healthcare practitioners’ clinical practice, the environmental harms incurred by an increasingly unstable climate make this an essential part of efforts to prevent significant physical and mental health problems now and in the future.

Advocating for Strong Climate Policies with Governments, DecisionMakers, Opinion Leaders Another critically important mitigation strategy that many health practitioners are involved in is that of advocating for strong climate policies with governments, decision-makers, and opinion leaders, and even within mental health practitioners’ own professional organizations. While world leaders agreed at Paris climate talks in late 2015 to reduce human contributions to greenhouse gas emissions in an attempt to limit global average temperatures to below 2° (preferably below 1.5 °C) (United Nations 2016), this agreement also needs to lead to actions around the world that are commensurate with the threat. Health Care Without Harm (HCWH), for example, advocates as an alliance of health and mental health practitioners for strong climate policies from a health platform. Many individual health practitioners also make submissions, appeals, and lobby politicians and leaders to protect health by limiting climate change. The Australian partner of HCWH, the Climate and Health Alliance (CAHA), is currently leading the push for a National Strategy for Climate, Health and Wellbeing for Australia (CAHA 2017). This Framework for a National Strategy for Climate, Health and Well-being provides a roadmap to support the Australian Federal Government in taking a leadership role in protecting the health and wellbeing of its communities from climate change and in fulfilling its international obligations under the Paris Agreement. Health practitioners all around the country are advocating to government representatives and policy makers that this strategy be adopted to ensure that climate and health be well considered in ongoing policies. Health professionals are an incredibly important voice in advocating for strong climate policies to protect the health of people around the world. Rural and remote practitioners in particular are often the ones to see first-hand the devastating impacts of climate change on people living in some of the more climate-sensitive parts of the country. There is an important role for health professionals and health organizations to advocate for an energy transition to clean renewables, to participate in the effort to shift the finances away from fossil fuels, and to be part of demanding accountability

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from elected representatives to respond to this as an urgent health issue, for which there is a comprehensive evidence base. Within one’s professional organization, rural and remote practitioners can be encouraging their organization and sector to see climate change policy as core business for health in the context of a “health in all policies” approach.

Adaptation While reducing future climate change risk is critically important, addressing the impacts that we are already seeing today and cannot avoid in the future, even with the most ambitious mitigation targets, is essential. The world is already in times of dangerous climate change. Many of the risks scientists have warned us about in the past are now happening (e.g., increased duration and frequency of heatwaves, increased risk of wildfires/bushfires, hurricanes/cyclone, floods, severe storms, shifting rainfall patterns, increased droughts, sea-level rise, coastal inundation, loss of species). And worse is predicted. An urgent task is to prepare for the unavoidable threats, like extreme weather events and altered disease distributions, in order to protect lives and minimize damage and to learn how to respond to, cope with, and recover from these events. In the field of climate science, this is called adaptation. Within the rural and remote healthcare sector, the main adaptation task is to enhance the capacity of the sector, including health facilities and services, to plan for, prepare for, and respond to the amplified public health threats posed by climate change. This includes both physical and structural adjustments. In the following section, thus, we will look at what adaptation means for the rural and remote practitioners, starting from the workplace and then the community and then from the perspective of the healthcare sector. As well as physical and structural adjustment to threats, however, adaptation also includes a range of coping actions that individuals and communities may take in response to climate change, as well as psychological processes that both precede and follow behavioral responses (Reser et al. 2012). So, from a psychological perspective, adaptation to climate change is also about “coming to terms with” climate change and includes how people perceive and understand the problems, how they cope with the feelings that are elicited in response to climate change, and how they decide what to do in response to the problems. So, this section will end with a segment on how individuals also adapt to climate change and the role that mental health practitioners play in understanding and promoting the importance of psychological adaptation and “coming to terms” with climate change.

Preparing for and Responding to Extreme Events Within the Sector The rural and remote healthcare sector does, in general, already have established systems for managing disasters and risks. Climate change, however, amplifies these threats and creates additional complexities because of the many direct and indirect

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ways in which it seriously affects health as well as acting as a stress multiplier for existing problems. The sector therefore needs to develop alternative, more effective, practices to manage the complex issues related to climate change while continuing to implement their traditional primary, secondary, and tertiary preventive models (Walter et al. 2014). Experts recognize that the current ways in which the healthcare sector operates are not fully able to take into account the profound implications and consequences of the connections between climate change and human health (McMichael et al. 2009; Walter et al. 2014) nor deliver progress on the scale and with the speed required (Hanlon et al. 2012; Morris 2010). Rather, a new approach, based on ecological principles, is needed, in which health is seen as interconnected with the physical and social environment. The health sector needs to develop interventions to reduce specific health vulnerabilities but also require the involvement of social, cultural, environmental, political, and economic interrelations (Ebi 2011). Adaptation within the rural and remote mental health care sector includes: • Assessing regional and remote mental health risks to identify vulnerable and resilient populations • Identifying the risks to mental and physical health and psychosocial wellbeing associated with particular extreme weather events • Making use of early warning systems which are developed for the use of all sectors in order to act when needed • Developing action plans to respond to extreme weather events, strong communication lines, equipment, and trained health personnel ready to meet the psychosocial needs of communities impacted by extreme weather disasters • Preparing for emerging disease patterns and disease migration to areas where health providers are not thoroughly trained to address previously non-endemic diseases • Ensuring adequate levels of existing health care will help to build the resilience of Australia’s rural communities as environmental conditions move beyond previous experience

Preparing for and Responding to Extreme Events Within the Workplace Adaptation tasks within a rural and remote practitioner’s workplace or organization are also extremely important as a way of preparing for future shocks. Adaptation to climate change does not “just happen,” though. There are four key stages that an organization will usually pass through before commencing adaptation planning. These stages are: • • • •

Clear understanding of climate change as an important issue Awareness of the organizations’ own climate change vulnerability Sense of responsibility for developing a solution or response Willingness to engage in adaptation planning and to mobilize resources Gardener et al. (2010)

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Organizations that are then at the point of engaging in adaptation planning are likely to perform a range of tasks to prepare for possible future shocks, including developing organizational disaster plans to incorporate increased scale and intensity of extreme weather events, retrofitting buildings for better protection against increased intensity of extreme weather events (e.g., heat waves, severe storms), mobilizing resources for assistance in the event of extreme weather events, like generators for back-up power. (For specific examples of organizations performing tasks to prepare for climate change impacts, see Walker and Mason’s (2015) textbook Climate Change Adaptation for Health and Social Services). The Australian Council of Social Services (ACOSS) developed a toolkit in 2015 by, and for, the community sector to help organizations measure and improve their resilience to disasters and emergencies (ACOSS 2016 or http://resilience.acoss.org. au/). Known as the Resilient Community Organisations toolkit, it includes a benchmarking system so organizations can assess their current state of preparedness for disasters and emergencies and identify areas of improvement. Following the benchmarking assessment, organizations can then follow Six Steps to Disaster Resilience, which provides information and resources organizations need to take action. The steps are: • • • • • •

Leading resilience Building networks Knowing your risks Managing your risks Preparing others Learning and inspiring

Rural and remote mental health practitioners can play an important role in helping their workplaces put climate change adaptation on the agenda using tools like the Resilient Community Organisations toolkit. For examples of communicating about climate change adaptation within the health sector, to help organizations see the importance of this sort of adaptation and disaster planning in the context of climate change, see Burke (2015). Case Study

Janelle worked as a psychologist in a small regional health centre. She knew that she needed to talk with the centre about getting climate change onto the agenda. She thought a lot about the audience. Janelle knew that a health frame would be very useful, given that this was their core business! She organized to make a presentation to her board about the many ways in which the health of people in their region was going to be impacted by the threat of climate change, and described how these predicted increases in clients would stretch (continued)

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their resources to the limit. She also knew that several of the board members were very risk-averse, so she described the enormous risks that she saw their centre taking by not acknowledging the threats that climate change made to their operation and by failing to take steps to adapt to these threats before they happened. She raised their awareness of how vulnerable their premises would be in the event of a bushfire or flood, both of which were paradoxically increasingly likely under climate change scenarios. If their building was damaged or destroyed, how would they continue to operate? What would happen to all of their documentation? How would they continue to provide a service? Would they even survive as an organization? An outcome of this conversation was that the board began to take serious steps toward adapting to these threats. They added climate change adaptation to their priorities and made changes on a variety of fronts, like extending their insurance against extreme weather events, storing copies of electronic information off-site, and purchasing a power generator to charge mobile phones in the event of power outages. They also made a start at reducing their carbon footprint by committing to an energy audit in the first instance so that they could then have a way of measuring their carbon reductions.

Preparing for and Responding to Extreme Events Within the Community Adaptation to climate change also needs to take place within the community, and rural and remote mental health practitioners can also play a role in this, for example, through strategies such as communicating about climate change (including framing climate change as a health threat) and contributing to household disaster preparedness. Communicating About Climate Change and Health One important way in which healthcare practitioners can contribute to climate adaptation efforts is by communicating about climate change in a way that helps the public to see that it is relevant and important to them and one that they therefore need to do something about. Otherwise, people have a tendency to downplay the risks of climate change because they can see it as being distant from themselves. It often seems distant in space. Most people tend to see the worst environmental problems as being global environmental problems or events that are far away from them (Leviston et al. 2015). However, people’s feelings of responsibility for the environment are greatest at the neighborhood level. In other words, they see the most serious problems at the level for which they feel least responsibility for doing anything about (Uzzell 2000). Most people also see climate change as distant in time. The worst impacts are far off in time, so it still feels distant from everyday concerns. Thirdly, as a global problem that requires global solutions, it is easy to think that world leaders, governments, and big multinational corporations have the most responsibility for doing something about it (Leviston et al. 2015). Climate

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change can thus feel socially distant, and not a problem that individuals can solve. It is easy, then, for people to discount the risk that it poses. Research has shown, however, that when individuals view climate change as being harmful to themselves and other people, they are significantly more likely to support climate policy responses. And the use of a health and wellbeing frame to talk about climate change, in particular, is a very effective way of engaging a much broader cross section of the public (Maibach et al. 2010). Communicators talk about using a “health frame” to discuss climate change (CRED 2014). This can include both the physical health impacts as well as the mental health and wellbeing impacts that climate change has. Another valuable tool for increasing the public’s engagement with climate change as a personal and salient issue is the use of trusted communicators. There is considerable perceived/felt uncertainty about climate change, particularly given both the contested nature of climate change as a political issue and the skeptic lobby. Using trusted communicators is another important way of helping people to understand the climate issues and see the importance of action. Most people value and highly respect the views of scientists and academics (while having very little faith in journalists or politicians). The big national surveys of public perceptions of climate change report this consistently (see, e.g., the Yale climate surveys, the Stanford surveys, and the Griffith University NCAARF surveys). Health practitioners fall within the “trusted” category of scientists and academics and thus have a powerful voice for communicating about climate change and particularly for raising the importance of climate change as a health threat. Another very useful communication strategy is that of focusing on solutions rather than problems and communicating a sense of hopefulness and efficacy, rather than doom and despair (Burke et al. 2017). Letting people know that we already have concrete, plausible solutions to drastically reduce carbon emissions can help to counter feelings of helplessness about the problem (CRED 2014). Moreover, when people believe there are solutions available, they are more likely to perceive climate change as a problem worth addressing. Also, when climate change is framed using positive narratives of opportunities to create a healthier environment and more resilient communities, then it is much easier for people to listen to and engage with the problem. Doom messages can backfire by triggering defense mechanisms and leading to people switching off to avoid the distressing topic (Fielding and Hornsey 2016). For example, communicators can show how action on climate change can create a more just, equitable, and healthy world. They can show how active transport, clean energy, sharing resources, and low-carbon diets (i.e., more local produce; less meat, dairy, and processed food) are much healthier for us and that sharing and doing things together is more fun and sustainable. They can show us that renewable energy choices can lead to an increase in jobs and economic prosperity. They can also show how action on climate change can leave the actor with a feeling of satisfaction, wellbeing, and optimism from contributing positively to a safe climate, thus

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alleviating some of the psychological angst that many experience. These stories leave people feeling hopeful and positive and encourage people to think broadly about how they and others can contribute to a new way of life. Co-benefits for Health and Mental Health While in 2009 climate change was described as “the biggest global health threat,” (Costello et al. 2009) the 2015 Lancet Commission on Health and Climate Change concluded that “tackling climate change could be the greatest global health opportunity of the 21st century” (IFMSA). So what are the potential health “co-benefits” of addressing climate change? The International Federation of Medical Students’ Association (IFMSA), with the support of the World Health Organization (WHO) published a Training Manual for Climate and Health in 2016 (IFMSA 2016). This excellent resource provides information and tools for doctors and health professionals to help them achieve a better understanding of climate change and health. They also include a useful section on the co-benefits of action on climate change for people’s health. The Climate and Health Alliance (CAHA) and The Climate Institute similarly focused on the health co-benefits of climate action, summarized in their co-publication “Our Uncashed Dividend – The Health Benefits of Climate Action.” In addition to the list of actions and benefits noted by IFMSA, they also include: Increased Active Transport: Shifting more journeys to active transport (such as walking or cycling) yields immediate health “benefits” such as improved cardiovascular health, improved mental health, and reduced risk of type 2 diabetes, reduces road traffic injuries, and of course, reduces (IFMSA 2016). Communities that are designed to facilitate active and public transport can reduce household costs, reduce social isolation, and improve social capital by improving community connectedness as well as improve mental health and wellbeing (CAHA 2012). Reduction in Air Pollution: The World Health Organization (WHO) estimates that seven million premature deaths per year are caused by indoor and outdoor air pollution, much of which is caused by burning fossil fuels. Transitioning to clean electricity production (such as wind, hydroelectric, solar, geothermal) and lowcarbon, low-pollution sustainable forms of transport will all have a significant effect in reducing deaths and diseases related to outdoor air pollution (cited in IFMSA 2016). Improved Diets: Food production and agriculture are major sources of carbon emissions. Measures to reduce the carbon impact of making the food we eat will also improve our diets. Sourcing locally grown foods creates far less carbon emissions than air-freighting imported foods as well as being more nutritious and requiring less pesticide use. Better Housing: Improving the sustainability of housing can provide major health co-benefits alongside reducing carbon emissions. These benefits include reducing exposure to extreme heat and cold, reducing mold and dampness, and improving natural ventilation, and energy efficiency can reduce respiratory and other noncommunicable diseases (IFMSA 2016).

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Protecting and Restoring Natural Ecosystems: It helps keep carbon stored in the landscape, prevents the spread of disease, and provides important psychological and mental health benefits. Altogether, climate action can lead to: • • • • • • • •

Improvements in health and life expectancy Fewer days off work or with restricted activity Fewer medical consultations Fewer hospital admissions Reduced use of medication Increased productivity Increased mental health and psychosocial wellbeing Sense of agency and efficacy

Household Disaster Preparedness Another way in which rural and remote mental health practitioners can play a role in community adaptation is through public education about disaster preparedness and crucially, through the inclusion of psychological preparedness techniques. Physical and psychological preparedness are both important strategies for individuals and communities to prepare for extreme weather events. While physical emergency preparedness is the principal concern and focus of disaster agencies, psychological preparedness is also important. Rural and remote mental healthcare practitioners are often the ones in a community who have the possibility of ensuring that psychological preparedness strategies are also promoted within communities. Psychologists use a term called “stress inoculation” to assist people to prepare themselves psychologically for natural disasters, which in other words means planning to be better protected from stress by working through the likely psychological reactions beforehand and learning strategies to cope. These strategies “inoculate” people against being overly anxious or overwhelmed by their emotional responses and will help prevent being caught up in unhelpful thinking in an emergency situation. Obviously, this approach will work better with some disaster events that may be more frequent and to some extent more predictable, but the psychological principles can be applied for any emergency. Of course, a first step in being inoculated to stress, and feeling in more control, is through being prepared physically for hazardous events common in one’s community. For example, having a household or family emergency plan that is well known and practiced by those in a household is vitally important. Such knowledge, practice, and a consequent increase in a sense of control can then assist with increased clarity in decision-making at the time of an event. Increased “clear thinking” promoted by being prepared, and having a well-drilled emergency plan can then have follow-on effects that can promote psychological adaptation to an extreme event (Reser and Morrissey 2009). In terms of a specific stress inoculation strategy that can be part of a larger household emergency plan, the way people feel in highly stressful situations is strongly affected by the way they cope with the signs of physical arousal (e.g., racing heartbeat, shortness of breath) and the thoughts that they are having (e.g., “I

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can’t cope”; “We’re going to get badly hurt”). These reactions and thoughts can make people feel anxious, hopeless, or even angry, and while these feelings are understandable, they are not very helpful in an emergency situation. Being psychologically prepared means that these natural reactions to stress can be anticipated and managed to help people feel more in control and confident. There are three main steps to being psychologically prepared for a threatening natural disaster: 1. Anticipate scenarios including any anxiety and concerns that will arise. 2. Identify uncomfortable or distressing thoughts and feelings that may cause further anxiety, along with ways of managing these situations both physically and psychologically. 3. Manage the responses so that the ability to cope remains as effective as possible.

Preparing for and Responding to Extreme Events Within the Individual: Psychological Adaptation: Coming to Terms with Climate Change As well as psychological preparedness for extreme weather events, there are also certain psychological processes that are an essential part of adapting to the ongoing threat of climate change. Understanding how climate change affects us psychologically and how people are coming to terms with, and psychologically adapting to, a climate-changed world and reality is crucially important as a way of reducing the threats of climate change as well as preparing people to adapt to the changes that cannot be avoided. Social scientists have long been interested in how people appraise and respond to threats. Considerable research evidence and best practice in the crafting of effective risk communications in preventive health contexts tells us that effective warning and preparedness communications require an honest and unvarnished acknowledgment of the danger accompanied by clear strategies and examples for both addressing the risk and managing one’s own emotions and internal environment (APS 2011, 2013). So psychological adaptation to the threat of climate change requires a similar set of responses. It requires an acknowledgment of this grave threat and profoundly consequential global crisis threat. It requires using coping strategies to manage the feelings and thoughts that arise so that people can face up to, and come to terms with, the threat, and not try to avoid it by distraction, etc. Then it also requires behavioral and psychological engagement, in which people change and adjust their behavior and lifestyle in order to reduce the threat and protect themselves. People can, of course, react in a variety of unhelpful ways to the threat of climate change: minimize the threat; distract themselves; put hope in God or silver bullet solutions; or become helpless and hopeless. This is why psychological adaptation involves managing the thoughts and feelings so that people can stay engaged with the problem and also the solutions. Knowing how climate change affects us psychologically is profoundly important for increasing mitigation and adaptation. “Coming to terms” with climate change requires psychological preparedness, adaptation, and adjustment as well as behavioral and lifestyle adaptation and change.

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Coping with Loss and Damage Finally, there are also extreme weather events for which adaptation is technically or practically not feasible, and this will inevitably result in loss and damage which then needs to be responded to. Acknowledging the importance of preparing for loss and damage is a critical component of the 2015 Paris Agreement (United Nations 2016) and something that rural and remote mental health practitioners also need to be prepared to do. While loss and damage to the built environment are an enormous part of the impact of a disaster, they are not the only part. Rural and remote mental health practitioners have a particular interest in the psychological sequelae of disasters and the mental health and psychosocial impacts of the disaster. There is a large literature on the mental health and psychosocial impacts of disasters like extreme weather events on individuals and communities. These impacts are well documented (e.g., Ferris et al. 2013; Hughes and McMichael 2011) and constitute a key public health issue. Mental health problems following a disaster include not only the direct psychological impact of the disaster itself but also the emotional difficulties arising from confronting the secondary stressors that disasters generate. After a large-scale natural disaster, people show a typical sequence of psychological responses to the disaster. Immediately following the disaster many people show high levels of acute distress. For the majority (70–80%), this resolves naturally after about a month with support. But a significant minority of disaster-affected people (approximately 30% – see Kessler et al. 1995) are at risk of developing enduring and severe mental health problems which require clinical assistance.

Necessary Elements of a Best-Practice Psychosocial Recovery Model In recent years, disaster experts have used a stepped care three-tiered system as the most cost-effective and useful approach to helping people recover psychologically from disasters. In the three-tiered system, a stepped care approach to psychosocial support is used, in which forms of psychosocial assistance are sequenced and start at more basic community or large group-focussed levels (least expensive interventions) and move progressively to those that are more intensive and family or individually focussed, as needed (more expensive interventions) (Wade et al. 2012). This model is based on the knowledge that large numbers of people in a disaster-affected community are likely to need only small amounts of assistance in order to recover well. Basic forms of assistance, requiring relatively minimal amounts of resourcing, might be enough to provide these people with the care they need. The idea of the stepped care approach is to start with the least expensive intervention first but also the intervention which is least intrusive in people’s lives. This provides people with the opportunity to see if they can manage first using their own resources. According to this model (Wade et al. 2012), Level 1 interventions are consistent with current models of psychological first aid (PFA) (Brymer et al. 2006) that aim to promote simple and practical recovery strategies to community members in the immediate aftermath of a disaster. Level 2 interventions are designed to treat individuals with more enduring subclinical mental health problems, who may not

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be at risk of a diagnosable mental health condition but who nonetheless are experiencing significant levels of distress and disruption. And finally, Level 3 focuses on the treatment provided by mental health specialists for those people who have a diagnosable mental health problem and would include trauma-focused interventions like cognitive behavioral therapies.

Concluding Comments and Recommendations Climate change is one of the principal threats to quality – and equality – of life on our planet. Climate change and other environmental problems threaten people’s health and wellbeing wherever they live on the globe but specific groups of people are at higher risk for distress and other adverse mental health consequences from exposure to climate change. This particularly includes people living in rural and remote areas because it presents additional problems (like increased threats of extreme weather events) as well as exacerbating existing vulnerabilities and risks. Reducing the threat of climate change, adapting to the risks that cannot be avoided, and coping with loss and damage ensuing from events that could not be managed are all urgent tasks requiring profound changes at all levels of society, backed up by the international Paris Agreement, signed and ratified by the majority of the world’s nations, to attempt to limit the rise in global average temperatures to below 2°, (preferably below 1.5°). Rural and remote mental health practitioners have a range of ways in which they should and can contribute to coping with climate change, by communicating about the threat of climate change (especially to health) as a respected and trusted “voice,” advocating for and engaging in mitigation activities to reduce the greenhouse gas emissions and adaptation to specific risks and vulnerabilities in their region. Rural and remote mental health practitioners bring particular strengths to the challenge of climate change. As health professionals, they have the advantage of being regarded by the public as a trusted communicator and can use this to communicate persuasively about the risks (particularly to health and wellbeing) of climate change. As rural and remote practitioners, they are likely to have already seen firsthand the particular vulnerabilities of these communities to additional environmental stressors. They have a compelling story to communicate about the urgency of climate change and the imperative for effective and timely adaptation and mitigation.

Take-Home Messages Rural and remote mental health practitioners are often the ones to see first-hand the devastating impacts of climate change on people living in some of the more climatesensitive parts of the country. Practitioners have a responsibility to participate in national and global efforts to mitigate the threat of climate change by reducing the greenhouse gas emissions of their sector, workplaces, and organizations, even more so because it is a problem

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which is caused by human behavior and which threatens human health and wellbeing. Within their professional organizations, rural and remote practitioners can encourage their workplace and sector to reduce emissions and energy consumption, implement sustainable practices, and see climate change policy as core business for health. Health professionals and health organizations are also a trusted and respected voice and can use this to advocate to state and federal politicians and decisionmakers to prioritize climate change as an urgent health issue, for which there is a comprehensive evidence base. Rural and remote mental health practitioners can make valuable contributions to educating communities about the importance of psychological preparedness for extreme weather events using a stress inoculation model to “anticipate, identify, and manage” distressing thoughts and feelings (see Morrissey and Reser 2000), in order to stay in control and keep safe in a disaster scenario. Preparing for loss and damage as a result of climate change impacts is also an essential part of rural and remote mental health practitioners’ work. A stepped care approach is recommended, in which different forms of psychosocial assistance are sequenced and start at more basic community or large group-focussed levels and move progressively to those that are more intensive and family or individually focussed, as needed.

References ACOSS. Resilient Community Organisations Toolkit. Australian Council of Social Services and NCARRF; 2016. [cited 2017 Sep 19]. Available from http://resilience.acoss.org.au/. APS. Submission to the Senate Inquiry into the capacity of communication networks and emergency warning systems to deal with emergencies and natural disasters. Melbourne: Australian Psychological Society; 2011 [cited 2017 Sep 19]. Available from http://www.psychology.org. au/Assets/Files/Submission-to-Senate-Inquiry-into-the-capacity-of-communication-networksand-emergency-warning-systems-to-deal-with-emergencies-and-natural-disasters.pdf. APS. Submission to the Environment and Communications References Committee Inquiry on recent trends in and preparedness for extreme weather events. Melbourne: Australian Psychological Society; 2013. Available from http://www.psychology.org.au/Assets/Files/2013-APSSubmission-Senate-Preparedness-for-Extreme-Weather-January.pdf. Armstrong F. Greening healthcare: thinking local and networking global. 2014. Available from http://www.thefifthestate.com.au/columns/spinifex/greening-healthcare-thinking-local-and-net working-global/70185). Brymer MJ, Jacobs AK, Layne CM, Pynoos RS, Ruzek JI, Steinberg AM, Vernberg EM, Watson PJ. Psychological first aid: field operations guide. 2nd ed: National Child Traumatic Stress Network and National Center for PTSD; 2006. Burke S. Communicating about climate change. In: Walker R, Mason W, editors. Climate change adaptation for health and social services. Melbourne: CSIRO Publishers; 2015. Burke S, Keast S, Gridley H. Climate change empowerment handbook. Melbourne: Australian Psychological Society; 2017. p. 2017. Center for Research on Environmental Decisions. Connecting on climate: a guide to effective climate change communication. New York: Earth Institute and Columbia University; 2014.

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Climate and Health Alliance. Framework for a national strategy on climate, health and well-being for Australia. Melbourne: Climate and Health Alliance; 2017. Climate and Health Alliance and The Climate Institute. Our uncashed dividend. The health benefits of climate action. Published by Climate and Health Alliance and The Climate Institute; 2012. [cited on Sep 19]. Available from http://www.climateinstitute.org.au/articles/publications/ouruncashed-dividend-briefing-paper.html. ClimateWorks Australia (CWA), Australian National University (ANU), CSIRO & Centre for Policy Studies (CoPS). Pathways to deep decarbonisation in 2050: how Australia can prosper in a low carbon world: technical report. Melbourne: ClimateWorks Australia; 2014. Costello A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009;373:1693–733. https://doi.org/ 10.1016/S0140-6736(09)60935-1. Ebi K. Climate change and health risks: assessing and responding to them through ‘adaptive management’. Health Aff. 2011;30(5):924–30. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. Ahmad S, editor. PLoS One. 2016;11(6):e0157014. Ferris E, Petz D, Stark C. The year of recurring disasters: a review of disasters in 2012. New York/ London: The Brooking Institution and The London School of Economics; 2013. Fielding KS, Hornsey MJ. A cautionary note about messages of hope: focusing on progress in reducing carbon emissions weakens mitigation motivation. Glob Environ Chang. 2016;39:26– 34. Gardener J, Parsons R, Paxton G. Adaptation benchmarking survey: initial report. Brisbane: CSIRO Climate Adaptation national Research Flagship; 2010. Hanlon P, Carlisle S, Hannah M, Lyon A, Reilly D. A perspective on the future public health: an integrative and ecological framework. Perspect Public Health. 2012;132(6):313–9. Hughes L, McMichael T. The critical decade: climate change and health. Climate Commission, Commonwealth of Australia (Department of Climate Change and Energy Efficiency); 2011. [cited 2017 Aug 16]. Available from: http://climatecommission.gov.au/report/the-criticaldecade-climate-change-and-health. Hughes L, Rickards L, Steffen W, Stock P, Rice M. On the Frontline: Climate Change & Rural Communities. Sydney: Climate Council of Australia; 2016. International Federation of Medical Students’ Associations (IFMSA). Training manual – climate and health. Published by IFMSA. 2016. [cited 2017 Aug 16]. Available from: https://issuu.com/ ifmsa/docs/ifmsa_climate_and_health_training_m/9. IPCC, 2014: Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Core Writing Team, R.K. Pachauri and L.A. Meyer (eds.)]. IPCC, Geneva, Switzerland, 151 pp. Kessler R, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60. Leviston Z, Greenhill M, Walker I. Australian’s attitudes to climate change and adaptation: 2010– 2014. Australia: CSIRO; 2015. [cited 2017 Aug 16]. Available from: https://publications.csiro. au/rpr/download?pid¼csiro:EP158008&dsid¼DS2. Maibach E, Nisbet M, Baldwin P, Akerlof K, Diao G. Reframing climate change as a public health issue: an exploratory study of public reactions. BioMed Central Public Health. 2010;10(1):299–310. McMichael A, Neira M, Bertollini R, Campbell-Lendrum D, Hales S. Climate change: a time of need and opportunity for the health sector. Lancet. 2009;374(9707):2123–5. Morris G. Ecological public health and climate change policy. Perspect Public Health. 2010; 130(1):34–40. Morrissey SA, Reser JP. Awareness, endurance, recovery trainer’s manual: psychological preparedness for natural disaster warnings and natural disasters. Cairns: Centre for Disaster Studies, James Cook University; 2000. Reser JP, Morrissey SA. The crucial role of psychological preparedness for disasters. InPsych. 2009:14–5.

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Reser JP, Bradley GL, Ellul MC. Coping with climate change: bringing psychological adaptation in from the cold. In: Molinelli B, Grimaldo V, editors. Handbook of the psychology of coping: psychology of emotions, motivations and actions. New York: Nova Science Publishers; 2012. United Nations Paris Agreement. United Nations treaty collection. 2016 July 8. [cited 2017 Aug 16]. Available from: https://treaties.un.org/pages/ViewDetails.aspx?src¼TREATY&mtdsg_ no¼XXVII-7-d&chapter¼27&clang¼_en. Uzzell DL. The psycho-spatial dimension of global environmental problems. J Environ Psychol. 2000;20:307–18. Wade D, Forbes D, Nursey J, Creamer M. A multi-level framework to guide mental health response following a natural disaster. Bereavement Care. 2012;31(3):109–13. https://doi.org/10.1080/ 02682621.2012.740285. Walker R, Mason W. Climate change adaptation for health and social services. Melbourne: CSIRO Publishers; 2015. Walter T, Stevens P, Verhoeven A, Boxall A-M. Impacts of climate change on public health in Australia. Recommendations for new policies and practices for adaptation within the public health sector. Deeble institute issues brief 7. 2014. [cited 2017 Aug 16]. Available from: http:// ahha.asn.au/publication/issue-briefs/impacts-climate-change-public-health-australia-recommen dations-new-policies.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description and Distinctive Features of Rural and Remote Communities . . . . . . . . . . . . . . . . . . . . . Unique Characteristics: Rural and Remote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment Modalities and Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culturally Adapted Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expanded Workforce and Community Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Depressive and anxiety disorders are among the most common mental health problems worldwide. They are associated with high rates of disability and poor physical health and often co-occur and go untreated. This may be particularly true for rural and remote communities given the lack of available providers, limited accessibility to services, and potentially unacceptable services (e.g., stigma, cultural competence). The present chapter first describes the standard diagnostic criteria for depressive and anxiety disorders as well as the importance of addressing unique cultural understandings when working in rural and remote communities. Next, treatment implications including the importance of evidence-

L. Curtin (*) · S. E. Moss · S. E. Keefe Appalachian State University, Boone, NC, USA e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_34

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based practice, consideration of adapting interventions, and the need for expanded models of care are discussed. Application of the chapter content is explicated in three case studies from Appalachia, and specific practice recommendations are made.

Introduction Depression and anxiety are among the most common mental health disorders worldwide (Steel et al. 2014; World Health Organization [WHO] 2001). Approximately 28.8% of individuals are estimated to suffer from an anxiety disorder at some point during their lifetime (Baxter et al. 2013; Steel et al. 2014), and approximately 20.8% are estimated to experience diagnosable depression (Richards 2011; Steel et al. 2014). Global estimates of 12-month prevalence rates are approximately 11.6% for anxiety (Baxter et al. 2013) and 6–12% for depression (Richards 2011), and rates of both are higher among women than men (Steel et al. 2014). In addition, the lifetime rate of comorbidity between anxiety and depression ranges from 45.7% to 81% (Lamers et al. 2011; Kessler et al. 2015). Symptoms of depression and/or anxiety can interfere with health, sleep, relationships, daily functioning, and overall quality of life. Although rates of depression and anxiety in rural and remote areas tend to be equal to those found in urban areas (e.g., Jameson and Blank 2010), rural regions experience relatively limited available, accessible, and acceptable mental health services (Mohatt et al. 2005). The present chapter first describes depressive and anxiety disorders as well as the unique features associated with assessment and diagnosis in rural and remote communities. Next, practice implications including the importance of evidencebased practice, consideration of cultural context and adaptation of interventions, and the need for expanded models of care are discussed. Application of the chapter content is explicated in case studies, and specific practice recommendations are made.

Description and Distinctive Features of Rural and Remote Communities According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) and the International Classification of Diseases-10 (ICD-10), the two main symptoms of major depression include depressed mood (e.g., sad) and loss of interest or pleasure in daily activities (American Psychiatric Association [APA] 2013; WHO 1992) and at least five of nine additional symptoms. The symptoms have to last for at least a 2-week period and cause clinically significant impairment in multiple areas of functioning. The other symptoms of depression may include diminished ability to concentrate, recurrent thoughts of death or suicidal

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thoughts or behavior, significant weight loss or gain, insomnia or hypersomnia, and feelings of worthlessness, among others. Episodes of depression can occur in the context of unipolar depressive disorders or bipolar disorders. Depression is noted as the leading cause of disability claims worldwide (Friedrich 2017; WHO 2001) and is highly associated with suicide, which is reliably higher in rural and remote areas (Curtin et al. 2014). It is important to note, however, that depression is quite heterogeneous and may vary in presentation and description as a function of culture and experience. One study found that nearly half (48.6%) of unique symptom profiles were endorsed by only one person, suggesting there is substantial symptom variation within the same diagnosis. Cross-cultural research suggests that somatization of depression is common outside the West. Arthur Kleinman (1986), for example, found that in China depression is relatively rare, while neurasthenia (an old medical term, which emphasizes somatic complaints) is a common label for mood-related problems. Although there are many types of anxiety disorders, all share common symptoms such as marked physiological arousal, fear, worry, and avoidance (e.g., of the experience of anxiety, or places, people, or objects associated with anxiety) and differ primarily in terms of the fear-provoking stimuli. Additional symptoms may include insomnia or other sleep disturbance, fatigue, restlessness, diminished concentration, and irritability. As categorized in the DSM-5 and ICD-10, the more common anxiety disorders include generalized anxiety disorder, characterized by excessive worry in many domains; specific phobia, characterized by anxiety related to a specific place, object, or situation; panic disorder, characterized by frequent and recurrent panic attacks and fear of the attacks; and social anxiety disorder, characterized by excessive worry and physiological arousal pertaining to embarrassing or humiliating experiences in social situations (APA 2013; WHO 1992). As mentioned earlier, depressive and anxiety disorders are commonly comorbid. It is estimated that approximately half of those with depression also meet criteria for an anxiety disorder (Richards 2011), and some evidence suggests that a combined presentation of symptoms of both anxiety and depression could be more prevalent than depression alone (Tyrer 2001). A combined presentation of both anxiety and depressive symptoms has received increased inquiry in recent years, described as “general neurotic syndrome” (Andrews et al. 1990) or “emotional disorders” (Barlow et al. 2017). Although a disorder-specific approach has dominated the conceptualization and treatment of both anxiety and depression for some time, disorder-specific treatments attend little to comorbidity or individualized and culturally relevant presentations (Barlow et al. 2017). In addition, similar etiology and maintenance factors may underscore symptoms of both depression and anxiety (Newby et al. 2015). Those with a more long-term or serious medical condition and clinically significant anxiety or depression tend to have worse health than those with anxiety or depression alone (Panagloti et al. 2014). Additionally, there is some evidence that those with comorbid anxiety and depression may be at greater risk of suicide (Hranov 2007) than those who only experience depression or anxiety. In addition to a relationship with poor physical health, depression and anxiety disorders impact work performance in terms of both absenteeism (e.g., missing work

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due to illness) and presenteeism (e.g., decreased work performance due to working while with illness) and negatively affect quality of life. Depressive and anxiety disorders are also associated with increased prevalence of substance abuse disorders (Quello et al. 2005) and non-adherence to mental or medical care (DiMatteo et al. 2000). The emotional health of pregnant women, in particular, represents an ongoing challenge in the area of prevention, as recent research has found an association between prenatal experience of anxiety and depression and birth complications and suboptimal fetal development (Conde et al. 2010). This may be a particular concern given, as noted, women are more likely than men to suffer from both depression and anxiety, and rural and remote areas have limited access to specialized medical providers. Besides the demonstrated impact on health and well-being, economic costs are associated with depression and anxiety disorders. Chisholm et al. (2016) conducted a global return on investment analysis across 36 countries and estimated that it would cost $147 USD billion over the period 2016–2030 to scale up effective treatments of depression and anxiety. Further, Chisholm et al. (2016) estimated that the expected returns to an investment in scaled-up treatment would lead to approximately 43 million extra years of healthy life over the time period, and the approximate economic value on these healthy life-years was estimated at $310 USD billion, representing a substantial return on investment.

Unique Characteristics: Rural and Remote Rural and remote environments are often characterized as relaxed, slow-moving, and stress-free compared with urban areas. However, stereotypes are not necessarily reality (Hargrove et al. 2017), and research supports more similarities than differences with regard to the prevalence of depressive and anxiety disorders in rural and urban environments (Jameson and Blank 2010; Morrissey 2014). Overall, more recent research suggests that rural residents experience diagnosable depression and anxiety at rates similar to urban residents but may present with more severe symptoms (e.g., Caldwell et al. 2004) likely related to limited access to professional services as well as concerns about confidentiality and stigma.

Assessment and Diagnosis Given the lack of specialized mental and behavioral health providers in rural and remote regions, medical settings, particularly primary care, are often considered to be a de facto mental health system (Fox et al. 1995). Despite the need for providing mental healthcare in these settings, primary care physicians often have trouble accurately diagnosing common mental disorders such as anxiety and depression, and rarely diagnosis both anxiety and depression, which is significant considering the high rate of comorbidity between the two disorders. In addition, primary care physicians may over-rely upon non-specific diagnoses (e.g., anxiety disorder not

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otherwise specified) which poses significant implications for treatment, particularly anxiety disorders in which treatment may vary depending on the specific focus of anxiety. Of note however, one large-scale study in the United States did not differ significantly in detection of anxiety and depression between rural and urban primary care settings, suggesting that improvement in mental healthcare is vital in primary care regardless of geographic setting (e.g., Jameson and Blank 2010). Primary care providers in rural areas have, however, reported difficulty treating common mental disorders (Caldwell et al. 2004; Jameson and Blank 2010). Formal and empirically supported assessment measures have been successfully integrated into primary care practices. The Primary Care Evaluation of Mental Disorders (PRIME-MD) included a 26-item self-report questionnaire followed by a physician interview, to assess for the common mental health problems of depression, anxiety, alcohol problems, somatoform disorders, and eating disorders. The PRIME-MD proved valid but time-consuming (average of 8.4 minutes of physician time). Thus, an entirely self-report version, the Patient Health Questionnaire (PHQ), was tested. The PHQ was found valid relative to the PRIME-MD as well as compared to independent mental health provider diagnoses. In addition, the PHQ9, which includes nine items to screen for symptoms of depression, can be used to also assess the severity of depression and track treatment outcomes across time (Spitzer et al. 1999). A variety of PHQ versions are used in the context of primary care, including a four-item version that includes two depression screening symptoms and two anxiety screening symptoms. PRIME-MD and versions of the PHQ can be found for free online and in multiple languages at http://www.phqscreeners.com/ select-screener. The website includes access to the instruction manual, which includes proposed recommendations in relation to scores as well as specificity and sensitivity indices. However, in the case of mental health services, in rural and remote as well as nonrural areas, it is not enough to know current diagnostic criteria as outlined above and as assessed using self-reports such as the PHQ. Rural and remote areas differ widely in history and acculturation, language, religion, spirituality, traditions and beliefs, economy, weather, transportation, community life, and many other factors that constitute culture. Kleinman (1988) and more recently Alarcón (2009) argue for the importance of considering individualized, culturally informed, explanations for “getting ill,” noting that understanding the cultural context is necessary for accurate detection and effective intervention. See case study number one (Amanda). The DSM-5 (APA 2013) includes a Cultural Formulation Interview (CFI; patient version and informant version; available at https://www.psychiatry.org/.../DSM/ APA_DSM5_Cultural-Formulation-Interview.pdf) that is influenced by medical anthropology (Kleinman 1988) and is designed to assess the client’s idiosyncratic and culturally informed understanding of presenting problems, coping and resources, and help-seeking. The CFI is designed to help clarify presenting problems, strengthen the therapeutic alliance, and inform psychoeducation and psychological intervention. A pilot study suggests that the CFI facilitates the client narrative and therapeutic rapport and is acceptable to clients as well as being clinically useful (Aggarwal et al. 2015).

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In our case studies, it is clear that while some in Appalachia accept a Western clinical diagnosis for their symptoms, many others do not, while still others follow a blend of their own cultural beliefs and practices along with the Western paradigm. Adapting to the individual’s perspective should lead to more successful outcomes in practice (Carey 2016). Case 1 Depression, Anxiety, Stigma, and “Nerves” (Amanda)

Amanda is a single, 38-year-old woman with a pleasant demeanor who has been sick since she was a teenager. Her first suicide attempt was as a senior in high school, and she has had numerous hospitalizations since then. She attended 2 years of college but is unemployed and currently lives on disability in a home next to her parents in a rural county in the Appalachian Mountains in the United States. She has been diagnosed with major depressive disorder, bipolar disorder type II, and PTSD. Rather than dividing health and illness into physical versus mental problems, as does Western medicine, rural Appalachians integrate health, religion, and morality in their conceptualization of wellness. The stigma against mental illness runs deep in Appalachia where symptoms are often considered a sign of moral or spiritual deficiency. Amanda says, “People do not talk about mental health issues at all, and if you have them, you keep them hidden. It’s gotten better, but there are still people who think they are shameful. They don’t think it’s an illness; they think it’s a character defect.” Given the social and religious stigma, family and friends often ostracize those with mental illnesses, thus increasing the stress and anxiety and lack of support. Amanda believes her parents were more concerned about the family name than for her when she first had problems. “People would blame the parents if a person got mentally sick,” she says. While she is now on better terms with her parents, her relationship with her sister still suffers. “She really won’t talk to me at all. She sees mental illness as something to be ashamed of. She doesn’t understand why I got it growing up in the same household she did, and she didn’t get it. She just doesn’t want any part of it. And maybe part of it is that she knows I go to therapy, and I deal with stuff from our childhood while she’s not ready to deal with it herself.” Certain triggers of mental illness, such as the sexual abuse Amanda experienced, provoke strong moral judgments in rural Appalachian communities. Family members often react by keeping family secrets, and avoiding psychotherapy is one common response. Amanda notes that her parents thought at first that she had “nerve problems, not a mental illness.” In Appalachia, “nerves” is a common culture-bound syndrome (or folk illness only recognized within a bounded cultural group). Nerves is characterized by sufferers as having a range of symptoms including feelings of nervousness, anger, impatience, fearfulness, and depression as well as physical agitation and restlessness, insomnia, and crying. Various somatic (continued)

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complaints are common, including gastrointestinal disturbances, weight loss, increased heart rate, headaches, difficulty breathing, and blacking out (Van Schaik 1988). The concept of nerves leads sufferers to primary care doctors for treatment of the physical symptoms seeking out medication or “nerve pills” (e.g. Valium, Xanax), and doctors frequently comply by diagnosing “nerves” as either anxiety or depression. While patients welcome treatment of the physical symptoms, few want to pursue psychotherapy to address the potential underlying factors. Amanda rejects the local cultural perspective of “nerves,” has adopted the Western model of depression and anxiety, and works with both a psychiatrist and a secular psychotherapist. However, she also mentions a very supportive evangelical Christian church that has a counseling ministry staffed with a licensed counselor where she also has participated in psychotherapy. Her case highlights the importance of respecting the individual’s perspective and experience rather than relying on assumptions, whether they arise from Western models of understanding or local cultural beliefs and customs.

Practice Implications Depressive disorders and anxiety disorders respond to a variety of evidence-based interventions both in randomized controlled trials and in real-world effectiveness investigations (e.g., Cuijpers et al. 2013; Stewart and Chambless 2009). Efficacious and effective interventions for depressive disorders include interventions ranging from lifestyle changes such as exercise to a variety of psychotherapies including cognitive behavioral therapy (CBT), behavioral activation, cognitive therapy, interpersonal psychotherapy, and brief dynamic psychotherapies. Evidence-based interventions for a range of anxiety disorders similarly include lifestyle changes such as exercise as well as a number of behavioral interventions. Behavioral interventions such as relaxation and mindfulness as well as CBTs that typically involve some form of exposure to feared stimuli and addressing cognitions are very effective. Pharmacotherapy, in the form of antidepressant medications, also has a strong evidence base in the treatment of anxiety and depression with increased tolerability noted for newer more targeted medications over older tricyclic antidepressants (Anderson 2000). Potential side-effects that may compromise adherence to pharmacotherapy and psychotropic medications are often contraindicated in the face of some physical health problems. Despite effective treatments, the vast majority of people experiencing a mental illness do not access professional help (Kohn et al. 2004), and this may be especially so in rural and remote areas with limited providers and unique cultural considerations. There is no evidence that empirically supported interventions work differently in urban vs. rural and remote communities. In a survey of community mental health

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clinic directors, rural and urban clinics did not differ in their reported use of empirically supported treatments (ESTs) for most presenting problems, and rural clinic directors were more likely than urban clinic directors to report using ESTs for major depressive disorder and obsessive-compulsive disorder. Further, rural and urban community mental health clinics were equally open to the use of ESTs. However, overall use of ESTs was low regardless of geography (Jameson et al. 2009). Greater attention to dissemination of ESTs including the use of webinars and follow-up consultation calls for ongoing supervision may prove especially useful for rural and remote practitioners. In addition to attending to the unique features of any given community and its residents, it is important to recognize that the mental health needs in rural and remote areas will likely never be met solely via the traditional model of individual treatment based largely on the Westernized medical model due to the focus on available, accessible, and acceptable services. Kazdin and Rabbitt (2013) thoughtfully outline a number of alternative models for delivering mental health services. To better meet the mental health demands, a service-delivery model should reach more people and communities, be applied on a large scale, be affordable, expand the nonprofessional workforce and intervention delivery settings, and be flexible and feasible to meet needs of diverse groups. A number of potential ways to help rural and remote communities meet unmet mental health needs are outlined below.

Treatment Modalities and Considerations Telehealth and Technology Telehealth services have the potential to reach more rural and remote people and communities. Telehealth typically involves “meeting” electronically by way of video-conferencing technology that may serve the needs of rural and remote communities. With specific parameters in place, such as on-site support in the event of an emergency or a technical issue, as well as dependable technology with a strong connection and attention to confidentiality, clinicians may be able to meet with potential clients from virtually anywhere in the world. Telemental health has been found effective for a range of presenting problems, in a variety of settings, and across diverse populations (Hilty et al. 2013). Telehealth, however, primarily relies heavily on human resources and the traditional individual treatment model, and the interactions with culture are not well investigated or understood (Hilty et al. 2013). Other technology-supported interventions, such as computerized CBT, may be an additional effective treatment modality for both anxiety and depressive disorders that addresses concerns of availability and accessibility in rural areas (Vallury et al. 2015) and is not entirely dependent upon human resources, including client attendance given high rates of attrition in outpatient psychotherapy (Roseborough et al. 2015). Of note, computerized CBT, or CCBT, demonstrates effect sizes similar to that of CBT treatment with a therapist (e.g., Grist and Cavanagh 2013). Finally, technology can be used to offer professional development, support, and supervision to professional and nonprofessional local providers or paraprofessionals.

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Integrated Mental Health Services Facility-based mental health services, limited in their availability and accessibility, may not be well suited to the realities of the rural environment. Rural mental health services may be better designed when integrated into existing organizations such as general healthcare (e.g., primary care, emergency rooms), faith-based organizations, workplaces, and schools. For example, churches and schools often function as social hubs in rural and remote areas and typically meet community needs beyond their original mission of religious guidance and education, respectively. Indeed, rural churches regularly help communities and support social and psychological welfare, and some incorporate counseling offered by religiously sanctioned licensed therapists (see Case 1; Pesonen and Vasala 2006). Although clergy vary in their knowledge of mental health, there is some evidence that clergy are above average in mental health literacy (MHL) but infrequently make mental health service referrals (Vermaas et al. 2017) perhaps due to cultural and spiritual interpretations of symptoms (see Case 2). For school-age youth, access to mental health services through school mental health centres may be an effective method of service delivery in rural areas especially given that families in rural areas may experience greater rates of poverty, live far from traditional mental health centres, and/or have greater concerns about confidentiality and stigma related to seeking mental health treatment (Michael et al. 2017). Integration of mental health services into primary care has long been suggested and pursued as a way to increase detection of mental health concerns and to increase access to services and decrease stigma. The WHO initiated the mental health Gap Action Programme (mhGAP) designed to address the gap between mental health needs and delivery of evidence-based services, particularly in low-resource settings, using trained non-specialists primarily in the context of primary medical care. Although this model of integrating mental health services has the potential to reach more people and expand the service location and workforce, there are concerns about the medicalization of psychological and socially influenced (e.g., poverty) suffering that may not match the cultural reality of many rural and remote areas (Ventevogel 2014). Case 2 Depression and Culturally Informed Treatment (Sammy)

Like many cultural minority groups elsewhere in the United States and previously colonized peoples elsewhere in the world, rural Appalachian people have little recognition or understanding of mental illness in the modern Western sense. Problems which therapists consider to be symptoms of depression and anxiety are more likely to be considered a weakness of character or a religious sin in Appalachia. Sammy is a 48-year-old married woman who lives in a rural North Carolina county adjacent to the one in which she was born. She is the first in her family (continued)

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to graduate from college, and she works as a substitute elementary school teacher. She first discovered the Western paradigm of psychological depression in a college psychology class. Sammy’s parents have both suffered from depression-like symptoms. Her mother was suicidal and suffered a number of “nervous breakdowns” while Sammy was growing up. When she was in high school and her parents were divorcing, Sammy attempted suicide and was hospitalized. Her father was ashamed and refused to take her to the recommended counseling afterwards, nor was she allowed to talk to a counselor or anyone else at school about it. Sammy believes her father, a Baptist preacher, would have suffered retribution from his church community if they knew. This response is common in the region where evangelical Christianity predominates, and congregations can shun errant members. It is commonly believed that symptoms of depression, including worry and feelings of helplessness and hopelessness, are often characterized as signs of spiritual weakness since born-again Christians should experience joy and love, having had their hearts filled with the Holy Spirit. Moreover, suicide is a sin, and the typical Appalachian evangelical Christian believes the individual will go to Hell if they complete a suicide. Sammy says the result for her “was pure isolation, and shame and guilt.” Her response was “caving”: not eating, not bathing, and not talking, just sleeping. She complains that people in this rural county consider depression a weakness. “Rather than wallowing in your misery, you’re supposed to be out in the working world.” In addition to lacking family or friends to provide support, Sammy avoids going to peer support classes because she is afraid of being fired, which she has observed happening to others. Confidentiality is a real concern in a small rural county where people often recognize the cars parked outside mental health facilities. Independence and self-reliance are highly valued in rural Appalachian communities, and Sammy’s first husband refused to let her take antidepressants for her postpartum depression saying: “You shouldn’t depend on pills.” In her current marriage, she sees a psychiatrist and praises her Christian counselor. Like many Appalachians in treatment, Sammy has an appreciation of therapists who share similar cultural beliefs and values, such as an understanding of the Biblical teaching about the sinful nature of humanity and the need to reconcile with God as a remedy for mental, emotional, and behavioral problems. Sammy has had less success with more secular therapists, who appeared unappreciative of her faith and who may have viewed evangelical Christians as “naïve and anti-intellectual.” Christian counselors, like Sammy’s, in contrast, will often pray with their clients for wellness and relief from suffering, providing significant spiritual support.

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Culturally Adapted Interventions Although there is no universal rural culture, the importance of adapting evidencebased practices and interventions to a client or a community is important. Guidelines for addressing culture include flexible practice that matches the cultural context, uses culturally appropriate assessments and traditional interventions (e.g., prayer; see Cases 2 and 3), and communicates a general appreciation for client experience(s). Treatments may be adapted to meet language differences (preferred language or meaning including cultural metaphors), client demographics (e.g., race, ethnicity), and the content, goals, and methods used (e.g., collectivist framing of goals and methods in a non-individualistic cultural context; attention paid to somatic symptoms). Although the literature on cultural adaptations of evidence-based interventions is limited, evidence suggests that culturally adapted treatments are moderately more effective than non-adapted treatments (Chowdhary et al. 2014) Further, the number of cultural adaptations in treatments related positively with improved clinical outcomes (Smith et al. 2011). Beyond evidence for culturally adapted mental health treatments in general, there is specific support for the benefits of cultural adaptations for psychological treatments designed to treat depressive disorders. Although adaptations were heterogeneous, the majority of the adaptations related to delivery methods rather than the intervention content, suggesting that fidelity to the original treatment was important, although attention to cultural acceptability resulted in improved outcomes in depressive symptoms (Chowdhary et al. 2014).

Expanded Workforce and Community Supports Increased community capacity to address mental health needs with non-specialists (known as task-sharing or task-shifting), including paraprofessionals, may help address the availability, accessibility, and acceptability of assistance with mental health and behavioral health problems (Mendenhall et al. 2014). This may be especially true in rural and remote areas that often have a strong sense of community, are rich in social resources, and are relatively less likely to seek professional help (Keefe 2005, 2009; see Case 3). The use of non-specialist nurses, physicians, and community health workers to deliver mental healthcare has been investigated in low- and middle-income countries. Stakeholders found the use of non-specialists to be acceptable and feasible as long as there was access to medications, that training and financial compensation were provided for health workers, and that ongoing support and supervision were provided (Mendenhall et al. 2014). Partnerships between universities and clinical service agencies, with a focus on training, hold promise in meeting these acceptability and feasibility conditions, particularly for common problems such as depression and anxiety (Judd et al. 2001). In addition, initiatives to increase awareness and knowledge of mental health concerns, or MHL, may also be an important area of community-level intervention

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in rural and remote areas (Jackson et al. 2007). Layperson or non-specialist training in MHL may aid in detection of common mental health concerns such as depression and anxiety, potentially leading to prevention or early intervention access and decreasing personal and public stigma (e.g., Mental Health First Aid; NAMI; Svennson and Hansson 2014). For example, a layperson high in MHL may recognize signs of a suicidal crisis, be confident speaking with a person, and take initial steps to maintain safety such as removing access to lethal means (e.g., firearms, medications). At the same time, mental health practitioners must become attuned to the historical experience of the people they treat who may have been stigmatized, often in a colonial context. The Appalachian people represented by our case studies, for example, have been stereotyped as ignorant, lazy, backwards, and fatalistic. Their religious orientation is often seen as regrettable rather than as a resource. In contrast, our third case reveals how local systems of meaning can assist in addressing mental health problems on an individual and a community level. If MHL programs are not inclusive of local cultural understanding and explanation, it is possible that such programs could impose an irrelevant and potentially harmful Western biomedical perspective. For example, there is some evidence that the biomedical model may increase stigma and negative treatment of those with mental health problems (Mehta and Farina 1997). Case 3 Natural Support Systems and Mental Healthcare (Johnny)

Rural Appalachian natives value self-reliance and tend to avoid agencies and institutional help in general. In times of personal difficulty, they more often turn to their extensive local kinship networks and their strong religious beliefs and practices to meet life’s challenges. Especially important religious resources are individual and group prayer, Bible study, hymn singing, and participation in religious services. While these are effective coping strategies in many instances, they are often unable to respond to problems eliciting negative moral and religious judgments, such as child abuse, substance abuse, symptoms of depression, and irrational or violent behavior. A case in which the natural support systems were effective involves Johnny, a middle-aged man who lives in his rural hometown in the Appalachian Mountains. Johnny experienced depression in high school including low self-esteem and social anxiety despite being a well-respected athlete. He began drinking alcohol and isolating himself. At one point, he almost attempted suicide sticking a rifle between his legs. Help came when he started talking with a couple of friends and his parents, although he never mentioned depression and never sought professional help. “I grew up here and my grandfather, my parents, they all went to church, and people who go to church see it as a bad thing to talk about these feelings,” says Johnny. He also acknowledges a desire to conform to the male gender role: “I was brought up to be a tough man, (continued)

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because that’s how my father was, and it was hard to talk about feelings with him.” Johnny is clear that stigma and shame contribute to the avoidance of professional help. He says if a young person tells their parents they are suffering from depression, the typical response will be: “Well, we won’t tell nobody.” He sees this social stigma related to pride: “The biggest stigma here in this area is pride and, I guess, being in a smaller county, everyone knowing everyone. People are concerned about how other people perceive them.” In collectivist societies like rural Appalachian communities, one’s status is defined by in-group relationships, so reputations are carefully curated. Johnny continued drinking after graduating from high school, but one night 2 years later, he went on “one pretty tremendous binge.” When he woke up, he decided he wanted something different for his life. “My wife and I went to church, and we got saved,” says Johnny. “A year later, I started into the ministry. Accepting Christ as my savior changed my whole life. It increased my sense of self-worth, and I want to bring that to help other people who are suffering like I was.” Evangelical Christians believe a personal relationship with God brings peace and joy as the heart is filled with the Holy Spirit, extinguishing any feelings of hopelessness and worthlessness. As a result, what mental health professionals consider mental health problems are often characterized in Appalachia as spiritual problems requiring spiritual help. A “patient-centered care model” which ensures that “the perspective of the patient provides the framework for the organization and provision of services” would seem to offer another way to approach care in non-Western and ethnic minority communities (Carey 2016, p. 47). Johnny has found personal stability through his religious faith and his work as an evangelical minister. Yet, he has also come to adopt much of the biopsychosocial model promoted by the local mental health alliance with which he volunteers to help those suffering from mental illness. Ultimately, however, he sees religious conversion as the final solution: “I’ve seen people in awful situations who have been medicated and had therapy, and then were saved [born again] and through that open relationship and having God in their life, they’ve come off the medication.” In his own case, he finds prayer and a personal relationship with God to be the best way to address emotional distress: “Once I chose to be saved and started my relationship with God and began reading the Bible, I’ve been more open and honest with myself and with others, and I feel better. I don’t feel that worthlessness. Prayer is the basis of a relationship with God. When talking to God, you won’t ever get put on hold, and you won’t ever get an answering machine. You have to be honest because God knows your heart. If you’re mad, He knows you’re mad. So why not just tell Him you’re mad? The Bible clearly states that He is a help when you need it. That’s where my faith lies.”

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Concluding Comments and Recommendations Although rural areas are underserved with respect to professional healthcare, they are often rich in social and cultural resources (e.g., family and faith communities; Keefe 2005, 2009). In many cases, these alternative cultural systems can offer successful detection and treatment paradigms (Kleinman 1986; Watters 2010). Thus, training professionals to serve rural and remote communities inherently entails applying a model that encompasses the interdependent nature of individuals, families, communities, and overarching systemic norms and policies. Evidence-based assessments and interventions can be expanded to community levels (e.g., public health model) and integrated into existing contexts (e.g., faith-based; schools; medical) and modalities (e.g., technology). In addition, non-specialists may be trained to increase MHL and support the mental health workforce, potentially increasing acceptability of interventions due to stigma and other concerns. Finally, attention should be paid to examining local understandings of symptoms and interventions, and appropriate cultural adaptations that maintain fidelity to evidence-based treatment theories and interventions should be implemented.

Take-Home Messages • Depressive and anxiety disorders are among the most common mental health problems worldwide, yet they commonly go undetected and untreated. • Rural and remote residents experience, overall, similar rates of depression and anxiety as suburban and urban residents but have lower access to available and acceptable treatments. • Detection of depression and anxiety can be increased by targeting community-level mental health literacy, by integrating screening into existing contexts (e.g., primary care, schools), and by using culturally informed diagnostic interviews to contextualize the experience and understanding of depression and anxiety symptoms. • Expansion of service-delivery models should attend to increased scalability, reach, and affordability. Use of technology, natural supports and existing agencies, and expansion of a nonprofessional workforce may help address depression and anxiety in rural and remote areas. • Coordination among diverse agencies (e.g., local and federal government, schools, professional organizations, and non-government organizations), with attention to local culture and resources, will be necessary to meet the mental health needs in rural and remote communities worldwide.

Cross-References ▶ Global Mental Health Perspectives on Rural and Remote Mental Health Provision ▶ Integrated Primary Mental Health Care in Rural and Remote Contexts: The Australian Experience

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▶ Peer Work in Rural and Remote Communities and Mental Health Services ▶ Providing School-Based Mental Health Services in Rural and Remote Settings ▶ Rural, Remote, and very Remote Mental Health ▶ Suicide and Self-Harm: It’s Everyone’s Business ▶ Telemental Health in Rural and Remote Contexts

References Aggarwal NK, DeSilva R, Nicasio NV, Boiler N, Lewis-Fernández R. Does the Cultural Formulation Interview (CFI) for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site. Ethn Health. 2015;20:1–28. https://doi.org/10.1080/13557858.2013.857762. Alarcón RD. Culture, cultural factors and psychiatric diagnoses. World Psychiatry. 2009;8:131–9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition: DSM-5. Washington, DC: Author; 2013. Anderson M. Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a metaanalysis of efficacy and tolerability. J Affect Disord. 2000;58:19–36. https://doi.org/10.1016/ s0165-0327(99)00092-0. Andrews G, Stewart G, Morris-Yates A, Holt P, Henderson S. Evidence for a general neurotic syndrome. Br J Psychiatry. 1990;157:6–12. Barlow DH, Farchione TJ, Bullis JR, Gallagher MW, Murray-Latin H, et al. The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders. JAMA Psychiat. 2017;74:875–84. Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43:897–910. https://doi.org/10.1017/ S003329171200147X. Caldwell T, Jorm A, Dear K. Suicide and mental health in rural, remote and metropolitan areas in Australia. Med J Aust. 2004;7:s10–4. Carey T. Beyond patient-centered care: enhancing the patient experience in mental health services through patient-perspective care. Patient Exp J. 2016;3:46–9. Chisholm D, Sweeny K, Sheehan P, Rasmussen B, Smit F, Cuijpers P, Saxena S. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry. 2016;3:415–24. https://doi.org/10.1016/S2215-0366(16)30024-4. Chowdhary N, Jotheeswaran AT, Nadkarni A, Hollon SD, King M, Jordans MJD, Rahman A, Verdeli H, Araya R, Patel V. The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: a systematic review. Psychol Med. 2014;44:1131–46. Conde A, Figueiredo B, Tendais I, Teixeira C, Costa R, Pacheco A, Nogueira R. Mother’s anxiety and depression and associated risk factors during early pregnancy: effects on fetal growth and activity at 20–22 weeks of gestation. J Psychosom Obstet Gynecol. 2010;31:70–82. Cuijpers P, Sijbrandij M, Kooke SL, Andersson G, Beekman AT, Reynolds CF. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a metaanalysis of direct comparisons. World Psychiatry. 2013;12:137–48. Curtin L, Cohn T, Belhuemer J. Suicide in the rural population. In: Lamis DA, Kaslow NJ, editors. Advancing the science of suicide: understanding and intervention. Hauppauge: Nova Science Publishers; 2014. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101–7. [Medline]. Fox J, Merwin E, Blank M. De facto mental health services in the rural south. J Health Care Poor Underserved. 1995;6:434–68.

708

L. Curtin et al.

Friedrich M. Depression is the leading cause of disability around the world. JAMA. 2017;317:1517. https://doi.org/10.1001/jama.2017.3826. Grist R, Cavanagh K. Computerised cognitive behavioural therapy for common mental health disorders, what works, for whom under what circumstances? A systematic review and metaanalysis. J Contemp Psychother. 2013;43:243–51. https://doi.org/10.1007/s10879-013-9243-y. Hargrove DS, Curtin L, Kirschner B. Ruralism and regionalism: myths and misgivings regarding the homogeneity of rural populations. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. Cham: Springer International Publishers; 2017. Hilty DM, Ferrer DC, Parish MB, Jonston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemed E Health. 2013:19: 444–54. Hranov LG. Comorbid anxiety and depression: illumination of a controversy. Int J Psychiatry Clin Pract. 2007;11:171–89. https://doi.org/10.1080/13651500601127180. Jackson HH, Judd F, Komiti A, Fraser C, Murray G, Robins G, et al. Mental health problems in rural contexts: what are the barriers to seeking help from professional providers? Aust Psychol. 2007;42:147–60. https://doi.org/10.1080/00050060701299532. Jameson JP, Blank MB. Diagnosis and treatment of anxiety and depressive disorders by primary care providers in rural and urban practice: national survey results. Psychiatr Serv. 2010;61:620–3. Jameson JP, Chambless DL, Blank MB. Empirically supported treatments in rural community mental health centers: a preliminary report on current utilization and attitudes toward adoption. Community Ment Health J. 2009;45:463–7. Judd FK, Jackson H, Davis J, Cockram A, Komiti A, Allen N, Murray G, Kyrios M, Hodgins G. Improving access for rural Australians to treatment for anxiety and depression: the University of Melbourne depression and anxiety research and treatment group-Bendigo health care group initiative. Aust J Rural Health. 2001;9:92–7. Kazdin AE, Rabbitt SM. Novel models for delivering mental health services and reducing the burdens of mental illness. Clin Psychol Sci. 2013;1:170–91. https://doi.org/10.1177/ 2167702612463566. Keefe SE, editor. Appalachian cultural competency: a guide for medical, mental health, and social service professionals. Knoxville: University of Tennessee Press; 2005. Keefe SE, editor. Participatory development in Appalachia: perspectives on identity, community, and sustainability. Knoxville: University of Tennessee Press; 2009. Kessler RC, Sampson NA, Berglund P, Gruber MJ, Al-Hamzawi A, Andrade L, . . . Wilcox MA. Anxious and non-anxious major depressive disorder in the World Health Organization world mental health surveys. Epidemiol Psychiatr Sci. 2015;24:210–226. https://doi.org/10.1017/ S2045796015000189. Kleinman A. Social origins of distress and disease: depression, neurasthenia, and pain in modern China. New Haven: Yale University Press; 1986. Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ. 2004;82:858–66. https://doi.org/10.1590/S0042-96862004001100011. Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AM, . . . Penninx BH. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry. 2011;72:341–348. https:// doi.org/10.4088/JCP.10m06176blu. Mehta S, Farina A. Is being “sick” really better?: effect of the disease view of mental disorders on stigma. J Soc Clin Psychol. 1997;16:405–19. Mendenhall E, DeSilva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, Luitel N, Ssebunnya J, Fekadu A, Patel V, Tomlinson M, Lund C. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Afrida, and Uganda. Soc Sci Med. 2014;118:33–42. Michael KD, Jameson JP, Capps E. Preface: making the case for rural school mental health. In: Michael KD, Jameson JP, editors. Handbook of rural school mental health. New York: Springer; 2017.

32

Depression and Anxiety

709

Mohatt DF, Bradley MM, Adams SJ, Morris CD. Mental health and rural America, 1994–2005. Rockfille: U.S. Department of Health and Human Services; 2005. Morrissey KM. An urban-rural exploration of depression, CVD, and their comorbidity in Ireland. Ir Geogr. 2014;47:77–94. https://doi.org/10.2014/igj.v47i1.450. NAMI: National Alliance on Mental Illness. https://www.nami.org Newby JM, McKinnon A, Kuyken W, Gilbody S, Dalgleish T. Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clin Psychol Rev. 2015;40:91–110. Panagloti M, Scott C, Blakemore A, Coventry PA. Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014;9:1289–309. Pesonen H, Vasala K. Congregations and rural development: the case of the evangelical Lutheran Church of Finland. Agric Econ Rev. 2006;7:5–14. Quello SB, Brady KT, Sonne SC. Mood disorders and substance use disorder: a complex comorbidity. Sci Pract Perspect. 2005;3:13–21. Richards D. Prevalence and clinical course of depression: a review. Clin Psychol Rev. 2011;31:1117–25. https://doi.org/10.1016/j.cpr.2011.07.004. Roseborough DJ, McLeod JT, Wright FI. Attrition in psychotherapy: a survival analysis. Res Soc Work Pract. Online First. 2015; https://doi.org/10.1177/1049731515569073. Smith TB, Rodriguez MD, Bernal G. Culture. J Clin Psychol In Session. 2011;67:166–75. Spitzer RL, Kroenke K, Williams JBW, et al. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;282:1737–44. https://doi.org/10.1001/ jama.282.18.1737. Steel Z, Marnane C, Iranpour C, Silove D, Chey T, Jackson J, Patel V. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. Int J Epidemiol. 2014;43:476–93. Stewart RE, Chambless DL. Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol. 2009;77:595–606. Svennson B, Hansson L. Effectiveness of mental health first aid training in Sweden: a randomized controlled trial with a six-month and two-year follow-up. PLoS One. 2014;9:1–8. Tyrer P. The case for cothymia: mixed anxiety and depression as a single diagnosis. Br J Psychiatry. 2001;179:191–3. Vallury KD, Jones M, Oosterbroek C. Computerized cognitive behavior therapy for anxiety and depression in rural areas: a systematic review. J Med Internet Res. 2015;17:1. https://doi.org/ 10.2196/jmir.4145. Van Schaik E. The social context of “nerves” in eastern Kentucky. In: Keefe SE, editor. Appalachian mental health. Lexington: University Press of Kentucky; 1988. Ventevogel P. Integration of mental health into primary healthcare in low-income countries: avoiding medicalization. Int Rev. Psychiatry. 2014;26:669–79. Vermaas JD, Green J, Haley M, Haddock L. Predicting the mental health literacy of clergy: an informational resource for counselors. J Ment Health Couns. 2017;39:225–41. Watters E. Crazy like us: the globalization of the American psyche. New York: Simon and Schuster; 2010. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO; 1992. World Health Organization. The world health report 2001: mental health: new understanding, new hope. Geneva: WHO; 2001.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biopsychosocial Interventions in Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ideal Models of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive features of Schizophrenia in Rural and Remote settings . . . . . . . . . . . . . . . . . . . . . . . . . . . Are People with Schizophrenia in Rural and Remote Communities Different? . . . . . . . . . . . Rural People with Schizophrenia Are Often More Disadvantaged . . . . . . . . . . . . . . . . . . . . . . . . . Health-Seeking Behavior in Rural Communities May Be Different . . . . . . . . . . . . . . . . . . . . . . . Care in Rural Communities May Be More Reliant on Informal Networks . . . . . . . . . . . . . . . . Aboriginal and Torres Strait Islander PwS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural and Remote Locations Have Fewer Mental Health Professionals . . . . . . . . . . . . . . . . . . . Effective Service Models in Rural and Remote Areas May Be Different to Urban Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Implications for Practitioners Working in Rural and Remote Settings . . . . . . . . . . . . . . . Working Creatively with Limited Resources and Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managing Risk and Uncertainty at Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Working in Smaller Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Working Well as a Lone or Small Team Practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychosis Skill Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Should a Curriculum for Rural Practitioners Working with Psychosis Be? . . . . . . . . . Psychosis and Phenomenology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychopharmacology in Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rural and Remote Whole System Working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Schizophrenia is an archetypal low prevalence psychiatric disorder that often causes profound distress and disability for individuals affected by the condition and exerts a significant economic burden on health and social care systems. People with schizophrenia live in all parts of Australia, so it is important that practitioners living in rural and remote parts of the country have some understanding of how to assess and manage psychosis. This chapter examines the concept of schizophrenia and how effective management of the condition may differ in nonurban contexts. Suggestions are made for rural and remote practitioners regarding how best to negotiate some of the common challenges of clinical practice in nonurban communities and how to enhance their individual practice.

Introduction The epidemiology of psychiatric disorders in Australia mirrors the same pattern seen in other developed countries internationally. Psychiatric illnesses can be grouped broadly into high and low prevalence groups. High prevalence psychiatric conditions are usually neurotic in nature and include common anxiety and mood disorders. Low prevalence disorders are largely comprised of psychotic conditions such as schizophrenia, drug-induced psychosis, and “affective psychosis” (such as schizoaffective disorder or bipolar disorder where episodes of psychosis are accompanied by an abnormal mood state). It is not always easy to determine whether an individual’s psychosis is drug induced or symptomatic of an underlying condition such as schizophrenia. Despite these conditions being described separately, they often present with similar symptoms (Rosse et al. 1994). Comorbid drug use is also common in patients with schizophrenia (“dual diagnosis”). In this chapter, schizophrenia will be the focus of discussion. However, the principles of schizophrenia management are broadly applicable to those presenting with other psychotic conditions such as those which are drug related. Schizophrenia is the archetypal psychotic disorder and was originally described by Kraepelin over 100 years ago. Since then, studies regarding schizophrenia’s epidemiology have produced consistent estimates of the prevalence across different countries and settings (Jablensky 1997). Although schizophrenia is a “low prevalence” disorder, with a lifetime prevalence of approximately 0.5%, it remains a challenging and complex public health issue in Australia and globally (Jablensky 2000). The epidemiology of drug-induced psychoses, such as those from methamphetamine psychosis, is less certain and more dynamic. Methamphetamine use in Australia is increasing (Farnia et al. 2016), and it is likely that psychiatric complications of methamphetamine are also increasing, including psychosis. This has a disproportionate impact on rural communities, where specialist drug and alcohol, rehabilitation, and mental health services are more limited (Wallace et al. 2009). It is beyond the scope of this chapter to discuss the challenges of managing drug-induced

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psychosis in rural and remote Australia as this will require a coordinated policy response from the judiciary, police, and health and social services. Symptoms of schizophrenia are traditionally grouped into three clusters: (a) distortions of reality involving fixed and false beliefs (delusions) or false perceptions (hallucinations), (b) disorganization of thought and speech, and (c) psychomotor disturbance (including lack of volition, poverty of speech, and flatness of affect) (Liddle and Barnes 2018). Although the course of these symptoms varies considerably in each individual (Arndt et al. 1995), schizophrenia often causes lifelong distress and disability. As a result, schizophrenia and other psychoses consume a significant amount of health and social care expenditure. In Australia, the average annual health and social care costs for an individual patient with schizophrenia are estimated to be almost $50,000 and collectively amount to at least 1.5 billion dollars (Carr et al. 2003). Although the concept of schizophrenia has evolved since its original description by Kraepelin, the medical model remains the dominant paradigm that health and social care systems have employed to understand the needs of people with schizophrenia. Psychotic experiences of a person with schizophrenia (PwS), such as paranoid delusions or auditory hallucinations, are typically viewed by society as symptoms that warrant assessment and treatment. Prior to the development of antipsychotic and other therapies in the 1950s, many people with psychosis were rapidly institutionalized, often in long-stay wards or asylums. Although the stated intent of these institutions was therapeutic, the experience was often custodial. “Therapeutic” interventions provided were often primitive and harmful (such as leukotomy) and were experienced as custodial. In the last few decades of the twentieth century, rapid deinstitutionalization occurred, and the focus of treatment has shifted to community care. This has radically transformed the process and delivery of mental health services from custodial treatment in centralized asylums or wards to a decentralized approach where the majority of mental health care is delivered in the community through clinics, home visits, and liaison with general practitioners and other community organizations. This has had profound implications with regard to access to services for rural and remote communities in Australia which may be dispersed over great areas with people living considerable distances from the nearest clinic or GP practice. The “recovery” philosophy has gained traction in the last few decades as an alternative explanatory paradigm of mental illness. The recovery model does not immediately label all psychotic experiences as symptoms and shifts the focus of “treatment” away from symptomatic reduction to the maintenance of social function and citizenship. Although the recovery philosophy has gained traction in the last several decades as an alternative approach to mental illness such as schizophrenia, the medical model remains the dominant organizing paradigm in Australia. A person experiencing psychotic symptoms is typically bought by a concerned family member to see their general practitioner. In this transaction, the PwS rapidly acquires patient status and then is referred to a community mental health team (CMHT) for further assessment. The initial focus of a psychiatric assessment is diagnostic. The phenomenology of the patient’s presentation will be examined for features of psychosis

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(such as hallucinations, delusions, or psychomotor disturbances). The patient will also be examined and investigated for an explanatory physical illness. The assessment will also attempt to determine whether the psychosis is a primary condition such as schizophrenia or secondary to an affective condition such as psychotic depression, bipolar disorder, or schizoaffective disorder or related to drug and alcohol use. Psychiatric diagnoses remain clinical diagnoses meaning that they are largely constructed on the basis of the presenting story relayed by the patient and/or an informant such as relative. Although routine investigations, such as blood and urine tests and structural brain scanning, are recommended, these are used primarily to exclude rare organic causes of psychosis such as a brain tumor or thyrotoxicosis, rather than to confirm a diagnosis of schizophrenia. Historical descriptions of presenting symptoms (or phenomenology) are still utilized to construct and confirm diagnoses. In particular, “first rank symptoms,” originally described by German psychiatrist Kurt Schneider, are types of psychotic symptoms and experiences that are thought to be more suggestive of schizophrenia. Although these have subsequently found not to be specific for schizophrenia (Carpenter et al. 1973), phenomenological classifications such as first rank symptoms continue to be employed in contemporary psychiatry to guide the diagnostic process more than any specific test or investigation.

Biopsychosocial Interventions in Schizophrenia After diagnosis of schizophrenia or a psychotic disorder is made, treatment is usually organized using a “biopsychosocial” framework. The biological aspects of treatment include the ongoing exclusion of organic contributors to psychosis (such as drug use, epilepsy, autoimmune disease, or delirium) and the consideration of “biological” treatments such as anti-psychotic medication. Anti-psychotics reduce “positive” psychotic symptoms of schizophrenia such as auditory hallucinations and delusional thinking but are less effective on “negative symptoms” which include poor motivation and volition. Drugs with anti-psychotic activity were first identified and used for this purpose in the 1950s. These “first-generation anti-psychotics” include drugs such as haloperidol and chlorpromazine and were thought to exert their therapeutic effects by reducing excessive levels of dopaminergic activity in the brain. However, it is now recognized that there is a complex array of biological processes including dopaminergic malfunction and social factors that converge neurochemically to cause psychoses like schizophrenia (Howes and Kapur 2009). The most commonly used anti-psychotics currently used in Australia are “secondgeneration anti-psychotics” such as olanzapine, risperidone, aripiprazole, and quetiapine. These drugs are less likely to cause abnormal movement (extrapyramidal side effects) than first-generation drugs, but are associated with metabolic side effects such as weight gain and the increased risk of the development of diabetes. Unfortunately, it is the case with all anti-psychotic treatment that there is a delicate balance of therapeutic and side effects. It is also known that patients with a severe and enduring mental health condition such as schizophrenia are more likely to

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smoke, develop comorbid health conditions, and die earlier than people without psychosis. As a result, the physical heath of a PwS needs an ongoing monitoring by a psychiatrist and/or their general practitioner, particularly if a patient remains on antipsychotics in the longer term. However, it is thought that the positive psychiatric benefit of anti-psychotic therapy (such as reduced suicide and death by misadventure) outweighs the metabolic and other negative side effects of anti-psychotic treatment (Brown 1997). As a result, anti-psychotic treatment remains an important biological treatment for PwS. Even though a psychiatrist practicing in Australia in 2019 has access to an increasing range of anti-psychotic medication, successful outcomes still depend on the quality of the therapeutic relationship with the treating clinician and team. Most medications are ineffective unless they are delivered as part of a comprehensive and holistic treatment package that also considers the psychological and social needs of the PwS. Psychological approaches to psychosis are increasingly recommended in contemporary treatment guidelines for schizophrenia (Haddock and Lewis 1996). This is for a number of reasons. There are still many patients who do not tolerate or respond fully to anti-psychotic medication. Also, some patients do not wish to take anti-psychotic medication but are open to non-pharmacological options. Lastly, there is an increasing evidence base that suggests that psychological treatments in schizophrenia can be helpful in several areas: (a) family interventions aimed at patientcarer functioning to reduce the risk of relapse, (b) individual cognitive-behavioral therapy (CBT) to reduce treatment-resistant psychotic symptoms, (c) mapping relapse signatures to assist earlier treatment, and (d) psychological strategies to improve compliance with medication (Haddock and Lewis 1996). However, the delivery of these psychological interventions is often limited by the expertise of community staff who rarely have training in family therapy, CBT, or other psychological approaches. Staff practice may also be influenced by a long-standing view of psychosis as a medical condition that cannot be treated through a talking therapy (Haddock and Lewis 1996). Social inclusion is vital for mental health (Schneider and Bramley 2008), and the social environment of a PwS is a major determinant on the individual’s experience of their condition. The social substrates that are necessary for good physical health such as adequate housing, employment, financial resources, and a sense of community are equally, or more, important for mental health. Psychosis is often complicated by social disadvantage, and a key function of any care plan is to identify and address the social needs of the individual. Social interventions in psychosis are numerous and varied. Although they rarely receive the same research attention as anti-psychotic and psychological treatment, anyone who works with PwS and their families intuitively understands their importance. These can range from housing and benefit advocacy and liaison with care providers and nongovernmental organizations (NGOs) to joint assessments for care packages and applications for guardianship and administration. Attending to any social need can be a potent social intervention, no matter how small. Picking up a client’s shopping, organizing a taxi to attend a medical appointment, or calling a bank to explain a missing payment may seem trivial, but is often experienced by clients as person-centred interventions that

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cement a therapeutic alliance. There are also more formalized social approaches such as “nidotherapy” in which a patient’s physical and social environment is systematically examined and modified in order to minimize the impact of a mental disorder (Tyrer 2018).

Ideal Models of Care There is increasing literature and guidance regarding what constitutes a good and effective service for a PwS. People living with schizophrenia have a wide range of health and social needs. An ideal service meets these needs through the construction and fulfilment of an individualized care plan. After the deinstitutionalization of mental health services, community teams became the main focus and hub for the delivery of secondary mental health care. Although inpatient treatment is still often required for a PwS experiencing an acute relapse or complicated episode of illness, the majority of care now occurs in the community. Increasingly, general practitioners also supervise the care of patients who are stable and in remission. For a PwS who has more complex needs, treatment is often led and supervised by secondary community mental health teams. And within these teams, case management has become the prevalent model that guides care (Gournay 2000). Case management has been described as “a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human services needs. It is characterised by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes” (p. 1) (CCMC CfCMC 1990). Psychiatric case management core activities include risk assessment, medication management, and physical and mental state monitoring (Scott and Dixon 1995). Care coordination enables evidence-based and integrated treatment in mental health (Katon et al. 1995) by coordinating the biopsychosocial elements of an individual’s care plan across different settings. This care coordination role is also increasingly important as a PwS may require a range of inputs from a number of professionals in an ever-changing health and social care provider landscape. The components of a comprehensive mental health system for a PwS have also been operationalized in the literature. The elements of an idealized service include effective needs assessment systems, case management and assertive outreach, community and hospital beds, day care and rehabilitation, crisis response teams, accessible primary care, hospital liaison services, and patient and carer advocacy (Strathdee 1995). Other characteristics of an effective and high morale mental health service have been proposed. These include a stable organization with progressive and deliberate staff turnover, strong clinical leadership and shared accountability, appropriate and sufficient resources to maintain adequate standards of care and individual clinicians who are given the necessary autonomy to manage the demands of their job (Wing 1996). Ideal information systems also should be designed and maintained to support clinical care, rather than being focused on providing data for activity monitoring and financial management.

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Distinctive features of Schizophrenia in Rural and Remote settings The features of low prevalence disorders (using schizophrenia as an archetype) in rural and remote context will be now considered. Rural and remote environments will be defined, and then the practical differences in schizophrenia management in these nonurban settings will be examined. Although the concepts of “rural,” “remote,” and “urban” may seem initially intuitive, there are no universally agreed operational definitions of these concepts. Traditionally, rural Australia has been constructed as a homogenous idealized society with bush iconography and rural imagery despite the diversity of nonmetropolitan Australia. This disparity is maintained by simplistic definitions of rural and remote communities (Fraser et al. 2002). The Australian Statistical Geography Standard (ASGS) is the current system for determining rurality and uses postcodes and distances from major Australian centres to categorize a centre’s level of remoteness within five categories from metro (Rosse et al. 1994) to remote (Wallace et al. 2009; ABo 2011). However, these simple reductionist geographical classifications of rurality and remoteness do not characterize the social reality and needs of a community. Furthermore, the way that communities are defined as urban, rural, and remote can significantly impact health and social care delivery (McGrail and Humphreys 2009). Boyd and Parr (2008) remind that “Rurality can also be considered a social construction with multiple associated meanings” (Boyd and Parr 2008) (p. 2). It may therefore be preferable to frame rurality in relation to the characteristics of the people who live in an area, rather than how distant that area is from an urban centre. Nicholson suggests that although “sociological definitions tend to be less used in mental health research, unless a system of classification considers the look or feel of a place, people included in the research may disagree about the findings” and that “it may be useful also to include rural attributes such as community cohesion, stoicism and self-sufficiency in a definition of rurality” (p. 303) (Nicholson 2008).

Are People with Schizophrenia in Rural and Remote Communities Different? Although epidemiological data in Australia is lacking, global research suggests that the prevalence of psychotic disorders such as schizophrenia is lower in rural and remote areas compared to urban centres (Nicholson 2008). There is no evidence however to suggest that people with schizophrenia living in rural and remote areas are clinically different to their urban counterparts. However, PwS living rurally may have a higher burden of psychiatric and physical comorbidity. Of particular note, men living in nonurban locations are more likely to be heavy consumers of alcohol and die by suicide, while both men and women living rurally are more likely to die of coronary vascular events and diabetes (Fraser et al. 2002). Rural populations also tend to be older, meaning that there may be a greater need for integrated rural services that can care for people with schizophrenia with medical comorbidities and frailty.

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Rural People with Schizophrenia Are Often More Disadvantaged The issue of rural deprivation remains overlooked by social and health-care policymakers (Nicholson 2008). Although rural communities in Australia are highly diverse, poverty disproportionately affects people living in nonurban centres (Judd et al. 2002). As a consequence, people with schizophrenia living rurally may experience increased socioeconomic deprivation compared to those living in cities. This may have significant implications when considering individual or family hardship if psychosis results in unemployment and loss of income. Recovery from psychosis in rural environments may be doubly affected by lower baseline socioeconomic status and reduced opportunities for reentry into employment. Similarly, events that affect rural industry such as drought and farm foreclosures may also impact significantly on local employment possibilities (Fraser et al. 2002). Higher levels of stigma against mental illness may also operate in nonurban centres excluding people with schizophrenia further from participation in rural workplaces. However, while reentry into employment is often difficult for a PwS living in both urban and rural areas, it is thought that there may be more opportunity for social participation in smaller, tight-knit rural communities (Judd et al. 2002).

Health-Seeking Behavior in Rural Communities May Be Different Health-seeking behavior in people with psychosis is important to understand in order to encourage early treatment, both during an initial psychotic episode and during any subsequent relapses. There are many influences on whether a PwS decides to seek treatment during a psychotic episode. These include an individual’s insight and background beliefs relating to mental health and perceived stigma (Wrigley et al. 2005). Context also appears to influence help seeking as it is observed that young men from nonmetropolitan areas are less likely than those from urban areas to seek professional help for a mental health disorder (Caldwell et al. 2004). Rural Australians are more inclined to view their mental health problems as “insanity,” and a culture of self-reliance may also contribute to a reluctance to seek help from mental health services (Fuller et al. 2000). This effect may be further compounded in smaller and more intimate rural communities where a PwS may avoid contact with mental health services because of concern about what others may think. The presence of “rural gossip networks” may also worsen the experience of stigma (Aisbett et al. 2007), and there may be concerns about the maintenance of confidentiality in smaller communities where a professional care giver may also be a peer (Judd et al. 2002).

Care in Rural Communities May Be More Reliant on Informal Networks Supportive social networks for a PwS vary considerably in both rural and urban environments. Although it is sometimes assumed that informal social supports from

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family and friends in the country are more cohesive and superior to those in urban environments, this is an unstable finding in the literature (Nicholson 2008). It is clearer however that the range of formal support (such as paid care) is more limited in remote areas, largely because of a reduced number of care providers. As a consequence, case managers working with a PwS rurally may need to make more creative use of informal care networks such as family or friends (Judd et al. 2002). More research is needed to understand the role that formal and informal social networks play in mediating the effects of mental illness such as schizophrenia. For example, it would be helpful for social care policy-makers to understand care preferences for people with schizophrenia and their families living in areas that have less formal care support. It is also important to understand what are the most cost-effective interventions to support informal carers in rural settings in their caring roles.

Aboriginal and Torres Strait Islander PwS A higher proportion of people living rurally identify as aboriginal. Aboriginal and Torres Strait Islander Australians are more likely to experience socioeconomic disadvantage compared to non-Indigenous Australians. This includes higher levels of unemployment, inadequate housing, and overrepresentation within the criminal justice system (Judd et al. 2002). These disadvantages are compounded by intergenerational trauma and an ongoing failure of social policy to address inequity. Aboriginal and Torres Strait Islander people with psychosis experience a number of additional challenges in accessing mental health services that are culturally secure (Hunter 2007). The transcultural validity of psychiatric diagnoses such as schizophrenia and phenomenology in Aboriginal and Torres Strait Islander Australians is also unclear and requires further research. It is beyond the scope of this chapter to examine these important issues with any meaningful detail. Thankfully, there is now an increasing body of research that incorporates an Aboriginal world view and methodology that explores why Aboriginal and Torres Strait Islander Australians are less likely to access mental health services and what can be done to make services more culturally acceptable (Wright et al. 2016).

Rural and Remote Locations Have Fewer Mental Health Professionals Australians living in rural and remote areas have access to considerably fewer doctors compared with those living in cities (Young et al. 2019), and this unequal distribution also includes psychiatrists (Burvill 1988). It is thought that the lack of mental health specialists remains a big obstacle in delivering effective mental health services in the country (Judd et al. 2002). Increased rural recruitment of GPs may provide a partial solution as rural GPs are observed to play a greater role in managing mental health in more remote areas (Judd et al. 2002). However, clinicians new to a rural role may not be adequately prepared for the challenges of broader clinical

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practice required in rural settings. This may be because most undergraduate teaching occurs in cities and most medical curriculums have an urban focus (Judd et al. 2002). The issue of geographical distance also has a significant impact on the delivery of mental health to rural and remote communities. It has been recognized for over 150 years that increasing distance between health services reduces utilization and people living in rural and remote areas are less likely to seek help from mental health services (Fraser et al. 2002). This may be due to perceptions of rural practitioners as having less knowledge and specialist credentials compared to city-based experts (Aisbett et al. 2007).

Effective Service Models in Rural and Remote Areas May Be Different to Urban Models Evidence-based medicine is usually constructed in urban environments with uniform populations. Similarly, most mental health policy, law, and models of care are devised within non-rural settings. In an Australian context, most mental health policy and governance are constructed within capital cities and then extrapolated to regional centres. While the key principles of quality care are unarguably universal, there is a danger in using a “one size fits all” or “crude universalist” approach (Fraser et al. 2002) to mental health. Rural and remote regions are remarkably varied and what may work well in one locality may not work well in another. In Western Australia, for example, each of the subregions of the state, the Kimberley(s), Pilbara, Mid-west, Southwest, Goldfields, Wheatbelt, and the Great Southern, all vary considerably with regard to population distribution, distances between major centres, climate, demographics, and Indigenous communities. In regional areas, there are likely to be many examples of devolved practice that have evolved organically to meet the needs and expectations of local consumers. This can sometimes be carelessly superseded by an imposed centralized mental health policy that is not nuanced to requirements of diverse rural communities (Fraser et al. 2002). One example of this is in relation to crisis care. Most metrobased services have clear escalation policies and processes for admission if a PwS is presenting in crisis in the community. These pathways may not be fit for purpose in remote areas that have no specialized mental health beds in local hospitals authorized to admit involuntary patients. Rural patients may then be transported to metro inpatient services many thousands of kilometers away from their local community. This isolates patients from carers and families and dislocates Aboriginal and Torres Strait Islander patients from their land and communities. It also complicates any attempt at planned leave and graduated discharge planning. Although some alternative models of care have been proposed to alleviate this, such as telepsychiatry, this does not compensate for the lack of heath infrastructure and mental health workforce that persists in rural and remote Australia. It also remains unclear what models of crisis care are preferred by Australians living in nonurban settings due to a lack of research.

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Many PwSs who are experiencing a psychotic relapse can in fact be managed creatively in local district hospital settings when nursed by dedicated and adequately supported staff. Rural general hospitals are more willing than their metro counterparts to be involved in acute psychiatric care (Samules and Owen 1998). However, centralized mental health policy and law do not always support a creative local crisis response. For example, in Western Australia, the Mental Health Act (MHA) does not allow people under section of the MHA to be treated outside of authorized hospitals which are based in Perth or in larger rural centres. If a clinical incident occurs in a remote location, local staff may also be criticized for not following a standardized and metro-devised policy, rather than acknowledging how local contributors such as distance and inadequacies in staff numbers are responsible. Research into many aspects of rural mental health remain neglected (Fraser et al. 2002). In particular, there is little commentary or evaluation of the consumer experience of local crisis care, particularly for Aboriginal and Torres Strait Islander patients with a serious mental illness like schizophrenia. It is recognized that meaningful relationships with local clinicians are fundamental in order to build up trust and usage of local services by indigenous people (Wright et al. 2016). However, a reliance on transient and locum staff in remote settings can interfere with this relationship building. Effective service delivery in rural settings for people with schizophrenia is also limited by a sparser, more generalized workforce. These can create specific challenges with medication management, compliance with mental health law and centralized governance, and risk management. Technology, such as telecare, can be used to bridge some distance divides, and mental health expertise can be shared with rural clinicians through consultative and integrated care models to improve quality of care (Fraser et al. 2002). The trend of deinstitutionalization has had a particular effect rurally (Huessy 1981) where the provision of comprehensive community-based care in remote and diverse rural communities remains a significant challenge. There are no agreed universal models of care that will work everywhere, and what may work well in one community will not necessarily work well in another. For example, the specialist as the direct provider of care may not always be feasible in rural and remote locations. In some areas it may be more useful for a psychiatrist or community psychiatric nurse to take on an indirect role through consultation liaison and the upskilling of local health professionals. In larger centres, a hospital-based or CMHT hub model may be the most practicable and acceptable solution. However, some models of care may be more difficult to apply outside of major cities such as intensive case management and assertive outreach (Judd et al. 2002) due to a number of implementation barriers that are uniquely rural (McDonel et al. 1997). While intensive case management has been advocated in urban centres, there is little evidence that it is superior to standard case management (Gournay 2000). As a result, a more generic CMHT model may be the most evidence-based and cost-effective approach in most real-world settings. The emphasis of treatment for people with schizophrenia remains the same irrespective of model and setting. Rural practitioners want the best for their patients, and the emphasis on quality remains the same: this has been defined as a mental health service that is safe, timely, effective,

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and experienced in a positive way (Atkinson et al. 2010). Rural care can often be superior in all three domains when delivered by a small, dedicated, and personcentred team that is trusted by their local community.

Practice Implications for Practitioners Working in Rural and Remote Settings The practice context of rural practitioners is distinctive and varied (Samules and Owen 1998). It is therefore an important preface to say that what may work well in one region may not work well in another. However, some responses to common challenges that an individual practitioner faces in working in rural and remote settings with people with schizophrenia are discussed below.

Working Creatively with Limited Resources and Distance Mental health services generally receive less funding and resources than those focused on physical health both in rural and non-rural settings. There are additional challenges in the country where local services may be at distance and less comprehensive. Fortunately, psychiatry is a specialty which is largely relationship based, where words, rather than complex investigations or expensive medicines, are the main substrates for diagnosis and treatment. Sharing information is usually the first step in deciding on the course of action if a PwS is presenting with a problem, such as the potential relapse of symptoms. A conversation with a referring GP and a carer can often elicit the key information for deciding on an initial response, such as watchful waiting, a change in medication, or a psychiatric review. Although face-toface is usually the preferred medium to then assess a patient, technology can bridge a distance divide if needed. Assessment by videoconference (“telepsychiatry”) is increasingly considered to be a viable medium (Simpson et al. 2001) and is usually legally required if the mental health act is to be deployed (Australia GoW 2014). However, telephone can also be used effectively and safely, especially if the patient, carer, and clinician are already known to each other. If a patient is referred for admission, transport can be another issue. However, rural collegiality is often a powerful force in brokering a solution, particularly if transport officers and clinicians have an existing working relationship. Similarly, rural pharmacists in Australia are au fait with medication-distance logistics and will readily accept an emailed or faxed copy of a prescription while they await the paper original. Wing (1996) believes that clinical competence not only involves professional knowledge but the ability to “prioritise and marshal. . . scarce resources into a program that will promote the long term welfare of the patient” (p. 71) (Wing 1996). Assessing and managing the needs of a PwS within a limited resource context is often a challenging but vital task for any care manager. There is often an imbalance between demand and supply of mental health resources (Andrews and Henderson 2000). This discordance can potentially be managed in a number of ways, none of

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which are mutually exclusive. Although the notion of health-care rationing remains controversial, there does need to be some reference to the original mission statement of CMHTs which, post deinstitutionalization, were originally devised to meet the needs of those with severe and low prevalence mental illnesses such as schizophrenia (Gournay 2000). Most CMHTs, rural or otherwise, need to engage in dialogue with primary care referrers and commissioners about what patients should be prioritized within secondary mental health care. Some protocols exist, such as the “the Threshold Assessment Grid,” to help to decide which patients would most benefit from CMHT input (Slade et al. 2000). Stepped care models offer another potential solution, whereby more complex psychotic patients are offered face-to-face psychiatric review, while less complex referrals of a neurotic nature may be appropriately managed with consultative advice to the referrer. Many treatment pathways for common psychiatric illness now exist that can support appropriate management in primary care and free up resources in secondary care (Unützer et al. 2002). The most limited resource for any rural and remote practitioner is often time. Fortunately, triage and time management competencies are usually rapidly acquired by rural clinicians when supported by their service to do so.

Managing Risk and Uncertainty at Distance Assessing and managing risk and uncertainty at distance can be a source of significant anxiety to rural and remote clinicians, particularly when commencing a new role. When assessing risk with a PwS, there are usually a defined number of issues that need consideration in deciding a reasoned and proportionate course of action. If the clinician has pre-existing relationships with the patient and other clinical stakeholders, then this is generally a simpler task as the risk history will already be known and the best predictor of future is the past. This also applies to risk behavior by the patient and successful crisis management by the service. However, it should be noted from the outset that predicting serious events such as suicide is almost statistically impossible. Large (2017) explains that while “it is generally considered that uncertainty in suicide risk assessment can be greatly reduced by a detailed assessment of the patient’s suicidal thoughts, plans and actions, and attention to other demographic and clinical factors,” suicide risk assessment offers a little better discrimination than chance because of “there is no widely accepted way in which this information can be combined to improve the predictive strength of suicide risk assessment” (p. 161) (Large et al. 2017). He argues that the way forward may be to focus less on paternalistic treatment and more on an individualized psychosocial assessment of a person’s presenting difficulties that aims to identify risk factors that can be modified. However, the practice of risk assessment is embedded in mental health policy and is an expected activity for any mental health clinician. The difficulty for many clinicians, rural and otherwise, is that centralized health providers often mandate the use of standardized risk assessment tools, which are unevidence based and unvalidated for use in all populations. Fortunately, there are a number of more flexible risk assessment strategies, such as structured professional judgment as suggested by

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Bouch and Marshall (Bouch and Marshall 2005). This is a pragmatic approach that combines the assessment of static, stable, dynamic, and future risk factors to inform an individualized risk management plan.

Working in Smaller Communities Working and living in the same community poses a number of issues for the rural and remote practitioner. The issue of confidentiality and maintaining professional boundaries (Schank and Skovholt 1997) in rural areas is an important and complex area (Judd et al. 2002). It may be impossible to completely maintain the confidentiality of a PwS where professional colleagues may also be members of the same community. However, most practitioners maintain high standards of probity and take their professional responsibilities seriously. Rural practitioners, who have worked in their communities for a long time, develop their own methods of maintaining professional boundaries while navigating personal ones. There is, however, little research on how this expertise is achieved. Awkward social encounters may invariably arise if a clinician meets their client outside the medical setting. This may be particularly challenging if the PwS is acutely psychotic. However, close relationships with the local care community, such as the police, may help buffer these tensions.

Working Well as a Lone or Small Team Practitioner Mental health workers in rural and remote settings often have more extended professional roles compared to their urban counterparts (Nicholson 2008). A significant difference for a rural clinician is the opportunity to practice as a “sole practitioner” or as part of a smaller rurally based CMHT compared to those in urban centres. This affords opportunities for a varied professional role with greater autonomy but also creates potential challenges such as practitioner isolation and selfcare, skill maintenance, and difficulties in obtaining supervision. Working well with rural peers in a smaller team may also become an additional issue. Fortunately, there is now greater understanding of the importance of supervision, practitioner care, and continuous professional development for all health workers. Many of these activities are now mandated as part of professional registration, job planning, or local accreditation by health providers. Practitioners in any setting, rural or otherwise, should approach their employers if they feel that there are inadequate local support processes. Supervision, in particular, by a senior peer is increasingly seen as a vital forum for learning and support in any practice setting and should be a prioritized and protected activity. Learning can be also be supported by conversations with peers to discuss challenging cases, management difficulties, or clinical incidents. There is no evidence that supervision provided in rural settings is impoverished compared to urban settings; however, rural-based practitioners do often feel professionally isolated due to the lack of peers (Nash et al. 2014). This can be offset by a greater sense of community and camaraderie that exists in rural and remote settings, where

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workers become a valued and welcomed member of the local health community, irrespective of professional discipline.

Psychosis Skill Development Developing and maintaining therapeutic skills to work with a PwS is a challenge for clinicians working in any setting. In the UK in the early 1990s, “the Thorn program” was devised in order to upskill clinicians in CMHTs working with people with schizophrenia (Gournay 2000). This was an intensive program that used classroom and real-world teaching, close supervision, and tape-recorded interactions with their patients to improve clinical skills. While new skills could be rapidly acquired, it was noted in subsequent Australian research that workers quickly stopped using these skills without regular support. This effect may be especially prevalent in rural and remote settings where practitioners may have less access to supervision, support, and peer review. However, this “might be offset by the greater opportunity [that exists rurally] to get involved on a more personal level with patients, families and general practitioners, thereby up-skilling interpersonal abilities and professional identity” (p. 322) (Balaratnasingam 2008). However, rural practitioners, who work more independently and with fewer peers, may require additional support to maintain their clinical skills. Fortunately, in the Internet age, there are a number of ways that rural clinicians can prevent skill entropy and take charge of their own skill and professional development. Clinicians now have more access than ever to a range of online materials aimed at supporting psychosis skill acquisition and continuing professional development.

What Should a Curriculum for Rural Practitioners Working with Psychosis Be? There is a wide variety of theoretical and practical knowledge that could be useful for any clinician working with psychosis. In the previously mentioned “Thorn program” for urban CMHT workers, core modules of training focused on assertive community treatment and helpful psychological and family interventions (Gournay 2000). However, a broader skills curriculum may be needed to support rural clinicians in their challenging but rewarding clinical roles. There are a number of topics worthy of study. These include phenomenology of psychosis, medication management and psychotropic use, psychological skills and interventions, risk assessment and management, social psychiatry, and the recovery model. Some of these will now be considered in turn.

Psychosis and Phenomenology Earlier, a brief summary of common psychotic symptoms was discussed. A deeper knowledge of psychosis will enable anyone working with PwSs and their families

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to provide some psychoeducation on the nature and management of the psychotic states. Knowledge of the role of particular substances (cannabis and methamphetamine) and other antecedents (such as stressors) in destabilizing psychosis will also aid relapse prevention work. A working knowledge of phenomenology may be important when working with Aboriginal and Torres Strait Islander patients, where unusual beliefs or sensory experiences may be better explained through cultural constructs rather than psychosis. There are also an increasing number of conceptual models to “explain” psychosis, which can be used by any practitioner to make some sense of their patient’s psychotic experiences. One model, proposed by Richard Lucas, suggests that practitioners can learn to “tune into the psychotic wavelength” which allows clinicians to distinguish between the psychotic and nonpsychotic parts of the person. This can, in turn, help patients make more sense of their psychotic experiences and help maintain effective treatment and staff morale (Lucas 2013).

Psychopharmacology in Schizophrenia It is beyond the scope of this chapter to provide a detailed summary of psychopharmacology in schizophrenia. The “Thorn program,” however, suggested some medication management principles that anyone working with psychosis would find useful in routine clinical practice. These include education regarding the action of commonly used drugs, psychoeducation methods about prescribed medications, awareness of medication side effects, and techniques to encourage and enhance adherence to medications (Gournay 2000). Fortunately, there are many excellent and easily accessible resources that consider these areas in details, including the Maudsley Prescribing Guidelines in Psychiatry (Taylor and Paton 2009). This guide provides mental health clinicians with a range of practical and useful advices on prescribing and monitoring psychotropic medications in a broad range of clinical situations.

Psychological Skills It is now well established that a PwS living with a family member who is highly critical, hostile, or emotionally overinvolved, displaying highly “expressed emotion” (EE), is more prone to psychotic relapse. The corollary of this observation is that family interventions for people with schizophrenia that reduce EE can reduce the likelihood of relapse and improve social functioning. Over the last two decades, there has been an increased interest in this phenomenon and why family work is effective. It may be that changes in family behavior such as reduced criticism and emotional overinvolvement may be responsible; however, the active ingredients of helpful family work are still uncertain (Barrowclough and Tarrier 2009; Tarrier et al. 1988).

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To a rural clinician, the prospect of trying psychological interventions for psychosis may be daunting, not at least due to uncertainties of the evidence base but also due to time and supervision inadequacies. However, rural practitioners should feel free to be creative with their style of engagement and also to “have a go” if they can access some supervision to support this work. As has been a common theme in this chapter, rural practitioners should feel free to trial any established therapeutic technique if this is delivered as part of their case management and is acceptable to their patient and their family. Many case managers often realize that their intuitive model of care has always had an inherent systemic quality without formal teaching or supervision. And after some interaction with systemic theory, many find that they can retrofit the systemic psychotherapy lexicon to describe their past work with clients. Similarly, many case managers may be unaware of the literature describing and operationalising the use of other psychological techniques for psychosis such as individual CBT, relapse signature mapping, and self /carer monitoring. It is helpful to have some awareness of the theoretical underpinnings of these and practical approaches that can be used by frontline clinicians in almost any setting. It is increasingly thought that equipping frontline staff with an improved psychotherapy skill base is more likely to result in a far great number of patients benefiting from psychological treatments than ever would be achieved by relying on the delivery purely by psychologists (Lovell and Richards 2000). This is particularly relevant rurally where the access to psychologists and counselors for conventional face-to-face treatments is far more restricted than in urban areas. It is beyond the scope of this chapter to provide a comprehensive practice manual of psychological treatments for schizophrenia for frontline staff in rural and remote communities. However, the author does have some recommendations on where a rurally based practitioner may start if he or she is interested in developing their psychology-based skills further to enhance their practice and professional development. Many introductory texts on different psychotherapies are available free and online, but some signposting to peer-reviewed and reader friendly articles may be helpful. For example, several excellent introductions to the CBT using the “5 areas” model from Advances in Psychiatric Treatment are available on the website of the UK Royal College of Psychiatrists (Wright et al. 2002). Although these resources are written by psychiatrists for psychiatrists, they are often excellent introductions to a variety of clinical topics and practices that any frontline clinician working with mental health would find valuable. It should be remembered that CBT itself is an umbrella term that refers to a wide variety of therapies ranging from simple exposure work in phobia treatment to cognitive restructuring and “schema” work used with people who have a personality disorder. CBT-based approaches in schizophrenia and psychosis (CBTp) are similarly varied. For a rural practitioner embarking on this kind of work, it may be easier to start with simpler distraction techniques for auditory hallucinations rather than attempting belief modification approaches to help counter delusional beliefs. An approach that is often helpful in working with a PwS and their family is “relapse

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signature” mapping. This aims to help patients and their carers identify early psychosis relapse symptoms and signs in order to promote earlier intervention in the event of a relapse. Although there is evidence that earlier intervention is always effective, the technique explicitly engages the PwS in an approach that emphasizes collaboration and can improve the overall experience of care (Haddock and Lewis 1996). Similarly, conversations focused on improving adherence with anti-psychotic medication can foster a joint approach to reducing the risk of relapse and staying well.

Rural and Remote Whole System Working Mental health clinicians working in rural and remote locations are usually valued members of a close-knit community care network. In contrast to bigger urban environments, they will often work more closely with GPs, other local health professionals, and formal and informal care networks. Familiarity with the local practitioners and care networks is important, and an intimate and live knowledge of support resources will make a clinician’s job easier and more effective (Judd et al. 2002). A more intimate working context also affords the opportunity to work in a more integrated way with a smaller care system of key professionals. There has been much written about the “lean” movement in health care which aims to improve the quality of health care by rationalizing patient care pathways to make them more effective (Andersen et al. 2014). For a PwS, presenting in crisis with psychotic symptoms, a lean care pathway is one that rapidly provides guidance on what may help the patient manage their symptoms, reduce distress and risk, and improve social functioning. Rural clinicians are already socialized to lean working. They can see their patient’s journey firsthand and understand their community’s expectations and resources. Unencumbered by large hospital process and protocol, they are often freer to directly deliver person-centred care in collaboration with trusted local colleagues. In smaller rural health economies, it is easier to enable whole system working in which everyone can develop some understanding on how everyone works. Once a mental health clinician feels confident in working with psychosis, there is no reason why they cannot educate the system around them. Rather than just making recommendations, it is often helpful to “think aloud” with a PwS, carers and GPs, and other local clinicians to explicate a rationale for therapeutic decisions (Denig and Haaijer-Ruskamp 1994). Overtime, this can mean that the psychiatric “standard” work that informs care for people with psychosis becomes shared with the rural care network. This then facilitates whole system working as all professionals in the care system began to share knowledge and work in a more integrated way. Referral and crisis pathways also become more streamlined and local services more efficient and effective. Ultimately, this can mean that people with schizophrenia in rural settings can receive care that is more responsive than their urban counterparts.

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Case Study

Corey is a 26-year-old Aboriginal man who lives with his mother and sister in a small town 250 kilometers from the nearest regional centre. He has a history of multiple admissions for psychotic episodes in the context of cannabis use and has been prescribed oral anti-psychotic medication. His family tended to contact the local CMHT with reports of disturbed behavior, namely, shouting at random and becoming more withdrawn. Previously, this has resulted in a cycle of revolving door admissions, which are often brief as his behavioral disturbances are not observed in hospital. Admissions and discharges were at times logistically difficult to organize because of transport and bed capacity issues at the “local” acute psychiatric unit, 250 kilometers away. Inpatient crisis-based care also distanced Corey from his family and support network. After the last crisis admission, a change in approach was trialed. His relapse signature was mapped with his family and in particular the early-warning behaviors that caused the family and Corey the most distress. His anti-psychotic medication was also rationalized to a depot preparation (Clopixol) with a more flexible dosage regimen that could be adjusted weekly according to his symptoms and distress. At the same time, his local GP, pharmacist, and district hospital (all 200 km from where his supervising psychiatrist was based) were included in the plan, and a clear crisis pathway was shared among all clinical stakeholders. Corey’s sister and mother now call the supervising psychiatrist directly if they have concerns about breakthrough symptoms, and his Clopixol dose can be remotely adjusted and delivered locally. Every several months, he also receives outreach visits from the CMHT to monitor side effects and for direct face-to-face review. This has reduced the rate of admission to a distant APU significantly and meant that Corey can spend more time with his local community and enjoy a higher quality of life.

Concluding Comments and Recommendations Rural and remote communities differ from urban environments not just in geographical terms but in sociological ways. These differences have implications for mental health services configured to care for people with low prevalence disorders such as schizophrenia. People with psychosis and their carers desire the same outcomes as those in urban settings, namely safe and effective mental health care that reduces distress, restores quality of life, and improves social and occupational function. However, the best way of delivering these outcomes may differ in rural and remote settings. Rural practitioners may need to be more creative and independent in their practice compared to their urban counterparts. However, there are many opportunities for varied and professionally satisfying practice in rural and remote settings.

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Take-Home Messages 1. 2. 3. 4. 5.

Get to know other clinicians in your local health-care system. Seek out opportunities for supervision and peer contact. Read strategically on psychosis using online CPD resources. Share your expertise about psychosis with your local care system. Embrace opportunities for more varied and creative work.

Cross-References ▶ Future of Rural, Remote, and very Remote Mental Health ▶ Maintaining Control: The Importance of Self-Care to Effective and Enduring RRvR Mental Health Service Provision ▶ Rural and Remote Mental Health Practice: Nursing Roles ▶ Supporting Communities

References ABo S. Australian statistical geography standard (asgs): volume 1 – main structure and greater capital city statistical areas. Canberra: Australian Bureau of Statistics; 2011. Aisbett DL, Boyd CP, Francis KJ, Newnham K, Newnham K. Understanding barriers to mental health service utilization for adolescents in rural Australia. Rural Remote Health. 2007;7(1):624. Andersen H, Røvik KA, Ingebrigtsen T. Lean thinking in hospitals: is there a cure for the absence of evidence? A systematic review of reviews. BMJ Open. 2014;4(1):e003873. Andrews G, Henderson S. Unmet need in psychiatry: problems, resources, responses. Cambridge: Cambridge University Press; 2000. Arndt S, Andreasen NC, Flaum M, Miller D, Nopoulos P. A longitudinal study of symptom dimensions in schizophrenia: prediction and patterns of change. JAMA Psychiat. 1995;52 (5):352–60. Atkinson S, Ingham J, Cheshire M, Went S. Defining quality and quality improvement. Clin Med. 2010;10(6):537–9. Australia GoW. Mental Health Act 2014. 2014. https://www.legislation.wa.gov.au/legislation/stat utes.nsf/law_a147019.html Balaratnasingam S. The wild west: rural and remote psychiatry training in North Western Australia. Australas Psychiatry. 2008;16(5):322–5. Barrowclough C, Tarrier N. ‘Psychosocial’ interventions with families and their effects on the course of schizophrenia: a review. Psychol Med. 2009;14(3):629–42. Bouch J, Marshall JJ. Suicide risk: structured professional judgement. Adv Psychiatr Treat. 2005;11 (2):84–91. Boyd C, Parr H. Social geography and rural mental health research. Rural Remote Health. 2008;8 (804):1–5. Brown S. Excess mortality of schizophrenia: a meta-analysis. Br J Psychiatry. 1997;171(6):502–8. Burvill PW. A survey of the distribution of psychiatrists in Australia and New Zealand in 1987. Aust N Z J Psychiatry. 1988;22(4):436–47. Caldwell TM, Jorm AF, Dear KB. Suicide and mental health in rural, remote and metropolitan areas in Australia. Med J Aust. 2004;181(7 Suppl):S10–4.

33

Low Prevalence Psychiatric Disorders in Rural and Remote Settings

731

Carpenter WT, Strauss JS, Muleh S. Are there pathognomonic symptoms in schizophrenia?: an empiric investigation of schneider’s first-rank symptoms. Arch Gen Psychiatry. 1973;28 (6):847–52. Carr VJ, Neil AL, Halpin SA, Holmes S, Lewin TJ. Costs of schizophrenia and other psychoses in urban Australia: findings from the low prevalence (psychotic) disorders study. Aust N Z J Psychiatry. 2003;37(1):31–40. CCMC CfCMC. About CCMC. 1990. https://ccmcertification.org/about-ccmc/case-management/ definition-and-philosophy-case-management Denig P, Haaijer-Ruskamp FM. ‘Thinking aloud’ as a method of analysing the treatment decisions of physicians. Eur J Public Health. 1994;4(1):55–9. Farnia V, Shakeri J, Tatari F, Juibari TA, Bajoghli H, Golshani S, et al. Demographic and mental history-related data predicted occurrence of psychosis in methamphetamine users. Psychiatry Res. 2016;240:431–4. Fraser C, Judd F, Jackson H, Murray G, Humphreys J, Hodgins GA. Does one size really fit all? Why the mental health of rural Australians requires further research. Aust J Rural Health. 2002;10(6):288–95. Fuller J, Edwards J, Procter N, Moss J. How definition of mental health problems can influence help seeking in rural and remote communities. Aust J Rural Health. 2000;8(3):148–53. Gournay K. Role of the community psychiatric nurse in the management of schizophrenia. Adv Psychiatr Treat. 2000;6(4):243–9. Haddock G, Lewis S. New psychological treatments in schizophrenia. Adv Psychiatr Treat. 1996; 2(3):110–6. Howes OD, Kapur S. The dopamine hypothesis of schizophrenia: version III – the final common pathway. Schizophr Bull. 2009;35(3):549–62. Huessy HR. Deinstitutionalization in a rural state: the Vermont experience. New Dir Ment Health Serv. 1981;1981(9):33–8. Hunter E. Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote indigenous Australians. Aust J Rural Health. 2007;15(2):88–93. Jablensky A. The 100-year epidemiology of schizophrenia. Schizophr Res. 1997;28(2–3):111–25. Jablensky A. Prevalence and incidence of schizophrenia spectrum disorders: implications for prevention. Aust N Z J Psychiatry. 2000;34(Suppl):S26–34; discussion S5–8. Judd F, Fraser C, Grigg M, Scopelliti J, Hodgins G, Donoghue A, et al. Rural psychiatry. Dis Manag Health Out. 2002;10(12):771–81. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273(13):1026–31. Large M, Galletly C, Myles N, Ryan CJ, Myles H. Known unknowns and unknown unknowns in suicide risk assessment: evidence from meta-analyses of aleatory and epistemic uncertainty. BJPsych Bull. 2017;41(3):160–3. Liddle PF, Barnes TRE. Syndromes of chronic schizophrenia. Br J Psychiatry. 2018;157(4):558–61. Lovell K, Richards D. Multiple access points and levels of entry (MAPLE): ensuring choice, accessibility and equity for CBT services. Behav Cogn Psychother. 2000;28(4):379–91. Lucas R. The psychotic wavelength: a psychoanalytic perspective for psychiatry. New York and London: Routledge; 2013. McDonel EC, Bond GR, Salyers M, Fekete D, Chen A, McGrew JH, et al. Implementing assertive community treatment programs in rural settings. Adm Policy Ment Health Ment Health Serv Res. 1997;25(2):153–73. McGrail MR, Humphreys JS. Geographical classifications to guide rural health policy in Australia. Aust N Z Health Policy. 2009;6(1):28. Nash L, Hickie C, Clark S, Karageorge A, Kelly PJ, Earle M. The experience of psychiatry training in rural NSW. Australas Psychiatry. 2014;22(5):492–9. Nicholson LA. Rural mental health. Adv Psychiatr Treat. 2008;14(4):302–11. Rosse RB, Collins JP, Fay-McCarthy M, Alim TN, Wyatt RJ, Deutsch SI. Phenomenologic comparison of the idiopathic psychosis of schizophrenia and drug-induced cocaine and phencyclidine psychoses: a retrospective study. Clin Neuropharmacol. 1994;17(4):359–69.

732

N. Collins

Samules A, Owen C. A day in the country: a perspective on rural psychiatry. Australas Psychiatry. 1998;6(6):283–6. Schank JA, Skovholt TM. Dual-relationship dilemmas of rural and small-community psychologists. Prof Psychol Res Pract. 1997;28(1):44. Schneider J, Bramley CJ. Towards social inclusion in mental health? Adv Psychiatr Treat. 2008; 14(2):131–8. Scott JE, Dixon LB. Assertive community treatment and case management for schizophrenia. Schizophr Bull. 1995;21(4):657–68. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Telepsychiatry as a routine service-the perspective of the patient. J Telemed Telecare. 2001;7(3):155–60. Slade M, Powell R, Rosen A, Strathdee G. Threshold Assessment Grid (TAG): the development of a valid and brief scale to assess the severity of mental illness. Soc Psychiatry Psychiatr Epidemiol. 2000;35(2):78–85. Strathdee G. Deploying a community mental health team for the effective care of individuals with schizophrenia. Adv Psychiatr Treat. 1995;1(7):199–206. Tarrier N, Barrowclough C, Vaughn C, Bamrah J, Porceddu K, Watts S, et al. The community management of schizophrenia: a controlled trial of a behavioural intervention with families to reduce relapse. Br J Psychiatry. 1988;153(4):532–42. Taylor D, Paton C. The Maudsley prescribing guidelines. London: CRC Press; 2009. Tyrer P. The importance of nidotherapy and environmental change in the management of people with complex mental disorders. Int J Environ Res Public Health. 2018;15(5):972. Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45. Wallace C, Galloway T, McKetin R, Kelly E, Leary J. Methamphetamine use, dependence and treatment access in rural and regional north coast of New South Wales, Australia. Drug Alcohol Rev. 2009;28(6):592–9. Wing J. Are we providing a good service for people with chronic schizophrenia? Adv Psychiatr Treat. 1996;2(2):69–75. Wright B, Williams C, Garland A. Using the five areas cognitive–behavioural therapy model with psychiatric patients. Adv Psychiatr Treat. 2002;8(4):307–15. Wright M, Lin A, O’Connell M. Humility, inquisitiveness, and openness: key attributes for meaningful engagement with Nyoongar people. Adv Ment Health. 2016;14(2):82–95. Wrigley S, Jackson H, Judd F, Komiti A. Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Aust N Z J Psychiatry. 2005; 39(6):514–21. Young L, Peel R, O’Sullivan B, Reeve C. Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation. BMC Health Serv Res. 2019;19(1):338.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Presentation of Mental Health Problems in Rural and Remote Communities . . . . . . . . . . . . . Practice Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practical Approaches to Prevention Programs for Rural and Remote Communities . . . . . . Implementation of Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modifying or Adapting Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The imperative for targeted mental health promotion, and mental illness and suicide prevention programs in rural and remote Australian communities, can in part be validated by the high prevalence of mental ill-health, acute distress, suicidality, and suicide deaths in these communities. In addition to the impacts on those with lived experience, mental health has collective implications for rural and remote communities, workplaces, and economies. These implications support the need for systemic change and greater investment in effective program delivery and evaluation. Whether programs or services are effective will depend largely on the extent to which they engage with the target audience; utilize culturally and geographically relevant approaches; reduce stigma and improve mental health literacy; influence positive behaviors; and fill gaps in the continuity of care between clinical services, in-community supports, and informal care methods. J. Bowers (*) Rural and Remote Mental Health Ltd, Adelaide, SA, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_43

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While “whole of community” prevention – from primary prevention through to secondary and tertiary prevention – is key, there is a definitive need to respond to particular “high-risk” cohorts as target sub-groups of rural and remote populations. This includes Aboriginal and Torres Strait Islander peoples; culturally and linguistically diverse communities; workers in certain industries such as farming, primary production, fishing, and forestry; older Australians; LGBTIQ +people; and youth cohorts – noting that these groups are not mutually exclusive and that a myriad of mitigating factors prevail depending on individual and community variables. Several priorities will determine program suitability: delivery and content relevance, localized communication methods, level of collaboration, facilitation of stepped care pathways, practical reach and accessibility, sustainability and scalability, evidence base, evaluation method, and demonstrable impacts. Integration of high-quality programs and services, with a community-led approach that is sensitive to local needs, experiences, and strengths, is the way forward.

Introduction An overview of statistics, target populations, and risk factors relating to the mental health of people living and working in rural and remote Australia provides an insight into some of the unique challenges which these people face. An overview will also provide the rationale for, and outlines the importance of, mental health promotion, as well as mental illness and suicide prevention programs. Around 33% of the Australian population live outside capital cities (Australian Bureau of Statistics 2018), and while the prevalence of mental disorders is similar globally – with 20% of the population experiencing mental distress in any year (Steel et al. 2014) – rates of suicide are 40% higher than in capital cities and increase with relative remoteness (Bishop et al. 2017; Harrison and Henley 2014). While population statistics on mental ill-health identify significant prevalence concerns across Australian rural and remote communities, it is the more granular analysis of priority “high-risk” cohorts, which supports the need for targeted mental health programs. For example, in some rural and remote workplaces, the prevalence of mental distress has been shown to be up to one in three in any 1 year (Bowers et al. 2018; Parker and Fruhen 2018). This makes some industries and workplaces groundzero for both mental health risk but also a prime location for implementation of evidence-based prevention initiatives. Another priority cohort is Aboriginal and Torres Strait Islander peoples. Recent research cites the prevalence of high distress as around three times higher in Aboriginal versus non-Indigenous participants, even though distress-related factors were similar (McNamara et al. 2018). Suicide rates in both Aboriginal males and females were double those of non-Indigenous people (Australian Bureau of Statistics 2017).

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Men in rural and remote areas also typically experience higher levels of psychological distress than their metropolitan counterparts (Australian Institute of Health and Welfare 2008, 2010). Male farmers are at particularly heightened risk, and young farmers (aged 18–34) had the highest rates of farmer suicide (Arnautovska et al. 2013).This may be due to many mitigating factors such as the day-to-day challenges of life on the land, financial pressures, isolation, and real or perceived stigma that inhibit help seeking. Suicide remains a crisis issue for rural and remote communities overall. Suicidal behavior is complex and can result from numerous factors such as social, cultural, psychological, biological, and environmental, and these can be compounded by geographic isolation (Bishop et al. 2017). Experts and community members engaged with programs readily agree that in rural areas there is often apprehension around help-seeking and fear of the stigma associated with mental illness and suicide – particularly in smaller communities where individuals are more visible and confidentiality may be less assured (Judd et al. 2006; Hoolahan 2002). It is for these reasons there is a need for a national focus on disseminating knowledge and raising awareness and understanding of stigma. This will further enhance the understanding of risk factors, symptoms of mental distress, signs of suicide, and local support pathways – to mitigate developing or living with a mental illness or suicidality, in the rural and remote Australian population. While statistics on poor mental health and the challenges of life in rural and remote communities may seem stark when viewed in isolation, they do not provide the full picture. There are many positive aspects of rural life such as higher levels of civic participation, social cohesion, social capital, volunteering, and informal support from friends, neighbors, and the community. People in rural areas also regularly score better than their major cities counterparts on indicators of life satisfaction and feelings of wellbeing (National Rural Health Alliance 2017).These positive factors demonstrate innate resources that can be drawn upon to deliver successful health promotion and prevention programs and an opportunity for capacity building to improve community care networks.

Distinctive Features There are distinct factors that are important when there is a need to understand the perspectives of rural and remote individuals and communities and the context of working in them in a professional capacity. Key factors include the magnitude of the population; the definitions of interventions; background information about the structure of mental health services; risk factors; and the importance of recognizing stigma in a rural and remote context.

Target Populations The population in regional Australia is increasing, for example, between 2007 and 2017, the population outside major cities grew by 10.6%, and it is predicted that

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between 2007 and 2026 the population will grow by 26% (Australian Bureau of Statistics 2018). The mentally well population in rural and remote Australia – The distribution of mental health among the Australian population (National Mental Health Commission 2014) shows that 15 million Australians are mentally well and, as at June 2017, 32.7% of Australia’s population (a little over 8 million people) resided outside greater capital city areas (Australian Bureau of Statistics 2018). This equates to five million mentally well people outside greater capital city areas. A localized “whole of community” approach to preventative interventions is essential to building the capacity of those in rural and remote areas to understand and respond to mental ill-health in the context of themselves, their families, and their own communities. The at-risk population in rural and remote Australia – Data further indicate that there are 5.8 million Australians at risk (Productivity Commission 2019). If the risk factors for those residing in rural and remote areas are equal (which in some industries or communities is clearly not the case), it could be concluded that over 1.9 million people are at risk in rural and remote Australia. Preventative interventions that are available before the onset of a mental disorder can target known risk and protective factors on causal pathways. In addition to the populations outlined above, groups or individuals exhibiting early signs of mental distress, those currently experiencing mental illness, or those recovering from mental illness, will benefit from interventions. Early interventions can reduce the severity or duration of mental ill-health and promote recovery from a mental illness. Rural and remote communities vary greatly and have different geographic locations, demographic profiles, societal concerns, environmental issues, and levels of capacity, which require culturally tailored, awareness-raising, and prevention programs, to improve early help-seeking behavior, thereby reducing the pressure on the limited clinical, end-user services.

Definitions Prevention Primary prevention initiatives prevent the onset or development of mental ill-health and can target: • Entire population groups, e.g., rural and remote Australians • Sub-groups of the population who are at a heightened risk of developing a mental disorder, including those who are identified as having minimal but detectable symptoms and signs, such as Aboriginal and Torres Strait Islander communities, farming and agricultural communities, and the mining and resource sector workers, fishers, and the seafood sector, etc. • Those who are at high risk of a mental disorder and who are showing early signs of mental ill-health (The Ottawa Charter for Health Promotion n.d.)

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Secondary prevention initiatives are aimed at decreasing the severity and length of a mental illness via an early intervention and treatment (The Ottawa Charter for Health Promotion n.d.). Tertiary prevention is about intervening to reduce the impact of mental ill-health through rehabilitation and prevention of relapse. Interventions may include access to care for not only mental health but for physical health, as well as housing, employment, and social supports (The Ottawa Charter for Health Promotion n.d.). Early interventions are a form of prevention and intersect with primary and secondary prevention (The Ottawa Charter for Health Promotion n.d.). When considering prevention initiatives in the rural and remote context, local community knowledge and awareness are essential for encouraging support and safety when mental health services are limited or inaccessible. Promotion Mental health promotion in rural and remote populations is about raising awareness to improve mental health and social and emotional wellbeing and reduce stigma and discrimination within population groups ranging from age (e.g., young people or the elderly) to settings (e.g., workplaces). The World Health Organization (WHO) defines health promotion as “the process of enabling people to increase control over, and to improve their health” (Herrman 2001). Positive mental health is the desired outcome of health promotion interventions. Promotion and prevention are complementary; however prevention is about avoiding a mental illness or in the instance of suicide prevention is about stopping deaths by suicide. It is important to promote the benefits of mental health as well as identifying the symptoms and signs of mental distress. Responsibility Responsibility for mental health services, including promotion and prevention programs, is not just the remit of all levels of government. There is a need for the private sector, non-government agencies, not-for-profit and charitable organizations, local communities, rural and remote families, and individuals to take some level of responsibility. Primary Health Networks (PHNs) are increasingly a key link in coordination of service provision in Australia and take a regional approach to the planning, commissioning, and delivery of mental health services – core to mental health change. However, in the context of the delivery of local services, mental health and suicide prevention services and programs must remain part of mainstream services but in such a way that the identity and accountability of mental health outcomes remain independent (National Mental Health Commission 2014). The National Mental Health Commission (NMHC) envisaged that regional entities would work in partnership and apply targeted, value-for-money interventions across the whole continuum of mental wellbeing and ill-health to meet the needs of their communities. This would ensure the aims of a stepped care approach are met:

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• • • • • • •

Promoting mental health and wellbeing Reducing risk factors Preventing mental ill-health Reducing or delaying the onset of mental ill-health experiences Managing and supporting people in the community as much as possible Providing timely access when needed to hospital and other acute services Managing the handover from hospital back into the community, step-down care and rehabilitation, aged care, and palliative care • Reducing adverse events, waste and duplication (SANE Australia 2019) There are many initiatives now being commissioned and delivered that are addressing these aims. The systemic changes proposed by the NMHC were designed to move funding away from separate payment arrangements for primary, secondary, and post-acute services, to a focus on promotion and prevention for the population in general and those at risk in particular, and to provide Integrated Care Pathways for those in need to encourage the best and most efficient use of resources. Based on population data, the first step of the PHN Stepped Care Model (Fig. 1) covers a rural and remote population of around seven million at present in 2019, with an expected increase in population to 8.2 million in 7 years. In order to achieve the defined aims of the Stepped Care Model, much greater proportional investment and focus should be placed on the prevention of mental illhealth and the promotion of mental health. Complex needs Personal and flexible packages of comprehensive health care. High needs Personal control and choice of services, including clinical and psychosocial support.

One system that responds to the needs of the individual.

Targeted and integrated clinical and social support.

Coordination and integration with assistance to navigate the system.

Single care plan and eHealth record.

Support emphasising recovery and connection with the workplace and community.

Single electronic health record and care plan.

Support care coordinator.

Moderate needs

Low needs Universal access for self-directed low intensity therapies. Whole population Investment in: • mental capital • community and personal resilience • self help

Non-health supports • Support payments • Housing support • Education and training • Disability services

• Aged care services • Justice services • Early detection and intervention programs outside the health system

Fig. 1 The Stepped Care Model. (Source: PC Issues paper 2019 (National Mental Health Commission 2014))

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While more change and cross-sector commitment is needed, in light of the growing evidence base around the prevalence and impacts of mental illness and suicide, there is an increasing recognition by society as a whole, and at all levels of government and philanthropy, that prevention programs are needed. Government investment and resource allocation into mental health and suicide prevention initiatives have grown appreciably in the past 25 years (National Mental Health Commission, 2014); however due to this heightened awareness, there are expectations that systemic changes will be made and a redistribution and/or additional resources will follow. Further, all sectors of communities, from workplaces through to schools, are becoming more mental health literate, and collectively they are becoming the enabler of the provision of programs for end beneficiaries. For communities, industries, and organizations in rural and remote Australia who engage with mental health programs, there is, and will continue to be, a clear pay-off in terms of social and economic return on investment. Risk Factors There are many risk factors that affect mental health and wellbeing, related to work and home lives in rural and remote areas. Some are well known, but some are hidden and not declared or talked about. Just because someone is exposed to one or more of these risk factors, it does not mean that a mental health problem or mental illness will eventuate – everybody is different. It is important to recognize change in family, friends, and colleagues. Some risk factors and early warning signs include: • • • • • • • • • • • • • • • • •

A family history of mental illness Stressful or traumatic life events Death of a loved one Relationship difficulties – including separation and/or divorce A lack of self-esteem and/or personal confidence Feeling a loss of control of the present or future High risk work locations or practices Isolation – social or geographic Lack of social support Working long hours and unrealistic time pressures Financial or legal problems Substance abuse Medical conditions and/or being on certain medications Physical/sexual assault or abuse Child custody issues Humiliation and/or failure (real or perceived) Being gay, lesbian, bisexual, transgender, or other non-binary gender, in a nonsupportive environment • Bullying and intimidation • Racism and discrimination Suicidality, as a key concern for those in rural and remote communities, may present with its own warning signs as a person contemplates or further plans suicide.

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Suicide prevention and intervention courses delivered within rural and remote communities will often focus on recognizing and responding to these. Stigma In small rural communities, stoic attitudes often prevail and, when combined with a fear of stigma associated with mental illness, lead to apprehension around seeking help, as confidentiality and privacy are not assured (Hoolahan 2002; National Rural Health Alliance 2017). This makes stigma one of the greatest barriers to help seeking and, as such, is the focus of many mental health awareness campaigns. Fear and ignorance about mental illness also contribute to discrimination and may make it difficult for those with a mental illness to find work, a place to live, and acceptance – especially in small rural communities. Negative attitudes and community ignorance or misunderstanding may cause people with mental illness to feel isolated and to withdraw (Rickwood 2006). In one example, remote mine workers who reported stress related to stigmatization of mental health problems were at the greatest risk of high to very high psychological distress. Workers who reported being stressed by stigma were 20 times more likely, and those who were extremely stressed about it were 24 times more likely to have high or very levels of distress (Bowers et al. 2018). Improving community attitudes toward mental illness and encouraging help-seeking behavior are, therefore, priorities in small and more remote communities (Orygen, The National Centre of Excellence in Youth Mental Health 2018a). Evidence from some specific programs targeted at rural and “at risk” sectors of rural and remote communities indicates positive outcomes in terms of improved attitudes; early help-seeking behavior; greater confidence in talking to professionals, family, and friends; and, ultimately, reductions in stigma. These results show that educational, culturally tailored programs delivered in rural and remote communities and workplaces are successful in breaking down stigma, starting community conversations, and improving help-seeking behavior (Orygen, The National Centre of Excellence in Youth Mental Health 2018b; Everymind 2017). A localized educational, awareness-raising approach to breaking down stigma is essential in communities, workplaces, and schools. Building the capacity for locals to understand and respond to mental ill-health in the context of their own communities is key.

Presentation of Mental Health Problems in Rural and Remote Communities Most psychiatric conditions have genetic underpinnings that are increasingly understood through ongoing research; however, there are other determinants of mental health that include race and ethnicity, gender, sexual orientation, and age. The overarching social and environmental determinants are related to:

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Income Education Employment Housing Work and school conditions Interpersonal, family, and community dynamics Access to services Physical health

Ensuring that these factors are available and accessible is the objective of mental health promotion and prevention of mental disorders (Donovan et al. 2006). In rural and remote areas, these social and environmental determinants become challenging and amplified, for example: • Income and employment insecurity due to: – Economic or industry downturns – Regulatory change – Water and land use issues (coal seam gas, water access disputes) – Environmental impacts and weather events (droughts, fires, cyclones, floods) • Linguistic and cultural diversity are important: – Particularly in relation to Aboriginal and Torres Strait Islander communities across Australia – Due to the increasing growth of ethnic groups and migrants moving to rural areas • Geographic and social isolation and loneliness limiting accessibility to supports and social connections, for example: – Those who drive (DIDO) or fly (FIFO) in and out of mine or resource sites – Health workers who drive or fly to deliver services – Truck drivers and others involved in freighting of primary products – Those who are elderly • Aging populations in rural communities especially among primary producers and farmers • Limited affordable, reliable public transport • Population densities, which do not allow for service economies of scale • Impact of drugs and alcohol misuse on families and communities, in particular, Aboriginal communities • Stigma and entrenched cultures, particularly in men, preclude timely accessing of services These barriers provide context for the unmet needs and challenges of rural and remote communities and an understanding of the basis for strategies that would most effectively address them. Promotional campaigns not only raise awareness of the risk factors but the positive protective factors, which can apply in any setting, help to maintain mental

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wellbeing and resilience, and reduce the likelihood of mental health problems. These may include: • • • • • • • • • • •

Being physically healthy Easy temperament Feeling optimistic Positive connections, socially and at work Supportive, caring parents Family harmony with partner, children, parents, siblings Problem-solving skills Ability to cope with traumatic or critical events Feeling productive and worthwhile A sense of connectedness to your cultural heritage A positive attitude to seeking help

Promotional initiatives – such as the long-standing, successful “Act, Belong, Commit” and “RUOK?” campaigns – communicate positive mental health to individuals and the community generally. They raise awareness, promote mental health, break down stigma, and provide information about how to recognize a problem and support someone suffering from a mental health problem or suicidal ideation and how to seek help (Jorm 2014). Changes can be achieved through campaigns, activities, and programs designed to break down these barriers, in particular stigma, and improve outcomes, not only at the regional population level but for those who are at risk or for those experiencing mental ill-health.

Gaps in the Continuity of Care As much as there is an urgent need for adequate primary care through to tertiary clinical care for those experiencing mental illness, there is also a need for promotion and prevention initiatives as a critical means of addressing the ever-increasing demand on clinicians and service providers. Community knowledge and awareness, alongside support for informal community care models, are essential for promoting support and safety in the absence of accessible, clinical mental health services. There is, therefore, a strong case to fill gaps in the provision of funded prevention initiatives that support seamless transition and linkages to early interventions and primary care when required. Primary and secondary prevention strategies are the vital missing links and are most in need for at risk rural and remote Australians. In rural and remote areas, early interventions are often not available for all age cohorts, with a particular lack of strategies for young and older men. This is due to a lack of awareness of risk factors, knowledge of symptoms and signs, stigma, and the historic paucity of services as “Australia has focused resources largely on reducing the duration of mental disorders through provision of more treatment and has neglected reducing the incidence of disorders through prevention” (Slade et al. 2009). With many Aboriginal and Torres Strait Islander communities and peoples residing in rural and remote areas across Australia, it is important to recognize the

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often numerous barriers they face to receiving appropriate care. It is well recognized that Aboriginal and Torres Strait Islander people experience a greater likelihood of social and emotional problems and that these cause significant disability and disruption to daily function. Less than one third of Aboriginal and Torres Strait Islander people access any form of professional health service (Morley et al. 2007), particularly those in rural and remote communities (Vos et al. 2009). Rates of help seeking are low and are compounded by limited access to specialist emotional health services (Bailey et al. 2002) and marked differences in literacy (including emotional health literacy), language, and worldview (Carson et al. 2010; Westerman 2004; Rural Health Information Hub 2019). Based on these challenges, it is imperative that culturally acceptable emotional health promotion interventions and prevention programs can be delivered in their communities. It is further essential that community collaboration and co-design are elements of the programs delivered. For people working in some of the high-risk industries and workplaces in rural and remote Australia, for example, agriculture, primary production and farming, forestry, fisheries, maritime, mining, resources, defense or defense industries, healthcare, and education, these interventions and programs are essential due to their heightened risk of mental distress from working in challenging environments and also due to their contributions to the productivity and economic prosperity of Australia. Raising awareness and investing in prevention programs within these workforce sectors ensure that they will have essential information and will not “slip through the cracks” of mental health supports. This will ensure that these essential workforces can have access to mental health and wellbeing information and knowledge about how and where to access help when needed, at a much earlier stage. Despite the above challenges and barriers, rural and remote communities are well placed to grasp opportunities to implement successful mental health promotion, prevention, and early interventions due to their: • Strong relationships with family and neighbors • Robust networks within communities which are evident especially in times of adversity or trauma • Need for information and programs which are often easier to introduce into smaller, tight-knit communities • A “bush telegraph” that expedites local communication • Creativity, resilience, and community spirit

Practice Implications Practical Approaches to Prevention Programs for Rural and Remote Communities Mental health promotion and suicide prevention programs can improve social and emotional wellbeing at every stage of life. In order to achieve this, there are strategies for integrating promotion and prevention perspectives into everyday

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practice, for example, there is the need for systemic change, targeted communication, and education and training (Rural Health Information Hub 2019).

Achieving Systemic Change Systemic change is achieved by reviewing and resetting policies and practices at various levels of government as well as at community and organization levels. Despite numerous reviews and inquiries over the past couple of decades, the Australian Government commissioned the Productivity Commission in November 2018 to inquire into the social and economic benefits of improving mental health. Some of the key issues identified by the Productivity Commission (Productivity Commission 2019) about mental health included: • more than 3,100 deaths from suicide in 2017, an average of almost 9 deaths per day, and a suicide rate for Indigenous Australians that is much higher than for other Australians (Australian Bureau of Statistics 2018); • for those living with a mental illness, lower average life expectancy than the general population with significant comorbidity issues — most early deaths of psychiatric patients are due to physical health conditions; • gaps in services and supports for particular demographic groups, such as youth, elderly people in aged care facilities, Indigenous Australians, individuals from culturally diverse backgrounds, and carers of people with a mental illness; • a lack of continuity in care across services and for those with episodic conditions who may need services and supports on an irregular or non-continuous basis; • a variety of programs and supports that have been successfully trialled or undertaken for small populations but have been discontinued or proven difficult to increase scale for broader benefits; and • significant stigma and discrimination around mental ill-health, particularly compared with physical illness. (Productivity Commission 2019)

Although not specifically identified in these key issues, references to suicide rates, particularly for Aboriginal and Torres Strait Islander peoples, comorbidity, gaps in services, lack of continuity of care, successful programs for small populations, and, lastly, but importantly, stigma and discrimination are all highly relevant in the context of promoting mental health and preventing mental illness and suicides for rural and remote Australians. The ultimate systemic reforms and changes resulting from this major inquiry will inevitably impact on prevention and promotion programs and interventions.

Targeted Communications Television, radio, the Internet and websites, digital apps, social media, local or national newspapers and other print media, brochures or flyers, direct mail campaigns, and promotional events can all be used as communication tools to inform and empower individuals and communities. They can be used to promote positive messages and potentially change attitudes to mental ill-health by breaking down stigma and improving help-seeking behavior by encouraging people to talk about their mental health problems or suicidal thoughts (R U OK? n.d.).

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There are, however, limitations to the impact of public campaigns as found by Munro et al. (2017) when they measured the impact of a community-led advertising campaign in a remote Aboriginal community. They found the campaign increased awareness of the harm of substance abuse but had limited impact on formal helpseeking. For awareness initiatives and those that promote changes in attitudes and behaviors to be effective, targeted communications to improve mental health literacy in rural and remote areas should be focused on explaining which interventions are effective for particular mental illnesses and which professionals are trained to effectively manage them (Griffiths et al. 2009). In a more general sense, promoting discussions around mental health and help seeking can be a positive medium for generating community connectivity as a basic protective factor. While many public campaigns do focus on high-level awareness, more evaluations are needed to determine real, long-term impacts, as they are not always evident.

Education and Training Mental health education and training programs should raise awareness, improve knowledge regarding the signs of mental ill-health and suicide, facilitate access to information or support, and develop skills in responding to mental ill-health and suicidality. Due to the sensitivity of the topics and the need for engagement of participants, programs must be designed and delivered in such a way that they relate to the culture and language of the community or the workplace, as well as take account of the barriers outlined above. For example, Arnautovska et al. (2015), in their study relating to suicide among farmers in different roles, highlighted the need for tailored suicide prevention initiatives that include risk and protective factors. Face-to-face programs in rural and remote communities not only provide education and training but also the opportunity for the development of informal support and care networks, when access to clinical services may be limited. They further empower individuals to influence change and build their knowledge and skills. Faceto-face programs can also encourage “yarning” about sensitive topics that individuals (men in particular) would not normally engage in. Education and training programs in rural and remote areas can be targeted at various community or workplace cohorts: • Local community members • Health workers and professionals • Service providers, council workers, and other professionals, managers, and other workers • Lay people, community leaders or elders, peer workers • Schools and universities, including both students and teachers Depending on knowledge and education of the intended participants, the program selected may vary. Some programs contain clinical content and a high level of detail which would be most appropriate for health workers, practice nurses, frontline staff,

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and occupational health and safety managers among others. Alternatively, some programs have been designed to provide essential information in a brief format for all community members. Community leaders, elders, peer workers, teachers, and local mental health champions or advocates could be trained to deliver such programs locally. Some communities respond well to programs being delivered by respected local leaders and others request independent, professional trainers, and presenters. In addition, when facilitated by local leaders from their community, it can be a cost-effective means of reaching people, especially those who are isolated. All communities are different and have different expectations, so the design and delivery of programs must be flexible. Some cultural groups or minorities may require sensitive and culturally tailored approaches to programs due to stigma, discrimination, or racism, such as: • Aboriginal and Torres Strait Islanders • Culturally and linguistically diverse groups, in particular migrant groups who are settling in rural communities • Lesbian, gay, bisexual, transgender, questioning, and “plus,” representing other sexual identities (LGBTIQ+) • Workplaces or industry-based groups, e.g., small businesses, stock and station agents, fishers, farmers, primary producers, miners, and resource or quarry sector workers Some essentials to be considered when developing or selecting a program include: • Culturally relevant content – tailored and specific in terms of language, imagery, topics, e.g., inclusion of different risk factors and topics such as stress related to succession in relation to farmers. • Comprehensive – inclusive of information about breaking down stigma, how to start a conversation, risk factors, mental ill-health signs and symptoms, signs of suicide, local and other sources of help, and connecting with support and care. • Integrated – complementary of community/workplace/school programs and services (including, in the case of workplace, their occupational health and safety programs) and connecting with practical pathways. • Committed – delivered over the long term, as stigma and entrenched cultures take time and persistence to be broken down. • Proactive – not a reactive approach, for example, following traumatic events, a whole of community approach is required, and this needs a sensitive approach and could include some education and training. • Engaging – information is relevant and presented in an engaging manner that appeals to the specific audience, allows for different personalities, addresses participants’ needs, and harnesses their potential. • Practical – presentations and delivery that naturally must: – Allow for conversation and participation, enable yarning, and not too formal – Build a safe environment and trust among participants to share experiences

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– Enable the creation of a local network for ongoing support – Be cathartic, uplifting, positive Provides choices – offering different pathways to access services and support – locally and online. Embedded – particularly into rural and remote communities/workplaces by being delivered face-to-face by, or with, locals who know the unique culture and issues, as well as services and supports. Convenient – programs delivered at convenient locations and times that overcome access and attendance barriers. Inviting – consider mediums and venues that may attract certain participants, e.g., there is no chance of farmers attending at harvest, and limited chance during the day, so evenings and a more casual approach, e.g., a BBQ, are more likely to attract people to attend. Flexibility – where possible, flexible adaptations or tailoring to meet audience needs or changing environment is preferable. For example, alternative arrangements may need to be made due to weather events or in Aboriginal and Torres Strait Islander communities due to Sorry Business.

It is important that the unique issues and systemic challenges facing rural and remote Australians be recognized now and plans for the future made to accommodate the anticipated regional population expansion. It is equally important to get the balance right between preventative and promotional strategies, early interventions, and clinical services. The current health system is increasingly faced with more chronic illness and comorbidities in those who live with mental illness, and rates of anxiety and depression in rural and remote communities are increasing. In order to inform these plans, clinicians, professionals, consumers, carers, nonclinical and peer workers, community leaders, and local government and government agencies (e.g., PHNs and state public mental health services) who understand the demographics, cultures, and challenges in their communities must have the knowledge to advocate for and implement promotional activities and prevention programs.

Implementation of Programs When rural and remote practitioners decide to implement promotion or prevention programs, consideration should be given to the continuum of care ranging from mental health promotion to availability of treatment and recovery programs. When combined, the complex factors outlined above and the implementation and evaluation strategies discussed below can be time-consuming and challenging, especially when there are limited human or financial resources. It is, therefore, necessary to consider collaboration and partnerships; how best to reach target audiences in communities or the workplace; and how to ensure sustainability of programs and measuring their impact or changing them if necessary, at an early stage of the program implementation.

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Collaboration and Partnerships Rural and remote communities have traditionally been renown for strong networks and the ability to galvanize an entire town around locally identified events or initiatives. Collaboration and partnerships with key individual champions, community leaders, elders, and local organizations can assist with: • Access to specific social and industry cultures, expertise, and knowledge, for example, like-minded farmers be they dairy, sheep, or crop; open-cut or underground miners; fishers from the net or trawl sector • Access to specific cultural or minority groups where ethnicity, language, beliefs, and different social norms need to be considered • Improving and strengthening networking and bonds within the broader community • Increasing sponsorship, commitment, and resourcing of the program • Enabling localized pathways to support and care • Building trust and engagement among key stakeholders There is also an increasing emphasis on and need for consumer co-design and ensuring engagement of people with a lived experience with mental ill-health and/or suicide, in the development and delivery of programs. Given the complexity of mental illness and suicide, there is the need for crosssector collaboration and partnerships. This occurs between different organizations and service providers and may include funding partnerships, program sponsorships, collaborative delivery, consortium programs, and cross-referrals. In service delivery within rural and remote communities, it is of particular importance to also connect the pathways between clinical support, community-based programs, and informal community care.

Reaching the Target Audience in a Community Communication in rural and remote communities has traditionally been through the local newspapers, radio and word-of-mouth, and in many cases, these mediums are still used. Other forms of communication now being used to disseminate information and advertise programs are numerous and include various forms of digital and social media. Hefler et al. (2019) recently investigated the use of social media, particularly among Aboriginal and Torres Strait Islander people, and suggested that there may be greater traction for health-related issues including mental health promotion via social media than for traditional media campaigns. Further, consulting and building relationships with the local community about the relevance, type of program, and delivery mode are essential. If these communication considerations are not taken into account, there could be significant challenges associated with engagement and commitment to the program or initiative. Many of these challenges can be overcome by engaging with community leaders and elders to ensure the cultural relevance of the program, the way it is delivered, and the best way to communicate and promote the program – this will, in turn, encourage participation.

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Train-the-trainer or presenter programs – Local leaders and elders, service providers, and passionate champions can be trained to not only promote the programs but deliver them. This train-the-trainer/presenter model not only ensures ongoing buy-in and the sustainability of the program but also the embedding of the essential information within the community through the participants. As there always seems to be finite resources and a limited number of local leaders who often end up doing the “heavy lifting” in their local community, the train-the-trainer form of program delivery is all too often used. Nevertheless, their involvement and credibility ensure the program is respected and the information valued.

Program Sustainability The sustainability of prevention programs can depend on the perceived value of the program, derived from the evaluation results and positive outcomes, and the communication of them to participants and the community at large. Sustainability for promotion and prevention programs is a major challenge due to the unpredictable and competitive nature of funding availability. More recently, and to a significant degree, funding is also dependent on the strength of the evidence base. It will be due to the support derived from participants, partner organizations, and the community that commitment to the ongoing delivery of the program, in its existing or modified form, will be made. It will be through support and recognition of improved awareness, attitudes, early help-seeking behavior, and destigmatization in the community or workplace that community engagement will be sustained. Evidence on tangible impacts gained from evaluations will support ongoing or new funding to continue the programs. In workplaces, ROIs do not accrue from one-off, generic interventions with no recognition of culture or risk factors. Companies are looking for sustainable and evidence-based programs that can be confidently integrated with existing safety and health programs for the long term. Evaluation and the Importance of an Evidence Base Evaluation is more than just the collection of information and data; it involves making a judgment about the “worth, merit or value” of a program or practice (Scriven 2003). Therefore, it is about quality assurance and whether the program is effective. There are several other reasons to evaluate a program or practice and clarifying these can contribute to the scoping and management of an evaluation. Evaluation can: • • • •

“support applications for new or continued funding; secure support from stakeholders and the community; improve staff performance and management; and contribute to the broader evidence-base about what does and what does not work for clients and providers with regard to specific issues and experiences” (Parker & Lamont, 2010).

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There is much written about evaluation in the context of health and mental health promotion and prevention programs and the different types of evaluations, whether they be based on process, impact, or outcomes. There are various evaluation designs such as pre- and post-testing, comparison or control groups, and common measures and indicators such as quantitative and qualitative (Bauman and Nutbeam 2013). There is, however, little information to be found about evaluation and the challenges associated with the design and implementation in rural and remote areas. The overall aim of evaluating promotion or prevention programs is to determine if they produce a change and how effective they have been. It is not only important to evaluate whether programs have been effective but also what factors influence the effectiveness (or not) of the program in different settings. A mixed methods approach, using quantitative and qualitative methods, helps to explain whether and how particular outcomes were achieved. Service providers or organizations delivering the program must define the objectives of the program and, in collaboration with the researcher or evaluator who should be engaged as early as possible (preferably in the developmental stages of the program), determine the measures and outcomes. Program content and materials; the target population; form of delivery and process; expected outputs, outcomes, or impacts; and timelines need to be taken into account. The evaluation content, length, layout, language, target sample size, and how it is administered – for example, either by paper or online – all need to be carefully considered. Questions and validated instruments embedded into the evaluation should be easily understood, culturally sensitive, and well-defined. In the context of rural and remote areas, all these considerations are important due to local attitudes, beliefs, and culture, education levels, Internet access and technical capacity, and more. Further, the evaluators/researchers require an in-depth knowledge or lived experience of rural and remote communities. There is much more to achieving reliable, rigorous, and valuable outcomes from evaluations, and this detail is readily available. However, achieving this is not always easy. Some examples of challenges, particularly in rural and remote areas, include: • Securing sufficient human and financial resources to undertake an independent evaluation from a reputable university or institute, e.g., government or philanthropic program grants do not always provide substantial funds for evaluation. • The competitive nature of National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC) grants for this type of research. • Securing ethics approval for mental health and suicide prevention research can take time, in some cases up to 1 year – noting that ethics approval is required for peer-reviewed publications. • Finding an experienced specialist researcher/evaluator who has the time and capacity – noting, it may sometimes be necessary for researchers to have cultural or sector experience or knowledge. • Validated instruments to measure various factors are generally long, may not be designed in a culturally sensitive way, and do not allow for various literacy levels of those in rural or remote areas – noting that length is an issue in the workplace

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because time is money and program participants are not always engaged in the process, especially at the pre-test stage. • The traditional evaluation designs and ethical requirements do not always lend themselves to: – Tracking or following up participants over time, e.g., at the post-test stage – Workplace procedures and protocols or access to a remote workforce Future research and evaluation in relation to the impact of, and change in, attitudes and behavior resulting from promotion and prevention programs need to be long term and transcend election cycles and traditional short-term funding and impact expectations. Attitudes, behaviors, and culture take years to transform, as evidenced by the long-term nature and impact of the “quit smoking” and “slip, slop, slap” campaigns. Traditional time-limited funding for program research and evaluation ensures that they are often unsustainable and, therefore, leads to their demise. To ensure there is translational value, evaluations must take into account the cultural context and ensure skills and capacity are integrated within the community or industry. Despite the complexity and challenges associated with undertaking an ethically approved, independent evaluation, the results generally reward the effort involved, are valuable, and demonstrate the changes achieved. The results of evaluations allow for the tweaking and modifying a program, promoting the value of it more broadly, and, importantly, proving the value and ROI to funding bodies and/or, in the case of the workplace, companies who wish to purchase the program. Case Study 1 provides an example of outcomes achieved from pre- and posttests of programs delivered in rural and remote Australian communities and workplaces. Case Study 1: Rural and Remote Mental Health Ltd (RRMH) Rural Minds Pre- and Post-Evaluation in Rural and Remote Australia

(continued)

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Case Study 1: Rural and Remote Mental Health Ltd (RRMH) Rural Minds (continued)

The Rural Minds program adopts a holistic, integrated approach to mental health awareness and suicide prevention. It is specifically tailored to connect and empower rural and remote communities to have “life-saving” conversations about mental health and suicide. The program builds knowledge, understanding, and confidence in participants about the prevention of mental illness and suicide, while providing practical advice and information around seeking help early and local services for mental health problems. The independent, ethically approved evaluation findings (n ¼ 697 with over 70% response rate) from Rural Minds (Orygen, The National Centre of Excellence in Youth Mental Health 2018b) provide a valuable insight into the lives and mental health of many people living in rural Australia. They include: Pre-workshop • Approximately one in seven (14%) reported having attempted suicide at some point in their lives with 11% being considered at a moderate-high risk of suicide at the time of the evaluation. • Alcohol consumption was 1.5 times higher than national rates for exceeding single occasion consumption guidelines. • Participants were 13 times more likely to have used amphetamines in the past 3 months than the population average. • More than half of participants reported previously seeking help from a mental health professional, with females more likely to have sought help than males (58% vs. 48%). • Finance and relationships with partners and/or children were the biggest causes of stress. • Males were much less likely to attend programs and get the required support through established channels. Post-workshop • The majority of community respondents agreed that they felt they were more comfortable talking about mental health issues (82%) and that they could use the information they had learned to benefit themselves and others (93%); • Likelihood of help seeking from a variety of sources for mental health issues increased significantly for participants. • 87% of participants of the program were confident they knew about the early warning signs of mental distress, and 85% were confident (continued)

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• • • • • • •

they would know how to support others experiencing a mental health crisis. Participants reported perceiving fewer barriers to help than their view prior to the session. The majority of participants following the presenter’s workshop reported good to high “confidence in their ability to deliver Rural Minds workshop” (81%). Participants reported high confidence on statements, e.g.: “I feel confident to communicate with others about mental health problems.” “I am confident that I would know what to do in a mental health emergency.” “I know about mental health issues.” “I know about treatment services.”

The results of this evaluation highlight the acceptability of the Rural Minds program in rural and remote farming and agricultural communities across Australia. The relevance of the information and resources provided was highly valued by participants and demonstrated the success of the Rural Minds program in this cohort.

Modifying or Adapting Programs Following consideration of evaluation results, changes to elements of the program may be considered for various reasons. These changes may be necessary due to the length of the program, cultural specificity or language in questions, or age-related content. Review of, and changes to, the program can provide an opportunity to value-add to it by, for example, designing new collateral such as posters for the workplace; promotional or informative flyers to take-away; and new or additional audio-visual aids and videos. It may also factor in adaptation of the program for another particular at-risk group in the community or population – taking lessons learned and applying them to reach new audiences. Case study 2 demonstrates applied program adaptation in relation to a program with specific cultural significance for Aboriginal and Torres Strait Islander participants living in rural and remote Australia. It highlights how a program successful for a particular audience cohort can be strategically changed to suit a new audience cohort, on the basis of evaluation and consultation.

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Case Study 2: Adapting Successful Programs – Adapting Deadly Thinking Youth from Deadly Thinking for Adults

Deadly Thinking helps Aboriginal and Torres Strait Islander people: • feel strong in mind, body and spirit; • yarn about what makes them feel unsafe and how to overcome bad thoughts; • know when and how to get help; and • talk about how to have a strong mind with no stress worries. Deadly Thinking recognizes and respects the unique needs of Aboriginal and Torres Strait Islander people. The program has been developed by and for Aboriginal and Torres Strait Islander people and is facilitated by RRMHtrained Aboriginal and Torres Strait Islanderpresenters who are elders or who have backgrounds in mental health and/or education. It is very much in keeping with the recommendations of the recent comprehensive, national Aboriginal, and Torres Strait Islander Suicide Prevention Evaluation Project. About Deadly Thinking Youth (DTY) The DTY program is adapted from the adult program, based on feedback from Aboriginal and Torres Strait Islander people, facilitators and youth involved in Deadly Thinking groups run with younger participants. DTY aims to help young Aboriginal and Torres Strait Islander people in rural and remote communities to: • Learn the importance of yarning with family and friends • Be more aware and understanding about what causes depression, anxiety and, suicide (continued)

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Case Study 2: Adapting Successful Programs – Adapting Deadly Thinking Youth (continued)

• Understand how life changes can contribute to stress • Understand their own worries and how to deal with them – topics covered include cyber-safety, bullying, and body image • Develop plans to help deal with challenges to their social and emotional well-being • Connect to culture and country as a source of strength The DTY program has been designed for flexible, group-based delivery, either as a single 1-day workshop, 2–3 half-day workshops, or as individual units over a number of days or weeks. Designed primarily for Aboriginal and Torres Strait Islander young people aged 12–20 years and can be run separately for younger (12–15) and older (16–20) age-groups. As with the adult program, DTY involves a train-the-trainer model, including: • A 2-day training for potential DTY facilitators • Trained DTY facilitators running the 12-unit DTY program in an open, comfortable, and culturally-appropriate forum • Various hard copy and online resources for DTY program participants, including videos and workbooks DTY facilitators are experienced in working with and supporting vulnerable youth and, therefore, well-equipped to identify any participants experiencing distress, provide any necessary immediate assistance, and encourage them to contact the various support services promoted as part of the DTY program which are included in the DTY Workbook that participants keep. DTY has received ethics approval from Australian Institute for Aboriginal and Torres Strait Islander Studies (AIATSIS) and is being evaluated by the Sax Institute.

Investing in and Scaling Evidence-Based Programs Mental illness and suicidality in Australia are significant health, social, and economic concerns. The efforts to respond to these issues with timely, effective, and appropriate services and supports requires a multi-agency, collaborative approach that recognizes investment into complementary programs and services. However, duplication, competition for scarce funding and resources, and ill-fitting programs that lack an evidence base or proven results can threaten to undermine the work of other agencies and organizations. Due to the cost incurred by service providers who undertake research and evaluation of their programs and due to their greater likelihood of impact, it is important to allocate resources to programs that have strong impact metrics and

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proven efficacy. It should be expected that funders recognize evaluated programs with demonstrated success as “preferred providers” over those that are unable to provide evidence of impact. The exception is, of course, in the piloting of new, innovative programs – particularly those that aim to support priority or hard to reach cohorts and emerging needs – but these should not be funded at the exclusion of programs that will “actually work” in communities and should be delivered by capable providers. There are challenges and barriers to securing sufficient resources to demonstrate the success of any intervention or initiative, and this, therefore, precludes significant numbers of small, local providers with limited funding from being able to independently evaluate programs. In order to rectify this, these providers should either be supported with additional evaluation funding and/or encouraged to collaborate with experienced organizations and/or research organizations to measure program outcomes (and not just outputs). For service providers who have made a commitment and investment, under a reformed mental health system, it would be beneficial if priority for funding was given to organizations to scale and disseminate successful, evidence-based programs more broadly.

The Importance of Workplace Programs Mental illness is now the leading cause of incapacitation and extended sick leave in Australian workplaces. Untreated mental health conditions cost Australian workplaces an estimated $11 billion per year in absenteeism, presenteeism, and compensation alone (PriceWaterhouse Coopers 2014). These issues are significant given that 67% of the value of Australia’s exports comes from rural and remote areas (National Rural Health Alliance 2015). Business leaders play a critical role in driving policies and practices that promote mental health. They are able to positively influence workplace culture, management practices, and the experience of employees by the way they lead, communicate, and live the values espoused by the workplace. Most importantly, they are in a position to show commitment and leadership and make the time and resources available to deliver prevention programs and benefit from their investment in them. In workplaces operating in rural and remote settings, they are a vital gateway for connecting effective programs with the people who need them. Although there is limited research, analysis shows that there is variance in return on investment (ROI) in prevention programs across industries. The average ROI across all industries for investing in a mental health initiative in the workplace is 2.3. However, there are potentially higher return on investment (of up to 15) in industries such as small to large mining organizations, which generally have significant workforces in rural or remote areas (PriceWaterhouse Coopers 2014). Recent research by Street et al. (2019) confirm that in order to achieve a high ROI in this sector, health promotion needs to be strategically targeted in order to engage stressed employees with reduced productivity and a low desire to seek help. As other studies in the UK and European Union have demonstrated, there is great potential, and there can be positive return on investment in mental health prevention programs

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for the funder (Knapp et al. 2011). Studies such as these, and the experiences of mental health program providers who operate within the prominent industries in rural and remote Australia, provide insights into how to engage staff but also how to sell the importance of prevention and promotion programs to industry decisionmakers. As well as the significant financial benefits flowing from an increase in productivity and profitability and a decrease in absenteeism, presenteeism, and compensation payments, there are many tangible and intangible benefits a company accrues from investing in workplace mental health: • • • • • • •

Improved risk identification, mitigation, and management Better integrated work health and safety (WHS) policies and procedures Improved status as a preferred employer Improved morale, motivation, and job satisfaction Improved interpersonal relationships and less conflict Less turnover/improved retention of skilled staff Reduced incidents and accidents

A key consideration in working with often male-dominated and environmentally challenging industries, with a diverse workforce in rural and remote Australia, is that of workplace barriers to receiving care and assistance in a timely manner. Depending on the work site and its location, some workplace barriers include: • • • • • • • •

Stigma, real or perceived Trusting and confident relationships with service providers Fear of losing a job Lack of access to primary care or other specialists Isolation or distance to travel to avoid identification Costs of services, travel, or transport Lack of culturally or linguistically appropriate services Lack of sick leave or, in the case of farmers, an unwillingness to admit a problem or seek help

Prevention programs designed for specific workplaces such as farms and mine sites ensure that crucial issues are addressed, such as stigma and risk factors; information about symptoms and signs of mental distress; signs of suicide; and where and how to access more information and help – before an illness or traumatic incident occurs. Many workplaces have Employee Assistance Programs (EAPs) which help with the resolution of problems that affect a worker’s performance (and these problems do not have to be caused by the workplace). These programs are confidential and are designed to help workers and, if necessary, their family understand or overcome their personal problems. Case Study 3 provides a real-life example of a workplace program delivered in rural and remote locations within the mining and construction industries. It

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demonstrates a suite of tools and activities that can be delivered and highlights key findings from the program. Case Study 3: RRMH Resource Minds – Flexible Program Design and Delivery, Culturally Tailored for Different Workplaces

Resource Minds is a flexible, innovative, evidence-based mental health and suicide prevention program that creates sustainable and positive changes in workplace culture, behaviors, and attitudes towards mental health. Resource Minds consists of: • Mental Health for Leaders – training for managers, supervisors, WHS, and human resource staff • Suite of 13 Toolbox Talk presentations including videos • Toolbox Talk Presenter’s Training and Presenter’s Guide • A Passport to Mental Health in Mining and Resources booklet for every employee • Site visits by RRMH staff to deliver training and presentations • Onboarding handbook for new employees • Posters and flyers promoting key mental health messages • Dedicated RRMH Program Manager providing on-going support to the management team, WHS staff, and presenters • Survey and evaluation of the Program’s outcomes Results from research associated with the development of RRMH Resource Minds (Bowers et al. 2018) – a cross-sectional, anonymous Wellbeing and Lifestyle Survey was administered at ten mining sites in South Australia and Western Australia to 1,754 respondents, providing a final sample of 1,124 employees at remote construction, and open cut and underground mining sites. • 28% of fly-in, fly-out (FIFO) workers in remote mining and construction sites rated their psychological stress as high or very high, compared with just 10.8% of the general population. (continued)

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Case Study 3: RRMH Resource Minds (continued)

• Significant and most frequently reported stressors were missing special events (86%), relationship problems with partners (68%), financial stress (62%), shift rosters (62%), and social isolation (60%). • High psychological distress was significantly more likely in workers aged 25–34 years and workers on a 2-weeks-on/1-week-off roster. • Workers who were very or extremely stressed by their assigned tasks or job, their current relationship, or their financial situation were significantly more likely to have high/very high stress scores than those not stressed by these factors. • Workers who reported stress related to stigmatisation of mental health problems were at the greatest risk of high/very high psychological distress. Most importantly, the strongest predictor of psychological distress overall was fear of stigmatisation for mental health problems. Given that 40% of respondents rated stigma a source of stress, this finding is alarming and highlights the importance of early interventions and suicide prevention.

The Role of the Healthcare and Support Workforce In Australia, the mental health workforce is generally made up of general practitioners, psychiatrists, psychologists, social workers, nurses and mental health nurses, occupational therapists, and peer workers (Australian Institute of Health and Welfare [AIHW] 2018). Other professionals are playing active roles in the treatment and recovery of those with a mental illness including, for example, dieticians, physiotherapists, and speech therapists. Mental health non-government organizations also play an important role in Australia’s mental health system. However, national data about the activities of these mental health organizations and their workforce are not currently collected on a routine basis in Australia (Australian Institute of Health and Welfare [AIHW] 2018). Access to appropriate and timely, formal mental healthcare in rural and remote areas depends largely on the availability and capacity of the local mental health workforce. To date, detailed data on the size and characteristics of the mental health workforce are limited to psychiatrists, nurses, and registered psychologists who worked principally in mental healthcare. There continues to be a significant decline with remoteness of mental health professionals (Australian Institute of Health and Welfare [AIHW] 2018). However, despite recent efforts to rectify this imbalance by governments and professional organizations, to recruit and train clinicians, there will always be challenges in retaining them, especially in remote areas. Although the majority of people receiving Medicare (the publicly funded universal healthcare system in Australia) reside in major cities, the number of people receiving services declines as remoteness increases. There is a gradual positive effect emerging as the number of Australians receiving Medicare-subsidized mental health-specific services, who live in Very remote and remote areas, have increased

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by 9.9% and 9.7% per year, respectively, over the 9 years to 2016–2017 (Australian Institute of Health and Welfare [AIHW] 2018). However, it should be noted that the reporting of levels of service by medical practitioners and other health professionals can vary and depends on whether it is based on Medicare data or Australian Institute of Health and Welfare (AIHW) surveys. The location and time spent delivering a service can vary significantly (e.g., full-time versus short-term duration in a remote location) the broader scope of practice required and the need for GPs to be “on-call” in remote areas. These factors must be adjusted for, and it is proposed that if they were, the resulting statistics would show greater disparity and less access to services in rural and remote areas (National Rural Health Alliance 2015). Challenges for professionals in rural and remote communities can include difficulties relating to local cultures, lack of trust of professionals or newcomers, and spiritual beliefs and cultures about social and emotional wellbeing services. For these reasons, as found in a study of characteristics of farm-related suicides in New Zealand, there can be resistance to seeking care and lack of contact with professional services with tragic consequences for young male workers (Beautrais 2018). Hence, the need for a variety of community organizations and service providers to be trained to be aware of the signs of mental distress and suicide, in addition to the clinical care workforce. Prevention programs need to be tailored to proactively connect and empower rural and remote communities to have “life-saving” conversations about mental health and suicide. General practices and mental health services, however, due to the shortages in rural and remote areas, are often providing reactive care. There needs to be a better approach to balance and integrate support and care between the reactive services of clinicians and the proactive, community-based approach. General practices and mental health services must be engaged and collaborate with local community groups in order to be alerted to problems arising and provide early interventions (Thomas et al. 2016). The Senate Committee Report on the accessibility and quality of mental health services in rural and remote Australia (The Senate, Community Affairs References Committee 2018) provided substantial and relevant evidence of the need for initiatives that address the significant service gaps for people requiring early interventions and those with psychosocial disability who do not have access to services. This paucity of capacity is due not only to the lack of availability of appropriately trained people but the logistics and significant financial costs associated with workers fulfilling their role in remote locations. These deficits in workforce capacity are projected to be exacerbated by the need for 80,000 health and social assistance workers (and over 28,000 education workers) in the next 5 years in regional Australia. It is anticipated that these new jobs will be filled from a mix of relocated Australians, new migrants, and the re-entry of workers into the expanding sectors. The capacity of the regions to accommodate the workers will be challenged in terms of amenities and services (Houghton 2019).There will also be the need for training, re-skilling, and professional supervision of this workforce. Online and video educational and professional resources are rapidly expanding and will be essential in order to support the needs of this workforce.

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They provide a cost-effective means to maintain contact with, and support for, the most very remote communities. The development and training of a non-clinical or peer workforce, and the investment into prevention programs, would not only reduce the burden on primary care providers but also services such as emergency services. By enabling local people to play an active role in the mental wellbeing and suicide prevention support model, there is an emphasis on community capacity building that will incrementally and, more sustainably, improve mental health and wellbeing networks within rural and remote communities. It is well recognized that unless community or workplace leaders, champions, and elders demonstrate belief in, and support for, programs that are designed to change attitudes and behaviors, such as mental health and suicide prevention programs, the implementation and success of them may be diminished.

Concluding Comments and Recommendations Everyone living and working in rural or remote Australia will, at some time in their lives, be directly or indirectly impacted by the consequences of mental distress or illness or the ripple effects associated with suicide due to the nature of close-knit communities. Men, especially those who are young, those who are elderly, and Aboriginal and Torres Strait Islander men, are most at risk. The impact on these cohorts is disproportionately high when compared with those in cities. In addition to these high-risk groups, there are many industries with prominence in rural and remote Australia, with workers who are more susceptible to mental ill-health and suicidality. Despite the inherent challenges, rural and remote communities possess many positive defining characteristics which will assist them in building their capacity to respond to these concerns. Everyone living and working in rural and remote Australia, regardless of age, gender, or ethnicity, needs to have a basic understanding of the risks, symptoms of mental illness, signs of suicide, how to look after themselves, their friends, and families, and where to go for help. It is for these reasons mental illness and suicide prevention programs and mental health promotion initiatives are so important in rural and remote areas. The evidence tells us that culturally tailored, locally delivered programs break down stigma and give people the confidence to talk about these issues and to seek help early. Policy makers, funders, service providers, communities, and individuals all have a role to play in supporting successful programs that drive positive change in rural and remote Australia, for better mental health outcomes.

Take-Home Messages • Rural, regional, and remote communities need mental health prevention and promotion programs tailored to their specific challenges, profiles, and capacity and to build on their strengths.

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• There are several strategies for implementing successful mental health prevention and promotion programs in rural and remote communities including: influencing systemic change; conducting targeted communication; and delivering education and training programs. • Program design, delivery, content, and communication must be tailored to be locally relevant, culturally sensitive and engaging in order to impact positively on attitudes and behaviors – particularly in rural and remote communities, industries, or workplaces, where stigma remains a major barrier. • Creating integrated pathways for care and building local capacity is essential to successful mental health prevention. This includes linking clinical services, local service providers, communities, workplaces, and individuals, among other key audiences. • Evidence for program success is achieved through appropriate, independent evaluation, and this is a key to determining real program outputs, outcomes, and impacts. Evaluation can further inform program adaptations and increased scale to reach new audiences. It can also build a case for program funding.

Recommendations To address the unique challenges of rural and remote communities in terms of mental ill-health and suicidality and to ensure the effective and measurable impact of promotion and prevention programs, the following recommendations are made: • A greater commitment to prevention programs that engage with rural and remote Australians. The prevention programs will be culturally sensitive to mitigate developing a mental illness, support those experiencing stigma and/or suicidal ideation, connect those at risk with suitable support services, provide a focus on several priority cohorts like people in rural, and remote specific workforces (e.g., farming, mining and primary industry, fishing, forestry, defense), Aboriginal and Torres Strait Islander peoples, older Australians, and young people, with a focus on men in every cohort. • The rural and remote professional health workforce be complemented by the recruitment and training of locally based, non-clinical community care coordinators recruited from leaders, champions, elders, and peers to improve local engagement, support for prevention programs and promotion activities, and address health workforce shortages and availability of psychosocial supports in rural and remote areas. • Implement a better approach to balancing and integrating support and care between the reactive services of clinicians and the proactive, community-based approach of local organizations and service providers. • Prioritize funding to service providers who have made a commitment and investment in independent evaluations of promotion and prevention programs. This will enable increased scale of delivery and dissemination of successfully implemented, evidence-based programs across communities.

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References Arnautovska U, McPhedran S, De Leo D. A regional approach to understanding farmer suicide rates in Queensland. Soc Psychiatry Psychiatr Epidemiol. 2013;49(4). Arnautovska U, McPhedran S, De Leo D. Differences in characteristics between suicide cases of farm managers compared to those of farm labourers in Queensland. Australia. Rural Remote Health. 2015;15(3):3250. Australian Bureau of Statistics [ABS]. National Aboriginal and Torres Strait Islander Social Survey 2014–15 [Internet]. Canberra: ABS; 2017. Cat. no. 4714.0. http://www.abs.gov.au/ausstats/ [email protected]/mf/4714.0 Australian Bureau of Statistics [ABS]. Regional Population Growth, Australia, 2007–2017 [Internet]. Canberra: ABS; 2018. Cat. No. 3218.0. http://www.abs.gov.au/AUSSTATS/[email protected]/mf/ 3218.0 Australian Institute of Health and Welfare [AIHW]. Rural, regional and remote health: indicators of health status and determinants of health [Internet]. Rural Health Series. Canberra: AIHW; 2008. No. 9, Cat. No. PHE 97. https://www.aihw.gov.au/getmedia/354a7e07-bf35-4e54-a7e6fc6659789b0f/rrrh-ihsdh.pdf.aspx?inline¼true Australian Institute of Health and Welfare [AIHW]. A snapshot of men’s health in regional and remote Australia [Internet]. Rural health Series. Canberra: AIHW; 2010. No. 11. Cat. no. PHE 120. https://www.aihw.gov.au/getmedia/c6068d06-1f98-4a97-b7b6-c069cbfffe76/10742.pdf. aspx?inline¼true Australian Institute of Health and Welfare [AIHW]. Mental health services – in brief 2018 [Internet]. Canberra: AIHW; 2018. Cat. no. HSE 211. Bailey R, Siciliano F, Dane G, Bevan L Paradies Y, Carson B. Atlas of health-related infrastructure in discrete Aboriginal communities [Internet]. Melbourne: The Aboriginal and Torres Strait Islander Commission (ATSIC); 2002. http://dro.deakin.edu.au/view/DU:30058669 Bauman A, Nutbeam D. Evaluation in a nutshell a practical guide to the evaluation of health promotion programs. McGraw-Hill Book Company Australia: Australia; 2013. Beautrais AL. Farm suicides in New Zealand, 2007-2015: a review of coroners’ records. Aust N Z J Psychiatry. 2018;52(1):78–86. Bishop L, Ransom A, Laverty M, Gale L. Mental health in remote and rural communities [Internet]. Canberra: Royal Flying Doctor Service of Australia [RFDS]; 2017. https://www.flyingdoctor. org.au/assets/documents/RN031_Mental_Health_D5.pdf Bowers J, Lo J, Miller P, Mawren D, Jones B. Psychological distress in remote mining and construction workers in Australia. Med J Aust. 2018;208(9):391–7. Carson N, Le Cook B, Alegria M. Social determinants of mental health treatment among Haitian, African American, and White youth in community health centers. J Health Care Poor Underserved. 2010;21(2):32–48. Donovan RJ, James R, Jalleh G, Sidebottom C. Implementing mental health promotion: the act– belong–commit mentally healthy WA campaign in Western Australia. Int J Ment Health Promot. 2006; 8(1):33–42. Everymind. Prevention first: a prevention and promotion framework for mental health [Internet]. Newcastle: Everymind; 2017. Version 2. http://s3-ap-southeast-2.amazonaws.com/everymind/ assets/Uploads/EM-0026-Prevention-First-Framework.pdf Griffiths KM, Christensen H, Jorm AF. Mental health literacy as a function of remoteness of residence: an Australian national study. BMC Public Health. 2009;9:92. Harrison JE, Henley G. Suicide and hospitalised self-harm in Australia: trends and analysis [Internet]. Injury Research and Statistics Series. Canberra: Australian Institute of Health and Welfare [AIHW]; 2014. No. 93, Cat. No. INJCAT 169. https://www.aihw.gov.au/getmedia/ b70c6e73-40dd-41ce-9aa4-b72b2a3dd152/18303.pdf.aspx?inline¼true Hefler M, Kerrigan V, Henryks J, Freeman B, Thomas DP. Social media and health information sharing among Australian Aboriginal people. Health Promot Int. 2019;34(4):706–715. Herrman H. The need for mental health promotion. Aust N Z J Psychiatry. 2001;35(6):709–15.

764

J. Bowers

Hoolahan B. ‘The tyranny of distance’: issues that impact on mental health care in rural NSW. Orange, NSW. New South Wales: Centre for Rural and Remote Mental Health [CRRMH]; 2002. Houghton K. The future of regional jobs [Internet]. Canberra: The Regional Australia Institute; 2019. http://www.regionalaustralia.org.au/home/wp-content/uploads/2019/04/RAI_SIP-20182-1-2_FutureRegionalJobs_Booklet_Print_3.pdf Jorm AF. Why hasn’t the mental health of Australians improved? The need for a national prevention strategy. Aust N Z J Psychiatry. 2014;48(9):795–801. Judd F, Jackson H, Fraser C, Murray G, Robbins G, Komiti A. Understanding suicide in Australian farmers. Soc Psychiatry Psychiatr Epidemiol. 2006;41(1):1–10. Knapp M, McDaid D, Parsonage M. Mental health promotion and mental illness prevention: the economic case [Internet]. London: UK Department of Health; 2011. https://www.pssru.ac.uk/ pub/Knapp_et_al_2011_MHPMHP-Economic-Case.pdf McNamara BJ, Banks E, Gubhaiu L, Joshy G, Williamson A, Raphael B, Eades S. Factors relating to high psychological distress in Aboriginal Australians and their contribution to Aboriginal– non-Aboriginal disparities. Aust N Z J Public Health. 2018;42(2):145–52. Morley B, Pirkis J, Naccarella L, Kohn F, Blashki G, Burgess P. Improving access to and outcomes from mental health care in rural Australia. Aust J Rural Health. 2007;15:304–12. Munro A, Allan J, Shakeshaft A, Snijder M. Riding the rural radio wave: the impact of communityleg drug and alcohol radio advertising campaign in a remote Australian Aboriginal community. Aust J Rural Health. 2017;25(5):290–7. National Mental Health Commission. The national review of mental health programmes and services [Internet]. Sydney: NMHC; 2014. http://mentalhealthcommission.gov.au/media/ 119896/Summary%20%20-%20Review%20of%20Mental%20Health%20Programmes%20and %20Services.PDF National Rural Health Alliance [NRHA].The little book of rural health numbers [Internet]. Deakin West, ACT: NRHA; 2015. https://www.ruralhealth.org.au/book/little-book-rural-health-numbers National Rural Health Alliance [NRHA]. Mental health in rural and remote Australia, fact sheet [Internet]. Deakin West, ACT: NRHA; 2017. https://ruralhealth.org.au/sites/default/files/publi cations/nrha-mental-health-factsheet-dec-2017.pdf Orygen, The National Centre of Excellence in Youth Mental Health. Evaluation of Rural Minds: A mental health promotion program for rural and remote agricultural communities, 2018 Report [Internet]. Parkville, VIC: Orygen, The National Centre of Excellence in Youth Mental Health; 2018a. https://www.rrmh.com.au/wp-content/uploads/2019/02/Rural-Minds-Report.pdf Orygen, The National Centre of Excellence in Youth Mental Health. Evaluation of Deadly Thinking: An emotional health promotion program for remote and rural Aboriginal and Torres Strait Islander communities, 2018 Report [Internet]. Parkville, VIC: Orygen, The National Centre of Excellence in Youth Mental Health; 2018b. https://www.rrmh.com.au/wp-content/uploads/ 2019/02/Deadly-Thinking-Final-Evaluation-Report-2018.pdf Parker S, Fruhen L. Impact of FIFO work arrangements on the mental health and wellbeing of FIFO workers. Western Australia: Centre for Transformative Work Design, Curtin University, University of Western Australian, WA Mental Health Commission; 2018. https://www.mhc.wa.gov. au/media/2548/impact-of-fifo-work-arrangement-on-the-mental-health-and-wellbeing-of-fifoworkers-summary-report.pdf Parker R, Lamont A. Evaluating programs, CAFCA Resource Sheet [Internet]. Australian Institute of Family Studies, Commonwealth of Australia; 2010. https://aifs.gov.au/cfca/publications/ evaluating-programs PriceWaterhouse Coopers, Beyond Blue. Creating a mentally healthy workplace: return on investment analysis, final report [Internet]. Sydney: National Mental Health Commission; 2014. https://www.headsup.org.au/docs/default-source/resources/beyondblue_workplaceroi_ finalreport_may-2014.pdf Productivity Commission. The social and economic benefits of improving mental health: issues paper [Internet]. Canberra: Commonwealth of Australia; 2019. https://www.pc.gov.au/inquiries/ current/mental-health/issues/mental-health-issues.pdf

34

Promotion and Prevention of Mental Health Problems in Rural and Remote. . .

765

R U OK? What we’re about [Internet]. R U OK; n.d.. https://www.ruok.org.au/what-were-about Rickwood D. Pathways of Recovery: Preventing Further Episodes of Mental Illness (Monograph) [Internet]. Canberra: Commonwealth of Australia; 2006. https://health.gov.au/internet/publica tions/publishing.nsf/Content/mental-pubs-p-mono-toc Rural Health Information Hub. Rural health promotion and disease prevention toolkit [Internet]. Rural Health Information Hub; 2019. https://www.ruralhealthinfo.org/toolkits SANE Australia. Reducing stigma [Internet]. SANE Australia; 2019. [updated 2019 March 25]. https://www.sane.org/information-stories/facts-and-guides/reducing-stigma#what-harm-doesstigma-do Scriven M. Michael Scriven on the differences between evaluation and social science research [Internet]. The Evaluation Exchange; 2003-04. https://cdn.ymaws.com/www.sacsa.org/resource/ resmgr/imported/JuneResearchTipdifferentiatingbetweenresearchAssessmentandProgramEval.pdf Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J, Saw S. The mental health of Australians, Report on the 2007 National Survey of Mental Health and Wellbeing [Internet]. Canberra: Department of Health and Ageing, Commonwealth of Australia; 2009. http://www. health.gov.au/internet/main/publishing.nsf/Content/A24556C814804A99CA257BF0001CAC45/ $File/mhaust2.pdf Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. Int J Epidemiol. 2014;43(2):476–93. Street T, Lacey SJ, Somoray K. Employee stress, reduced productivity, and interest in a workplace health program: a case study from the Australian Mining Industry. Int J Environ Res Public Health. 2019;16(1):94. Published online 2018 Dec 31. https://doi.org/10.3390/ijerph16010094. The Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa, 21 November 1986 [Internet]. Geneva: Department of Health Promotion, NCD Prevention and Surveillance (HPS), World Health Organization; n.d.. https://www.who.int/ healthpromotion/conferences/previous/ottawa/en/ The Senate, Community Affairs References Committee. Accessibility and quality of mental health services in rural and remote Australia [Internet]. Canberra: Commonwealth of Australia; 2018. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ MentalHealthServices/Report Thomas S, Jenkins R, Burch T, Calamos Nasir L, Fisher B, Giotaki G, Gnani S, Hertel L, Marks M, Mathers N, Millington-Sanders C, Morris D, Ruprah-Shah B, Stange K, Thomas P, White R, Wright F. Promoting mental health and preventing mental illness in general practice. London J Prim Care. 2016;8(1):3–9. Vos T, Barker B, Stanley L, Lopez AD. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples. Int J Epidemiol. 2009;38(2):470–7. Westerman T. Engagement of Aboriginal clients in mental health services: what role do cultural differences play? [Internet]. Aust e-Journal Adv Ment Health. 2004;3(3):1–7. https://www. tandfonline.com/doi/abs/10.5172/jamh.3.3.88

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinctive Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

For the effects of rurality to be minimized with regard to the impact of mental health problems in RRvR locations, a number of changes need to occur. While living in nonurban locations certainly has its challenges, it has a number of unique benefits that could be emphasized in order to improve recruitment and retention of a skilled mental health workforce. Lifestyle factors, community involvement, the beauty of the natural environment, and the scope of practice are some of the common features of living and working in RRvR settings that could be promoted to mental health professionals to encourage them to consider a career away from the city. Policy changes also need to occur in a number of different areas. Recruitment and retention problems of medically trained health professionals have been addressed in Australia by successive governments developing and introducing various incentive schemes. Similar schemes could be adopted for the recruitment and retention of a diverse mental health workforce. It is also T. A. Carey (*) Institute of Global Health Equity Research, University of Global Health Equity, Kigali, Rwanda e-mail: [email protected] J. Gullifer Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia School of Psychology, Charles Sturt University, Bathurst, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2021 T. A. Carey, J. Gullifer (eds.), Handbook of Rural, Remote, and very Remote Mental Health, https://doi.org/10.1007/978-981-15-6631-8_36

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imperative that policy changes are adopted to address the lack of evaluation of programs and services that occur. Ironically, if policy required that ongoing monitoring and evaluation occurred for all mental health services and programs, mental health professionals would experience increased professional satisfaction through enhanced effectiveness of the services they offer as well as greater engagement with the people to whom they provide services. Furthermore, current training programs, generally, do not adequately prepare mental health professionals for the demands and challenges of working in RRvR places. The training of mental health professionals should be expanded to include a greater focus on areas such as primary care; the social determinants of health; ethical and professional considerations; cross-cultural service provision; and working flexibly, responsively, and a-diagnostically. Moreover, although the opportunity to undertake placements in RRvR settings is becoming more common in mental health training programs, the availability of the opportunity is still limited and needs to be expanded to more training programs. Even more important is creating the capacity to complete mental health training while remaining situated in RRvR locations. Certainly in Australia it is still almost universally the case that people must travel to urban centres for extended periods of time to train to become a mental health professional. As changes such as these begin to be introduced, residents of RRvR locations will start to enjoy the access to high-quality and effective services they require to live the lives that they would wish for themselves.

Introduction From the extensive information provided throughout the preceding chapters of this handbook, predicting the contents of this chapter might be straightforward. It is entirely possible to reduce the impact of psychological distress in RRvR locations by improving both the quality and the quantity of the services that are provided there. Minimizing the geographic impact of rurality with regard to mental health problems needs to be prioritized highly by politicians, policy makers, health service managers, and other health decision makers. It is certainly the case that there are still things we do not know. In Australia, for example, there is a striking absence of assessment measures that are appropriate for Aboriginal and Torres Strait Islander peoples as well as a very limited evidence base of appropriate treatments for them. In most cases, however, it is more a situation of not doing what we know to be effective rather than not knowing what to do. Because of the diversity of RRvR situations, knowing what to do often means knowing which important principles to apply rather than which particular programs to import. Crucially, reducing the impact of mental health problems in RRvR locations implies policy changes just as strongly as it implies changes to practice. When discussing the changes that need to occur in RRvR localities, it is important to maintain a sense of what the purpose of any alterations or modifications should be. RRvR communities are indisputably different from metropolitan centres. Furthermore,

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RRvR communities are frequently different in important ways from each other. It would be a mistake to attempt to duplicate the mental health practices of the city in the bush. RRvR contexts are diverse and unique. In order to be as helpful as possible, however, attending to the differences among nonurban centres is the wrong level of analysis upon which to focus. Addressing the multifarious ways in which RRvR settings differ will make problems seem complex, insurmountable, and even “wicked.” We are not suggesting that the impact of mental health problems in RRvR locations is an easy problem to solve. We are suggesting, however, that, currently, we are concentrating on the most difficult aspects of the problem and the ones likely to be least productive in terms of positive and sustainable change. The heterogeneity of RRvR towns and communities is staggering. Fortunately, coming to terms with the multifarious nature of rurality is not required in order to minimize the impact of mental health problems. At the sixth Rural and Remote Scientific Symposium, in his keynote address, Australia’s first National Rural Health Commissioner, Emeritus Professor Paul Worley, provided an elegant and nuanced qualification to the often-repeated argument. He began by reminding the audience that “if you’ve seen one rural town, you’ve seen one rural town.” Then, he continued with the following crucial proviso, “Now there’s a truth in that and there’s a hazard. The truth is that we are all individuals. And each of us in this room are individuals as is each rural town has its own characteristics. The hazard is that if our research continues to focus on the ethos of ‘if you’ve seen one rural town you’ve seen one rural town,’ it will never translate into policy. Because for policy you need to see what is common across the differences” (Worley 2018). Rather than attending to superficial differences, it will be far more productive to promote common principles of effective service delivery that apply across different contexts (Carey 2018). In fact, it has been suggested that the power and precision of the physical sciences arose because disciplines in the physical sciences focus on invariance or common, underlying properties of apparently different objects and elements (Carey and Mansell 2009). The life sciences, on the other hand, have taken up the study of variability. Focusing on fundamental, shared principles will be far more useful than being beguiled and distracted by superficial differences for establishing and sustaining effective and efficient services in RRvR settings. Perhaps, the ideal present that we will reach at some point in the undetermined future will be a present time in which important principles of health systems and health service delivery are articulated and routinely attended to. While we should not expect, necessarily, to see the same type of service from metropolitan to RRvR locations, it is entirely reasonable to expect to see the same quality of service. As outlined in the chapter on social determinants, each community in RRvR has unique characteristics and unique challenges that should be ascertained, in parallel with addressing individual distress. Focusing on providing individual services (where they are available), without addressing the broader social determinants, may barely address the presentation of distress in RRvR communities. It has been our stance throughout this book that people in RRvR locations have the right to be able to access evidence-based programs and services that are as effective, efficient, and high-quality as services in urban locations. It is this perspective that has

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provided the framework for the way in which the future of mental health in nonurban settings is discussed in this chapter. In fact, because of the limited choices available in RRvR centres, there is perhaps a greater imperative to ensure services are effective, efficient, and high-quality than there is in metropolitan locations. Perhaps, as we head toward the future of RRvR mental health, we will also reconsider the tendency, as we will demonstrate relentlessly throughout this chapter and as has been demonstrated just as doggedly throughout the rest of the handbook, to compare RRvR contexts with urban, more densely populated settings. Is that a reasonable comparison? Why should metropolitan settings be the benchmark? There is certainly a lot of attention from policy makers and politicians about “closing the gap” on health inequities, but is that a reasonable standard? Is there any reason to believe that we have got it right yet in the cities? Should the ideal to which we aspire be that situation where everyone, regardless of where they live, has access to the resources they need to live the life of their design? Should we focus on an ideal standard of creating neighborhoods, communities, societies, and other social collectives where people have the opportunity to live life as they wish without preventing others from doing the same thing? Perhaps comparing our current situations with an ambition such as this rather than with people located in other geographical contexts would lead to enhanced conditions, contentment, and well-being for all. We will continue to make the geographical comparison throughout this chapter but will promote the idea of a different kind of comparison as a way to begin turning the tide.

Distinctive Features To significantly alter the impact of mental health problems in RRvR locations, fundamental changes need to occur in a variety of areas. Taking the geographical mental health disparity seriously will require changes to policy, practice, and training. It is only by addressing these different areas simultaneously that positive and sustainable change will be realized. Some of these changes will require structural reform, whereas others necessitate attitudinal shifts by health service managers and service providers. Perhaps even the way in which impact is understood for both research and practice in RRvR areas could be finessed in a brighter future. One approach to understanding impact uses the word itself as an acronym to demarcate important components that should be attended to in order to ensure services, interventions, and programs of research have the intended effects (Carey 2019a). Impact will be maximized when what is conducted in RRvR places is important to the community in which it is situated; monitored and measured so that genuine, tangible improvements can be demonstrated; planned so that whatever occurs does so through systematic, cohesive collaboration; adequately and appropriately resourced; courageously challenging the status quo, prevailing attitudes, and existing wisdom; and telling the story of what has occurred in a way that affects people’s hearts as well as their heads (Carey 2019a).

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Practitioners and researchers who are familiar with working in RRvR regions will recognize the importance of these criteria. Many of these will be highlighted in the sections below. Too many communities have programs imposed on them, and not with them as active partners. Additionally, even when communities are given the opportunity to contribute, it is not always clear that the people who are heard are the most appropriate people to be listened to. It is essential that monitoring and genuine measurement becomes a routine feature of the landscape of RRvR programs and services. Too many initiatives start from a great idea and are driven by a dynamic and energetic individual; however, their effectiveness is never adequately demonstrated, evaluated, or sustained. Hudson (2016) powerfully makes the point about the lack of evaluation of programs for Aboriginal and Torres Strait Islander peoples. Related to this point is the necessity for systematic planning that should include attention to evaluation as part of the initial design. Adequate resourcing is essential for the sustainability of programs and services, and it is important that bold initiatives are encouraged and supported to flourish so that we begin to develop new knowledge to address what have so far been intractable problems. And finally, the dissemination of important new work and key findings is often neglected or woefully inadequate. There needs to be much more attention given to RRvR narratives through storytelling, and telling it in a way that “moves” people as much as it informs them (Carey et al. 2019). In the following paragraphs, we discuss in more detail some of the important distinctive features of a future worth advocating for in RRvR places. Policy changes. In Australia, policy change is required in a number of different areas at federal, state and territory, and local levels. It would be surprising if the same situation did not occur, to a greater or lesser extent, in other countries. Australian policy makers can be guided by successful policy initiatives in disciplines other than mental health with regard to the types of changes that would be desirable. When designing or advocating for these kinds of changes, it is important to focus on the social processes that determine the unequal distribution of social resources, not just the social resources themselves. Only addressing their unequal distribution in society will affect outcomes (Solar and Irwin 2010). It is only with different policy directives that we can expect to see changes to the impact of mental health problems in RRvR locations. Recruitment and retention. Recruitment and retention issues require policy changes to ensure that a suitable mental health workforce is available in RRvR locations. There is good evidence, for example, of incentive strategies that have been effective for the medical workforce in Australia, and there is no a priori reason to expect that they would not work just as well with the mental health workforce (Wakerman and Humphreys 2013). To address staff turnover in RRvR primary healthcare services in Australia, for example, evidence indicates that flexible packages of retention strategies are most effective (Humphreys et al. 2009). What is an incentive for one person will not have the same attractiveness for another person. Some people might want access to affordable continuing professional development including fees for university courses; others might prefer rent subsidies or home loan incentives. School fees, suitable employment for partners, flexibility of working conditions such as working from home arrangements, and increased annual leave

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provisions are all some of the incentives that could help to make living and working in RRvR areas more desirable and feasible. Furthermore, there should be an expectation that those professionals recruited to work in RRvR situations are conversant with the social determinants that impact on health outcomes of RRvR individuals and communities and which are not easily addressed by a treatment-focused health system. Moreover, this would also require an understanding of, and willingness to, engage in community development, a requirement that goes beyond the treatment of individual distress. Unfortunately, this is not an area that is covered in any great depth in most health curricula. The structure of services: psychology as an example. Policy changes to the structure of services might enable people in RRvR locations to access the range of treatment options that are available in metropolitan centres. For example, in the Northern Territory Government’s Central Australia Health Service (CAHS) of remote central Australia, psychologists have not been routinely employed to deliver evidence-based treatments to patients of that service. While the Mental Health section of CAHS employs a number of psychiatrists and case managers (including mental health nurses and social workers), psychologists are noticeably absent. In the Adult Mental Health service, for example, no psychologists were employed full-time to deliver evidence-based psychological treatments between 2010 and 2019. The situation may very well still be the same. These recruitment decisions mean that the residents of Alice Springs and surrounding communities do not have access to evidence-based psychological treatments provided by psychologists in the public mental health service. The only option for non-Indigenous people living in remote central Australia, therefore, should they wish to access psychological treatment, is to engage a private practitioner. Fortunately, Aboriginal and Torres Strait Islander peoples are able to access psychological services through the local Aboriginal medical service: the Central Australian Aboriginal Congress (CAAC). The lack of psychologists in CAHS is not unique to the Mental Health section. For example, although the Australian Pain Society reports that psychologists play a crucial role in the management of chronic pain (Australian Pain Society 2016), there are no psychologists employed within the Pain Management Service of CAHS. Similarly, psychologists are not routinely employed in the Alcohol and Other Drugs Service of CAHS. The lack of psychologists employed throughout CAHS is not due solely to recruitment problems because, as mentioned above, the CAAC regularly employs clinical psychologists. The Social and Emotional Wellbeing (SEWB) service at the CAAC, for example, includes clinical psychologists, social workers, and Aboriginal health practitioners. Despite an increasing body of literature promoting the application of psychological knowledge when designing community interventions that can enhance community resilience (Hegney et al. 2008), we still see a very slow uptake in RRvR communities. Psychologists have been involved in research about the development of resilience after disasters. The Australian Psychological Society, the peak professional organization for psychologists in Australia, has developed a national network of psychologists who have a special interest and expertise in working with individuals and communities affected by disasters and emergencies in Australia. Indeed

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during the 2019 bushfire crisis in Australia, the requests for psychological services in these communities saw an increase in requests for psychological services and a commensurate increase in government funding. Psychologists deliver evidence-based, cost-effective psychological treatments, especially for people with high-prevalence mental health disorders, but access to such services in RRvR locations needs to be reconsidered. Australian governmentfunded programs such as Better Access to Psychological Services and Mental Health Services in Rural and Remote Australia have improved access through telehealth services for RRvR clients. Medicare rebates are now available for people in RRvR regions to see a psychologist via telehealth. Moreover, these services have been substantially expanded to cope with the COVID-19 epidemic. However, the imperative here is equity in provision of psychological services for RRvR communities and not service provision that is solely focused on telehealth. A metropolitan community has the advantage of greater access to all domains of treatment delivery, not just telehealth. It is certainly the case that an absence of the provision of face-to-face psychological treatments might not be peculiar to RRvR public mental health services. People in metropolitan centres, however, have access to a greater range of government and nongovernment services, so any lack of psychological treatment offered in an urban-based public mental health service will not have the impact that it has in nonurban centres. A revised policy that mandated quarantined time each week in any public mental health service for the provision of evidence-based psychological therapies would help to improve access to psychological services in RRvR locations. There is evidence that flexible and responsive forms of psychological treatment can be both effective and efficient in remote locations (Carey et al. 2013). Currently, however, decisions about whether or not psychological treatments are provided rest with local health service managers who may not always appreciate the importance of a range of treatment options that go beyond telehealth. Policy imperatives that stipulated different options would help to correct this situation. A policy change requiring a minimum amount of psychological service provision is one example of the type of policy change that would benefit everyone regardless of geography. There may be, for instance, some metropolitan services that have minimal or no psychological and social programs and interventions. This policy initiative would improve access to effective psychological and social treatments by establishing a baseline standard for all services. We have focused on services offered by psychologists in this section because they are the services we know best. We do not intend, however, that services by other mental health professionals should be excluded from the same level of analysis. The descriptions of, and suggestions for, services provided by psychologists are only examples of the possibilities that need to be explored and realized. The same level of analysis needs to occur with other mental health professions in RRvR locations in order to develop a more adaptive workforce. Why, for example, should it not be possible for mental health nurses in RRvR locations to work privately? It is essential that policies are reviewed with regard to increasing the options available to people in RRvR locations.

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Making routine evaluation routine. As has been previously mentioned, the monitoring and evaluation of services and programs does not commonly occur in RRvR locations. Evaluation might not be the standard practice in metropolitan centres either, but, again, the impact of a lack of service improvement through regular monitoring and evaluation is greater in RRvR settings. Hudson’s (2016) review, which has been mentioned previously, examined programs and services funded to be provided to Aboriginal and Torres Strait Islander peoples specifically although anecdotal evidence indicates that Hudson’s findings are generally applicable in RRvR contexts. Overall, there was a gross neglect of the evaluation of programs and services, and, even when evaluation did occur, the quality of the evaluations was so poor that conclusions regarding effectiveness could rarely be made (Hudson 2016). Changes to policy are required so that a proportion of any government funding for mental health programs and services is allocated to the evaluation of these interventions. During a 4-month Fulbright Scholarship in the United States (USA), TAC learned that between 15% and 20% of federal government funding for programs and services in the USA must be directed to evaluation. During an interview with Dr. Richard McKeon, Chief, Suicide Prevention Branch, Substance Abuse and Mental Health Services Administration (SAMHSA), Dr. McKeon confirmed the priority that SAMHSA places on evaluation (personal communication, 2 January 2018). McKeon underscored the importance of collecting and using data and highlighted the advantages of explicit congressional directions to include evaluation as a necessary component of any funding for programs and services. A similar approach to that in the USA has been adopted in Victoria, Australia, by VicHealth (https://www.vichealth.vic.gov.au/). Funding for VicHealth programs requires evaluation of the programs as standard. The evaluation process must be described in detail at the time of applying for the funding, and identifying a partner organization skilled in evaluation methods is required. If an approach such as this was adopted across RRvR Australia, substantial reductions in the impact of mental health problems might be realized. One of the nuances to program evaluation that was discovered during the Fulbright period was that ongoing monitoring and evaluation seemed to be preferred to the standard pre- and post- comparative assessments (Carey et al. 2019). The practice of ongoing monitoring and evaluation required rethinking the nature of programs and services as resources to help people create the outcomes they want rather than as “tools” that are arbitrarily effective or ineffective regardless of context and people. An ongoing approach to monitoring and evaluation also required a different relationship with external evaluation partners that service providers highly valued. The nature of this relationship changed over time to become more of a “mentoring” or “critical friend” type of relationship (Carey et al. 2019). The entire process of evaluation came to be considered more as a learning process rather than a judgment of effectiveness (Carey et al. 2019). The consequence of this was that practitioners and other service providers revised their attitudes toward evaluation and actually embraced it, rather than avoided it, because they now saw it as a way of enhancing their effectiveness for the people they served (Carey et al. 2019).

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Rethinking ethical and professional practice issues. RRvR contexts provide challenges to conventional approaches to ethical and professional guidelines. It is standard for various mental health professions, such as psychologists, to have codes of ethical practice to which they are required to subscribe when they practice. In RRvR settings, however, the blurring of boundaries which might be relatively rare in metropolitan locations can be common. A mental health professional, for example, might discover she has been assigned to the same tennis team as a client. Perhaps clients and mental health professionals use the same fitness centre and attend the same “boot camp” fitness sessions. Or, as mentioned in the introductory chapter, maybe a mental health professional might discover that his son is in the same class as the child of a client and they have become friends who would like to play at each other’s houses on weekends. What about a situation where the partner of a client is the receptionist at the GP practice the mental health professional uses? For the most part, the ethical and professional quandaries that arise in routine RRvR practice are not insurmountable, but they do require careful consideration and clear reasoning. It may also be the case that mental health professionals have imposed overly restrictive guidelines and demands on their practice. As was suggested in the first chapter, perhaps useful lessons can be learned from the approach of other health disciplines. Because of their apparent unfamiliarity to many mental health professionals, it is worth revisiting these points again. Some medical practitioners, for example, prefer practicing in RRvR locations, precisely because they can get to know their patients in settings other than the medical practice. A medical practitioner’s child may play on the same soccer team as a patient or a patient’s child. It is certainly the case that medical procedures can be invasive and intimate, and, yet, RRvR medical practitioners do not seem to have the same difficulty reconciling their practice with their interactions with patients in social settings. A medical practitioner, for instance, might conduct examinations for breast or testicular cancer with patients in the morning and then attend rehearsals for the community choir with the same patients in the evening. While it is undoubtedly important to treat the recipients of mental health services with care, compassion, and respect, there is, perhaps, also scope for mental health professionals to normalize the experience of mental health problems by the way they interact with their clients in the community. It may be that the most important aspect of these interactions is enabling the clients to control the nature of the interaction in terms of its duration and frequency. In this way, RRvR settings might provide ideal locations for mental health professionals to contribute to the destigmatizing of mental health problems by the way they conduct themselves in social situations with their clients. Some work indicates that mental health professional themselves have negative and stigmatizing attitudes toward people experiencing psychological and social problems (Hansson et al. 2013). Given the importance of stigma to the experience of severe psychological and social distress, with the impact being particularly severe in RRvR locations, perhaps, an important area to start addressing this is with mental health professionals themselves. Recasting mental health models. Perhaps one of the greatest challenges, but also a splendid opportunity, in RRvR settings is the opportunity, maybe even the

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necessity, to incorporate alternative models of psychological distress. The current prevailing model in the Western world is medical, with psychological problems being cast as discrete disorders that are analogous to medical illnesses. In Australia, this model has been described as inappropriate for Aboriginal and Torres Strait Islander peoples who advocate thinking about psychological functioning in terms of Social and Emotional Wellbeing (SEWB; Gee et al. 2014). From an SEWB perspective, psychological well-being arises through the strength of connections in seven different domains. To function effectively, an individual must have satisfactory connections to mind and emotion; body; family and kinship; spirit, spirituality, and ancestors; culture; country; and community (Gee et al. 2014). There are sound reasons to suppose that this model could apply more broadly than only to Aboriginal and Torres Strait Islander peoples. As mentioned in the introductory chapter, evidence-based healthcare is considered to be the integration of the best available evidence; knowledge of the context in which the care is delivered; client preferences; and the professional judgment of the health professional (Pearson et al. 2012). When these four components are considered within the purview of rurality, the importance of thinking flexibly about mental health problems becomes clear. Context is a crucial but varied component of day-today living in RRvR places. Context is important everywhere, but it is especially relevant in very remote communities where English might not be the dominant language. In the Warlpiri language of central Australia, for example, “wajampa” is the word for anxiety (Carey 2018). Wajampa, however, also means “sorrow” and “grief.” A mental health professional, therefore, would need to have an advanced understanding of the specific context if they were working with a Warlpiri speaker wanting to address wajampa problems. Similarly, client preferences will not necessarily be consistent with what a mental health professional might predict them to be particularly if they come from a different, perhaps metropolitan, background. Furthermore, when considering evidence, adopting a FAME approach to understanding evidence requires a broader scope than only evidence of effectiveness (Pearson et al. 2012). FAME refers to evidence of feasibility, appropriateness, meaningfulness, and effectiveness (Pearson et al.). A FAME attitude toward evidence would seem to be particularly helpful in RRvR settings when, because of the limited choices available, it is crucial to ensure that services are not only effective but are also feasible, appropriate, and meaningful. Addressing all of these areas comprehensively will require a range of methodological approaches and varying expertise. Of course, all of the issues we have raised also apply to the presentation of mental health problems in urban locales; however, as has been emphasized repeatedly throughout this book, when there are numerous and varied services, there is less of a problem if clients do not engage with a particular service immediately. In RRvR locations, however, if services do not seem useful, relevant, or helpful to clients, they frequently do not have other options. A lack of available, suitable option relates to the suggestion of a new benchmark and comparative standard that is based on degrees of freedom rather than geography. Mental health professionals in RRvR contexts, therefore, need to abandon an approach that conceptualizes problems of

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functioning as medical disorders. Instead, they need to seek to understand the client in terms of the contexts they are functioning in, and the preferences, priorities, and values that are important to them (Carey 2017). Changing training models. To realize many of the changes that are necessary to reduce the impact of mental health problems in RRvR locations, training models and programs in Australia need to be revised. Increasing the availability of relevant, ongoing professional training for current mental health professionals will also be important, but sustained and pervasive change will only emerge through training a new generation of mental health professionals who are suitably equipped to embrace the challenges and opportunities of living and working in RRvR areas. As this new generation establishes effective practices and services in RRvR locations, the approach we are advocating, which seems different and distant at the moment, will become mundanely routine. Of course, implicit in a revision to training models requires staff who are suitably qualified and experienced to contribute to the training models. Unfortunately, there is a concerning trend in Australia of lowering academic standards in RRvR areas (Carey 2019b). People in RRvR places are being recruited to academic positions for which they would, ordinarily, not be considered. Consequently, another inequity has been established and is being perpetuated whereby people in RRvR towns and communities are being forced to accept a university academic standard that is far below what would be permitted in cities. To ensure that a fit for purpose future workforce is appropriately trained for the demands and challenges of RRvR service provision, it is imperative that academic standards are at least as high in RRvR places as they are in academic institutions situated in cities. Structure of training. Postgraduate psychology training in Australia provides a potent example of the need to revise the structure of training. An accredited Master of Clinical Psychology degree, for example, has three components which must be successfully completed to obtain the degree. The three components are coursework, research, and placements. Currently, there are limited Master of Clinical Psychology degrees offered externally for trainee psychologists who have yet to obtain full registration as a psychologist. Moreover, clinical degrees may not be of themselves enough preparation for working in RRvR practice. Other branches of psychology have much to offer working in RRvR locations, including community psychology, health psychology, counseling psychology, and education and developmental psychology. As outlined in the social determinants chapter, changes to inequities that cover a broad range of structural, cultural, social, economic, and environmental factors that shape individuals’ opportunities and barriers to engage in healthy behaviors and mental health may be better addressed by branches of psychology that do not focus on a clinical/medical model. There are many RRvR locations, however, where it would be entirely feasible to negotiate all of the demands of the different specializations that a degree can offer without physically attending a metropolitan university campus. Students could complete a diverse curriculum that extends beyond a clinical focus that covers coursework components by attending lectures via videoconferencing technology and could complete placements on a broad range of issues beyond clinical case presentations and research in RRvR settings. There would be no reason to expect that there should be any decrease in standards or expectations of the quality

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of the work to be completed. It is certainly the case that pragmatic considerations, such as finding appropriate supervisors, would need to be accommodated. These considerations, however, are not insurmountable, and the benefits in terms of an improved RRvR mental health workforce far outweigh any inconvenience in the extra time taken to ensure an appropriate and successful training experience. It is also the case that as RRvR towns and communities become more populated with skilled and highly trained mental health professionals, negotiating high-quality training experiences will become more straightforward. Restructuring courses to enable students to complete their degrees externally is only one aspect of course revision. Another way of restructuring would be to adapt the timing of the different degree components to allow extended periods of time away from the campus. In a somewhat blended approach, students could complete their foundation coursework, preliminary aspects of their research, and an initial placement in the first year on campus and then their remaining coursework, research, and placements off campus in the second year from a RRvR location. An approach such as this would allow a suitable period of time for close observation of students to ensure a thorough selection process for determining the students most likely to thrive in a nonurban setting. Content of training. As has been alluded to, it is not just the structure of training, however, that will need to be reviewed. Much of the content of current training needs to be critiqued and modified to make it more relevant to practice outside of metropolitan centres. The concept of a scientist-practitioner model of training is sound; however, a scientist-practitioner can work much more broadly than simply delivering evidence-based psychological treatments in group or individual formats. Contributions from other psychology specialties such as community psychology, health psychology, counseling psychology, and education and developmental psychology would be especially relevant for working effectively in RRvR contexts. Primary care. Despite early successful examples of integrated rural internships and placements (Vines et al. 2002, 2004; Vines 2008), training of psychologists has typically not emphasized the importance of primary care as much as it could, and, yet, in RRvR settings, primary care clinics are often the hub of healthcare. Ironically, psychologists could be assets and valuable members of a primary care team, but training programs would need to constantly highlight the way in which psychologists could contribute. Obviously, psychologists could make valuable contributions to the delivery of evidence-based programs; however, they could also assist in the tailoring or adapting of treatments to local circumstances. Training programs should emphasize the way in which programs can be modified to maintain the integrity of the program while also maximizing their appropriateness to local contexts. Psychologists’ skills in research and evaluation could be harnessed to ensure that programs are being delivered effectively, or are modified appropriately, when problems of effectiveness are identified. Training in research, therefore, should include attention to program evaluation as well as innovations such as routine outcome monitoring and continuous quality improvement approaches. The way in which psychologists can make important contributions to community development and promotion and prevention initiatives in primary care settings should also be demonstrated to trainee psychologists.

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The social determinants of health. The social determinants of health (SDOH) are relevant to all geographical locations but are especially relevant in RRvR locations and particularly pertinent to mental health. As has been previously discussed, Marmot describes control and social engagement as an organizing principle for the SDOH (Marmot 2006). Although this principle is expressed as “control and social engagement,” the phenomenon of control could be considered primary. Marmot (2006), for example, states that “What is important is not so much what you have but what you can do with what you have” (p. 565). This sentiment clearly has control at its core. Social engagement is undoubtedly important; however, the extent to which one is able to engage socially in the manner one desires is just as undoubtedly a control issue. In an email exchange with Marmot about his latest book The Health Gap (Marmot 2015), he clarified that “We [Marmot and TAC] are agreed on the centrality of control” (personal email communication, 14 June 2018). Trainee mental health professionals need encouragement and opportunities to investigate the ways in which they can enhance their clients’ abilities to control through the treatments they offer to them. In some ways, this can be attitudinal on the part of the mental health professional as much as leading to overt actions and directions for intervention efforts. There are likely to be numerous instances during mental health professionals’ contact with their clients when they can facilitate or enhance the control their clients are able to exercise. Control is central to Aboriginal and Torres Strait Islanders’ understanding of health (Carey 2013), and the success or failure of any intervention may hinge on the extent to which control has been considered and honoured. Ethical and professional considerations. The fact that effective RRvR mental health practice requires different ethical and professional considerations from urban practice has already been discussed. RRvR mental health practitioners require a sophisticated and principled approach to ethical and professional decision making. Boundary issues are likely to occur routinely. It is important that training programs alert students to the ethical and professional situations that can arise in RRvR locations. Rather than these situations being portrayed as problems to be avoided, they could be presented as areas requiring advanced practice reasoning and an expanded scope of practice. Numerous opportunities could be provided during students’ training to consider typical RRvR scenarios and to generate possible solutions and courses of action. Ironically developing this kind of advanced reasoning would be of immense benefit to metropolitan practitioners as well. Cross-cultural service provision. Working effectively with people from different cultures is an essential aspect of service provision in RRvR communities. Obviously, for non-Indigenous Australians, working with Aboriginal and Torres Strait Islander peoples will be important; however, there will be people from other cultural and ethnic groups in many RRvR locations who will require the services of a skilled mental health professional. As with other nuances to RRvR practice, the importance of effective cross-cultural service provision is also a priority in metropolitan centres; however, once again, because of the range of options available in highly populated

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areas, there are likely to be specific services available for different cultural groups that do not exist in RRvR places. Thinking broadly about the concept of “culture” will incorporate considerations other than ethnic diversity such as the culture of a small and remote mining town, an isolated tourist destination, or the culture of a farming community. In many ways, the basics of sound clinical practice will provide an important framework for effective practice. Aspects of effective clinical practice that are likely to assist with crosscultural service provision are not making assumptions about the client; endeavoring to understand the client’s world view; exploring the client’s goals for treatment; and allowing the structure and pace of treatment to be determined by the client. Adopting a patient-perspective approach (Carey 2017) to mental health service provision is one way of ensuring the honouring of different cultural perspectives. During the training programs of mental health professionals, it is essential that opportunities are provided to both discuss and practice effective cross-cultural service provision. Where possible, it would be ideal to have a trainee’s clinical practice supervised by a trained professional from a different culture. It is also important that trainee mental health professionals are provided with the time and scaffolding to reflect in a constructive way about their own attitudes and assumptions regarding people from different cultures. An ethos of cultural safety must pervade all aspects of the training programs of mental health professionals. Working flexibly, responsively, and a-diagnostically. It is fundamentally important that trainee mental health professionals learn to work in flexible and responsive ways. Structured treatments and interventions that might be appropriate in urban centres will become highly problematic in RRvR locations where people might have to travel long distances or have other considerations that make attending regular sessions problematic. An earlier chapter of this handbook described a patient-led approach to appointment scheduling as an effective and efficient innovation in a remote mental health setting. RRvR settings, therefore, provide ideal locations for mental health professionals to question many long-held assumptions – such as the necessity for regular appointment schedules – and to innovate with regard to service provision for greater effectiveness and efficiency. Paradoxically, the lessons learned through these kinds of novel approaches could enhance service provision in urban centres as well. Questioning these kinds of assumptions is one example of the kind of courageous challenging of the status quo mentioned in the first chapter as an important component of the impact of services and programs in RRvR settings (Carey 2019a). We have already mentioned the importance of considering models of mental health that are alternatives to discrete disorder models. It is especially important in RRvR locations where it is extremely unlikely that there would exist specialist eating disorder, obsessive-compulsive disorder, or mood disorder clinics that mental health professionals, to be effective, learn to work a-diagnostically. It is well established that comorbidity is extremely common in routine clinical practice (Carey et al. 2017) which makes the delivery of disorder-specific models of treatment less than straightforward. If a middle-aged man in a rural farming community visits a mental health professional displaying symptoms of both anxiety and depression, which treatment protocol should be delivered? Recent innovations have proposed that it would be

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much more effective to focus on transdiagnostic principles of effective psychological treatment and to address the difficulties in functioning as described by the man (Carey et al. 2015). An even bolder and more courageous move would be to work adiagnostically. Working in this way would entail considering approaches other than conventional Western biomedical categories of disorder such as addressing any underlying psychological conflict that might be the source of a person’s distress (Carey 2008; Carey et al. 2015). The patient-perspective model of care and service delivery (Carey 2017) provides an ideal framework to explore alternative ways of working that are meaningful and effective for the recipients of the work. Models such as the SEWB conceptualization of psychological functioning and well-being are likely to be particularly important in assisting mental health professionals to work a-diagnostically so that they can be of assistance to a greater range of people presenting for treatment. Different cultural understandings of distress provide potent examples of the imperative to understand psychological functioning a-diagnostically. The example of “wajampa” was mentioned earlier, but the lesson is worth revisiting at this point. “Wajampa” is the Warlpiri word for “anxiety.” Warlpiri is one of the Aboriginal languages of central Australia. As well as referring to anxiety, however, wajampa also means worry, concern, upset, sorrow, and grief (Swartz 2012). In Warlpiri there are different words for “anxious for” and “anxious over” and wajampa-wajampa; in addition to meaning “a worrier” also means “determined to kill” and “relentless” when referring to hunting (Swartz 2012). A mental health professional working from a traditional, Western, biomedical perspective, therefore, could find it extremely difficult to separate anxiety from depression for a Warlpiri speaker complaining of wajampa. During their training, to become an asset to the RRvR mental health workforce, mental health professional trainees need repeated experiences in conceptualizing people’s problems a-diagnostically rather than in discrete diagnostic categories. Opportunities to identify and review the attitudes they have developed about the nature of psychological distress and its treatment will be important, and exploring ways to work flexibly, responsively, and a-diagnostically, with the perspective of the patient guiding treatment decisions, would be ideal. When the majority of the time undertaken in mental health training is characterized this way, the future workforce will be well prepared for the demands, challenges, and rewards of RRvR practice.

Concluding Comments and Recommendations There is no reason at all that health and social inequities should be the persistent problems they are in RRvR regions. This handbook provides a proliferation of evidence regarding the innovations and initiatives that characterize some RRvR mental health systems and services. To thoroughly address and eliminate these inequities, changes need to occur at many levels. Throughout this chapter we have outlined our recommendations for change at the levels of policy, practice, and training. We will emphasize the most important of those recommendations in the Take-Home Messages below. Sustained reform in RRvR areas requires cooperation,

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collaboration, and relentless and tenacious persistence from all levels of government. Cooperation, collaboration, and relentless and tenacious persistence are precisely some of the important features and characteristics of people who thrive and flourish in RRvR locations. Perhaps there is much that city dwellers could learn from the way in which problems are identified and addressed in RRvR. Have we had the direction of influence back-to-front all along? This handbook is our contribution to correcting that situation and providing the information that will help improve the ability of RRvR residents to live the lives they would wish for themselves.

Take-Home Messages • The benefits and rewards of living and working in RRvR locations in terms of factors such as lifestyle and career progression need to be emphasized. • Policy changes are needed to require that programs and services are routinely evaluated to ensure that interventions are effective and of high quality. • The recruitment and retention of health professionals other than medically trained practitioners need to be prioritized so that people in RRvR locations are able to benefit from the expertise of professionals such as occupational therapists, social workers, and psychologists. • Training programs for mental health professionals need to include a focus on working in RRvR contexts including adopting a broader scope of practice; the importance of primary care; and the relevance and value of the social determinants of health.

References Australian Pain Society. Australian pain society position statement: the role of the psychologist in the management of persistent pain. 2016. https://www.apsoc.org.au/PDF/Position_Paper/ 20160321_APS_Psychology_Position_Statement_MAR16.pdf. Accessed 25 Apr 2018. Carey TA. Conflict, as the Achilles heel of perceptual control, offers a unifying approach to the formulation of psychological problems. Couns Psychol Rev. 2008;23(4):5–16. Carey TA. Defining Australian indigenous wellbeing: do we really want the answer? Implications for policy and practice. Psychother Politics Int. 2013;11(3):182–94. Carey TA. Patient-perspective care: a new paradigm for health systems and services. London: Routledge; 2017. Carey TA. Same principles, different practices: the distance for geographic parity in health is not so great after all. JBI Database System Rev Implement Rep. 2018; https://doi.org/10.11124/ JBISRIR-2017-003827. Carey TA. Prioritizing impact to improve health services and reduce inequities in rural, remote and very remote locations. JBI Database System Rev Implement Rep. 2019a;17(9):1729–30. Carey TA. Academics in the bush: are rural, remote and very remote Australians being sold short? Aust J Rural Health. 2019b;27(5):372–3. Carey TA, Mansell W. Show us a behaviour without a cognition and we’ll show you a rock rolling down a hill. Cogn Behav Ther. 2009;2:123–33. Carey TA, Tai SJ, Stiles WB. Effective and efficient: using patient-led appointment scheduling in routine mental health practice in remote Australia. Prof Psychol Res Pract. 2013;44:405–14.

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Carey TA, Mansell W, Tai SJ. Principles-based counselling and psychotherapy: a method of levels approach. London: Routledge; 2015. Carey TA, Tai SJ, Mansell W, Huddy V, Griffiths R, Marken RS. Improving professional psychological practice through an increased repertoire of research methodologies: illustrated by the development of MOL. Prof Psychol Res Pract. Advance online publication. 2017; https://doi. org/10.1037/pro0000132. Carey TA, Fauth JM, Tremblay GT. Rethinking evaluation for improved health outcomes: implications for remote Australia. Am J Eval. 2019:1–21. https://doi.org/10.1177/109821401882 4040. Gee T, Dudgeon P, Schultz C, Hart A, Kelly K. Aboriginal and Torres Strait islander social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, editors. Working together: aboriginal and Torres Strait islander mental health and wellbeing principles and practice. 2nd ed. Canberra: Commonwealth of Australia; 2014. p. 55–68. Website for book: https://www.telethonkids.org. au/our-research/early-environment/developmental-origins-of-child-health/aboriginal-maternalhealth-and-child-development/working-together-second-edition/; Website for chapter: https:// www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working-togethersecond-edition/wt-part-1-chapt-4-final.pdf Hansson L, Jormfeldt H, Svedberg P. Mental health professionals’ attitudes towards people with mental illness: do they differ from attitudes held by people with mental illness? Int J Soc Psychiatry. 2013;59(1):48–54. Hegney D, Ross H, Baker P, et al. Building resilience in rural communities toolkit. Toowoomba: University of Qld/University of Southern Qld; 2008. Hudson S. Mapping the indigenous program and funding maze. Sydney: The Centre for Independent Studies; 2016. Humphreys J, Wakerman J, Kuipers P, Wells B, Russell D, Siegloff S, Homer K. Improving workforce retention: developing an integrated logic model to maximise sustainability of small rural & remote health care services. Canberra: Australian Primary Health Care Research Institute; 2009. Marmot M. Health in an unequal world: social circumstances, biology and disease. Clin Med. 2006;6(6):559–72. Marmot M. The health gap: the challenge of an unequal world. London: Bloomsbury; 2015. Pearson A, Jordan Z, Munn Z. Translational science and evidence-based healthcare: a clarification and reconceptualization of how knowledge is generated and used in healthcare. Nurs Res Pract. 2012:792519. https://doi.org/10.1155/2012/792519. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization. 2010. https://www.who.int/sdhconference/resources/Conceptualframework foractiononSDH_eng.pdf. Accessed on 8 Sept 2020. Swartz SM. Warlpiri-English dictionary: with English-Warlpiri finderlist. 2nd ed. Palmerston: Australian Society for Indigenous Languages (AusIL); 2012. Vines RF. Clinical psychology in rural general practice: a national pilot of a new model of collaborative mental health service delivery; PhD Thesis; University of Sydney. 2008 Dec 31. http://ses.library.usyd.edu.au/handle/2123/6640 Vines RF, Hurley BM, Thomson DM. Clinical psychology in rural general practice: a pilot of a collaborative model of mental health service delivery. Clin Psychol. 2002;6(2, Autumn):29–40. Vines RF, Richards JC, Thomson DM, Brechman-Toussaint M, Kluin M, Vesely L. Clinical psychology in general practice: a Cohort study. Med J Aust. 2004;181:74–7. Wakerman J, Humphreys JS. Sustainable workforce and sustainable health systems for rural and remote Australia. Med J Aust. 2013;199(5 suppl):S14–7. https://doi.org/10.5694/mja11.11639. Worley P. Setting the scene. Keynote address at the 6th rural and remote scientific symposium. 11–12 April, Canberra. 2018. Retrieved on 7 May 2020 from: http://ruralhealth.org.au/6rrhss/ program

Index

A Aboriginal and Torres Strait Islander, 600–606, 608–610, 612–614 Aboriginal Community Controlled Health Organisations (ACCHOs), 601 Aboriginal community controlled health service, 316 Aboriginal Healing Foundation, 403 Aboriginal Health Workers (AHWs), 377, 386 Access to Allied Psychological Services (ATAPS) program, 194 Access to psychological services, in remote Australia dose-response and good enough level models of treatment delivery, 258–259 recovery-oriented approaches, 259–260 strategies, 256–257 treatment design and treatment delivery, 257–258 treatment efficiency, 255–256 Access to services, 4, 5, 24, 518 Accident Compensation Commission, 420 Accountability, 165, 177, 185, 186 Addams, Jane, 423 Adolescent eating disorder, 285 Advocacy, 405–406 American Psychiatric Association, 3 Anti-oppressive assessment, 341 Anti-oppressive practice, and rural social work, 425–431 Anti-psychiatry movement, 466, 467 Antisocial personality disorder, 470 Anxiety, 477 Aotearoa New Zealand (ANZ), 419–422, 426, 427 Asperger’s syndrome, 470 Assessment, 360, 361, 368 Assessment, Support, and Counseling (ASC) Center, 592

At-risk population, 736 Attention deficit/hyperactivity disorder (ADHD), 70 Audio clarity, 335 Australia equity of access to primary health care services, 200–201 general practice, 204–205 group vs. solo practice, 205 incidence of mental health issues, in rural communities, 199–200 mental health issues, in rural communities, 205–206 mental health nursing, 208 mental health specialities in, 202–203 OTDs, 205 primary mental health service providers, mapping of, 203–204 psychiatrists, 206 psychologists, 207 risk factors and needs of rural people, 195–197 rural areas and equity, 195 social exclusion, 198 unique population characteristics of, 194–195 Australian Bureau of Statistics, 514 Australian Government funding businesses and organizations, 171 donations and philanthropic support, 171 funding distribution, 168–170 service users, 172 state and territory expenditure and funding, 169–171 total funding growth, 168–170 Australian Government Senate Community Affairs Reference Committee, 440 Australian Institute of Health and Welfare (AIHW), 20, 168, 183

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786 Australian Psychological Society (APS), 11, 146, 207 Australian Research Council (ARC) grants, 750 Autonomy, 379, 381 Axis II Borderline Personality Disorder, 470

B Bandura, Albert, 403 ’Barefoot counsellors’ program, 57 Better Access Scheme, 256 Better Access to Mental Health Care initiative, 194, 203, 209 Bio-psycho-social framework, 714 Biopsychosocial model, 4, 705 Bipolar depression, 470 British Charity Organization Societies (COS), 423 British Psychiatric Association, 467 Burnout, 493, 496, 504

C Canadian Community Health Survey, 25 Canadian Psychological Association, 402, 403 Caregivers, 478 Care planning, 301 Case management, 716 Centre for Rural and Remote Mental Health, 178 Child and adolescent mental health, 581, 589 Climate change, 659 adaptation, 680–687 anxiety, 666 coping with loss and damage, 688 gradual/indirect causes of, 662 health impacts, 660 household disaster preparedness, 686–687 impact on rural and remote population, 662, 663 impacts on health systems, 665 implications for rural and remote practitioners, 667–668 mitigation, 677–680 psychological impacts of, 671 resilience, 668 responding to, 676 vicarious threats, 665–666 Clopixol, 729 Coexisting mortality-related physical illness, 295 Cognitive behavior therapy (CBT), 96, 258, 365, 650, 715 Collaboration, 379, 386, 387, 748 Collaborative care, 368, 369

Index Co-location, 210 Communication, 748 Community, 53, 55–56 development, 33 Community-based participatory approaches (CBPA), 338, 339 Community-based services, 7, 26 Community Care Unit (CCU), 454 Community Managed Organisation (CMO), 446 Community pressure, 142, 143, 145 cultural dimensions, 144 integrity, 143–144 practice adaptations for, 145 visibility impacts, 144 Comorbidity, 295–296 Competencies, 221–224 Competition, 402–403 Complementary and alternative medicine (CAM), 75 Conflict, 502–505, 508, 509 Conjoint behavioral consultation (CBC) model, 592, 593 Consult-liaison (CL) care, 333 Control, 33–34, 497–504, 506, 508, 509 autonomous, 497–498 Conventional health services, 69–70, 83 Council of Australian Governments (COAG), 194 Council of Remote Area Nurses of Australia, 382 Critical psychiatry, 468 Cross-cultural psychiatry, 338 Culture, 46 diversity, 565–567 psychiatry, 472 safety, 566 Culturally and linguistically different (CALD) families, 631–632 Culturally informed treatment, 701–702 Culturally relevant content, 746 Cytochrome P450 enzymes, 568, 570

D Daily structure and social participation, 309 Decision-making, 478 Delusional symptoms, 465 Democratic psychiatry, 468 Depression, 477 diagnosis of, 477 Depression and anxiety, 694 assessment and diagnosis, 696–698 case study, 698–699 culturally adapted interventions, 703

Index culturally informed treatment, 701–702 facility-based mental health services, 701 practice implications, 699–700 symptoms of, 694 telehealth and technology, 700 workforce and community support, 703–704 Dewey, John, 22 Diagnostic and Statistical Manual’s Autism Spectrum Disorders, 470 Diet, 298 Digital technology, 237 Direct mental health expenditure, 166 Discrimination, 437, 441, 456, 601 Distress Questionnaire-5 (DQ5), 360 Dollard Health Center, 678 Dose-response (D-R) model, 258, 259 Double-blinded, randomized controlled trial (DBRCT), 81 Drapetomania, 469 Drive-in, drive-out (DIDO), 218, 219 Dysaesthesia aethiopica, 469

E Eco-anxiety, 666 Ecological systems theory, 419, 424 Education, 745 Effectiveness, 255, 265, 268 Efficiency, 255–257, 260, 261, 265 eHealth, 522 E-learning resources, 632 Electronic mental health (e-mental health), 73 technology, 517 Emergency departments (EDs), 377 Employment, 22, 24–25 Evaluation, 10, 13, 14, 749 Evidence-based healthcare, 13, 14 Evidence based medicine, 720 Evidence-based practice (EBP), 589 Exercise, 297–298 Explanatory model (EM), 46 Expressed emotion, 726

F Face-to-face programs, 745 Families, in rural and remote communities, 634 Aboriginal and Torres Strait Islander families, 631 access to support and treatment, 626–627 burden of care, 629–630 CALD families, 631–632 intimate partner violence, 630 LGBTI individuals, 633–634

787 peer support groups, 632 protective factors and stressors, 625–626 stigma, 627–629 systems change, 635–636 Farmstrong, 421 Far West Local Health District Mental Health Service, 443 Far West Mental Health Integration Project, 186 Feasibility, appropriateness, meaningfulness, and effectiveness (FAME) approach, 99 Financial counselors, 650 Financial stressors, 420 Finnish Turku project, 337 First Nations, 69, 77, 79 Flourish Australia, 452–454, 456 Fly in fly out (FIFO), 98, 218, 219, 496 Formulation, 362, 363 Funding, mental health, 186 accountability for mental health, in Australia, 177 Australian Government funding, 168–172 individual mental health consumers, 174–175 non-government, community-controlled, not-for-profit organisations, 172–173 PHNs, 174 private health providers, 173–174 private hospitals, 174 sources, 166–168 state and territory government services, 172 structure and flow of funding, 175 teaching and research institutions, 175 total funding, 166–167

G Gaps, continuity of care, 742–743 Gender differences, and social support, 644–645 Generalist practice and competency, 145–148 General neurotic syndrome, 695 General Practice Mental Health Standards Collaboration (GPMHSC), 359 General practice psychology, 408 General practitioners (GPs), 7, 8, 173, 194, 262, 263, 352, 353, 365, 377, 626 appointment, 357 assessment, diagnosis and formulation, 360–362 characteristics of, 354 collaboration, 368–369 health promotion and illness prevention, 357–359 identification and early intervention, 359–360

788 General practitioners (GPs) (cont.) psychological intervention strategies, 365 referral, 368 self-care, supervision and sustainable practice, 369–370 treatment planning and shared decisionmaking, 363–364 Genetic polymorphisms, 567 Geographic disparity, 399 Global Burden of Disease Study, 192 Global Green and Healthy Hospitals (GGHH) initiative, 678 Global mental health Bangladesh, 52–53 biopsychosocial model, 47 community resources, 55–56 culture and its impact, 46–47 emergence of, 45–46 ethical considerations, 56 rural and remote practice in low-and middleincome countries, 48–49 scaling-up and task-sharing, 47–48 training program, 54 Uganda, 49–52 Global public health policy, 193 Good enough level (GEL) model, 259 GP Mental Health Treatment Plan (GPMHTP), 359, 361, 362, 369 Group medical care, 74–75 Group support psychotherapeutic (GSP) approach, 58–60 H Health care provider, 69 definition, 69 Hearing Voices Movement, 467 Hearing Voices Network, 468 Holistic approach, 381 Homeostasis, 497 Horizontal integration, 310 Hospital-based psychiatry, 274 Household, Income and Labour Dynamics in Australia (HILDA) Survey, 519 Housing, secure, 26–27 Human rights, 301 based approach, 613 I Idioms of distress, 472 Improving Access to Psychological Therapies (IAPT), 256, 258 Inactivity, 307

Index Indigeneity, 198–199 Indigenous knowledge systems, 600 Indigenous languages, 76 Indigenous mental health, in remote communities cultural continuity and health, 76–77 group medical care, 74–75 indigenous languages, 76 internet and telemedicine for service delivery, 73–74 large group interventions, 81–82 local knowledge, 71–72 peer counsellors, peer support and mentoring, use of, 80–81 resilience, 81 self-continuity, 78–80 spirituality, in health care, 75–76 traditional cultural healers, in health care, 77–78 Integrated primary mental health care, in Australia, 208–209 culturally-appropriate health services, for Indigenous clients, 210 general practice, 204–205 group vs. solo practice, 205 joint training initiatives, 210 lifestyle interventions, 211 mental health issues, in rural communities, 205–206 mental health nursing, 208 mental health specialities, 202–203 multi-disciplinary primary health care teams, co-location of, 210 OTDs, 205 primary mental health service providers, mapping of, 203–204 psychiatrists, 206 psychologists, 207 Integration, 313 Interagency relationships, 148 Interdisciplinary, 275, 283, 284 Interdisciplinary collaboration and confidentiality, 148, 150 in practice, 148–149 practice adaptations for, 149–150 Intergenerational poverty, 72 Internal validity, 96 International Federation of Social Workers (IFSW), 424 Internet, 398 Internet-based services, 73 Interpersonal therapy (IPT), 365 Intimate partner violence, 630

Index J Joanna Briggs Institute (JBI) model, 97

L Lesbian, gay, bisexual, trans/gender diverse and intersex (LGBTI) individuals, 633–634 Life-course approach, 34–36 Life expectancy, 195 Lifestyle, 193, 196–198, 211 Local government areas (LGAs), 195 Local knowledge, 71–72

M Māori social work with, 418–419 Te Whare Tapa Wha, 422–423 Mechanistic brain disease model, 467 Medicare, 7, 240–241 expenditure, 179 mental health, 174 Medicare benefits schedule (MBS) funding models, 276 Medication effects, 297, 308 Mental disorders, 397 Mental health, 112, 113, 115–117, 119–130, 658 causes of climate change on, 662–663 environmental threats on, 660 funding (see Funding, mental health) impacts of climate change, 661–662 problems, 335 professionals, 96 reform, 458 Mental Health Act, 447 Mental Health Professionals’ Association of Australia, 203 Mental Health Professionals Network (MHPN), 369 Mental health research and evaluation, in RRvR settings categories of research, programs and services, 99–101 demonstrating impact, 105–106 evidence, 99 evidence-based practice, 97 form and function, 102 learning opportunities, 104–105 ongoing monitoring, 101, 104 principles, 103–104 purpose, 102 RCT, 96, 97

789 Mental health services, 451 limited access to, 377–378 Mental illness, 25, 390 incidence, 330 prevalence, 330 prevalence of, 624 recovery in (see Recovery, in mental illness) Mental state examination (MSE), 362 Mentoring, 80 Method of levels (MOL), 261, 263–264, 269 Metropolitan clinicians, 241 Mitigation advocating for climate policies, 679–680 description, 677–678 environmental footprint with rural and remote mental health practitioners’ workplace, 678–679 Mobile phones, 650 Motivational interviewing (MI), 545 Multidisciplinary care, 201 Multidisciplinary teams (MDT), 274, 425, 426 adolescent eating disorder, 285 challenges, 277–282 clinician autonomy and collective decision making, 280 conflict resolution, 281–282 definition, 275–277 establishment, 283–284 leadership, 278–279 regional adult mental health, 286 role and professional ambiguity, 279–280 strengths and advantages, 282–283 workforce, 277 Multi-tiered systems of support (MTSS), 587 data-based decision making, 588 evidenced-based interventions, 588 rural implementation, 588 universal implementation of interventions, 587

N National Aboriginal Community Controlled Health Organisation (NACCHO), 601 National Aboriginal Health Strategy Working Party, 603 National Disability Insurance Scheme (NDIS), 172 National Health and Medical Research Council (NHMRC), 175, 750 National Health Service (NHS), 107, 262, 267, 268

790 National Institute for Health and Clinical Excellence (NICE), 258 National Institutes of Health (NIH), 70 National Medicines Policy (NMP), 559, 560 National Mental Health Commission (NMHC), 170, 176, 438, 737 National Rural Generalist Pathway (NRGP), 201 National Schizophrenia project, 337 National Survey of Mental Health and Wellbeing of Adults, 199 Natural disasters, 502 Natural support systems, 704–705 Needs-adaptive approach (NAA), 337 Negative feedback colloquial, 497–498 engineering, 497–499 New Zealand, 418, 419 anti-oppressive practice and rural social work, 425–431 rural ANZ, 419–422 Te Whare Tapa Wha, 422–423 Ngangkari, 389 Non-communicable diseases (NCDs), 193 Non-government organizations (NGOs), 7, 172, 173 innovation, 316 Nursing and Midwifery Board of Australia, 208 Nursing roles appointments, 388 clinical nursing skills, 385 collaboration and working in isolation, 379–382 communication styles, 388 increased acuity, 378–379 multifaceted role and therapeutic relationships, 382–385 time-related cultural considerations, 388

O One sidedness, 469 Ongoing evaluation, 774–775 Open Dialogue, 336, 337 style approaches, 338 Open Dialogue in Acute Psychosis (ODAP I and ODAP II) projects, 337 Organization of mental health services, 6–8 Outcome Rating Scale (ORS), 264, 265 Overlapping relationships, 142 boundaries, 139–140

Index in practice, 141 and practice adaptations, 141–142 and professional ethics, 140–141 Overseas–trained doctors (OTDs), 205 Overseas trained psychiatrists (OTPs), 206

P Paraphilias, 470 Parkinson’s disease, 465 Partnerships, 748 Patient-centered care model, 705 Patient Empowerment Program for Schizophrenia (PEPS), 118 Patient Health Questionnaire (PHQ), 516, 697 Patient-led clinic access, 264–265 effectiveness, 265 efficiency, 265 establishing, 262 evaluating, 264 MOL, 263–264 operating, 262 patient-led appointment scheduling, 262–263 Patrick Dollard Discovery Health Center, 678 Peer Operated Service (POS), 452–454 Peer support, 73, 80 groups, 632 Peer work, in rural and remote mental health services and communities, 438, 455–457 benefits, 443 employment of peer workers, 438 local peer workers, 442 mental health service teams, 450 peer support initiatives, 443 service health staff, 441 telephone and video conferencing, online peer work communities of practice, 446 voluntary peer support, 438, 439 workforce culture, 451–454 Perceptual control theory (PCT), 22, 497–500, 502, 505 Personal recovery, in rural environment, 120–121 clinical support, 121–122 dual/overlapping relationships, 122 limited employment opportunities, 123–124 mental illness, rural community understanding of, 122–123 stigma, 123

Index Personal safety, 222, 380 Person-centred care, 284 Pharmacogenomics, 567 Physical exercise, 308 Physical health assessment, 360 Physical health treatment, 304 Politics, 469 Polymorphisms, 567 Poor nutrition, 307 Positive behavioral interventions and supports (PBIS) definition, 587 rural implementation, 588 Positive emotion, engagement, positive relationships, meaning, and engagement (PERMA), 357 Post-traumatic stress, 470 disorder, 472 Poverty, 400, 419, 600 Practice-based collaborative care, 334 Pressure, 142 Prevention definition, 736 early interventions, 737 primary, 736 programs, 747 secondary, 737 tertiary, 737 Primary care in RRvR settings, 778–781 Primary care services, 10 Primary health care services, 517 Primary Health Networks (PHNs), 7, 174, 194, 737 funding to, 7 role of, 7 Primary mental health care, in Australia barriers, 201 general practice, 204–205 group vs. solo practice, 205 mental health issues, in rural communities, 205–206 mental health nursing, 208 mental health specialities, 202–203 OTDs, 205 primary mental health service providers, mapping of, 203–204 psychiatrists, 206 psychologists, 207 stigma, 202 Private health providers, 173–174 Private mental health services, 7

791 Productivity Commission, 185 Professional development, 12 and support, 150–153 Professional ethics, in rural practice, 155–156, 402, 411 community pressure and integrity, 142–145 critical incidents and ethical development, 153–155 generalist practice and competency, 145–148 interdisciplinary collaboration and confidentiality, 148–150 overlapping relationships and objectivity, 139–142 professional development and support, 150–153 Professional mental health services, 397 Program sustainability, 749 Promotion, 737 Proportionate universalism, 29 Psychiatry, 206–207 case management, 716 medications, 471 Psychoeducation, 632 Psychological and psychiatric services, 238 Psychological distress, 4, 441, 514, 516, 519 Psychological preparedness, 686, 687 Psychological therapy, see Telepsychology Psychologist’s role, in rural and remote areas, 410 advocacy, 405–406 career, professional and employment opportunities, 401 competition, 402–403 funding programs, 407 geographic barriers, 407 government, 403–404 non-normative practice settings, 407 prescriptive authority debate, 404 professional practice norms, 407 registration and mobility, 404–405 social justice, 407 urban-centric practice, 407 Psychology, 207–208 Psychopharmacology in schizophrenia, 726 Psychosis, 725 curriculum for rural practitioners, 725 and phenomenology, 725 psychological skills, 726–728 Psychosocial recovery model, 688–689

792 Psychotropic medicines, 558, 571, 575 advantages and disadvantages, 563 cytochrome P450 enzymes, 570 human rights, 559 PsycINFO database, 96 Public transport, 518

Q Qualitative studies, 410 Quality use of medicines (QUM), in rural and remote settings clinical reasoning, in medicines management, 561–564 communication challenges, 567 cultural diversity, 566–567 decreased access to health services, 564–565 ethical considerations, 559 frameworks and policies, 559–560 medicinal trial data to clinical practice, 569–573 physiological variations, 567–569 practice implications, 573 Quantitative studies, 410

R Racism, 601, 603, 605, 610 Randomized controlled trials (RCTs), 96, 97, 100, 101, 258 Recovery, in mental illness, 114 anti-stigma/anti-discrimination interventions, 128–129 clinical, 115 co-design, 129–130 community support and service interventions, 126–128 connectedness, 115–116 distinctive features, 113 empowerment, 118 framing, 119 hope and optimism, 117 identity, 117 meaning in life, 117–118 personal, 120–124 positive identity, developing, 118–119 practice implications, 113 self-managing, 119 social inclusion, 125–126 social roles, developing, 119–120 Recruitment and retention incentives, 771–772

Index Regional commissioning authority (RCA), 185 Registration, 405 Reliability, 103, 104, 107 Remote and rural communities, health care in, see Telemental health Remote areas nurses (RANs), 9 Remote collaborative care program, 336 Remote health, 8 Replication, 103, 104, 107–108 Reporting, 94, 100, 103, 104, 108 Resilience, 54, 58, 81, 496, 607 Resilient Community Organisations toolkit, 682 Response to intervention (RtI), 587 Responsibility, 737 Returns on investment (ROI), 756 Richmond, Mary, 423, 424 Rigor, 103, 104, 107 Routine, 94–97, 99, 103, 104, 106, 108 Royal Flying Doctors Service (RFDS), 199 Rural and remote communities characterization, 696 description and distinctive features of, 694–696 integrated mental health services, 701 telehealth and technology, 700 Rural and remote mental health characteristics, 183–184 Medicare-subsidized mental health-specific services, 182, 183 prevalence and burden of disease, 178–179 rural mental health expenditure, 179–180 rural mental health workforce, 180–181 youth mental health access, 182–184 Rural Aotearoa New Zealand, 419–422 Rural community building, 646 recovery in mental illness (see Recovery, in mental illness) Rural Health Alliance Aotearoa New Zealand (RHANZ), 421 Rural Health Multidisciplinary Training Program (RHMTP), 203 Rurality, 399 Rural mental health providers, 651–652 Rural mental health workers, 310 Rural, remote and very remote (RRvR) mental health, 4, 6, 14 Aboriginal and Torres Strait Islander Australians, 9 characteristics, 769 ethical and professional challenges, 12–13 ethical and professional practical issues, 775

Index evaluation of programs and services, lack of, 13–14 mental health model, 775–777 ongoing education and professional development, for mental health practitioners, 11–12 organisation of mental health services, 6–8 policy change, 771–773 primary care, importance of, 10 recommendations, 781 routine evaluation routine, 774 SEWB (see Social and emotional wellbeing (SEWB)) social determinants of health (see Social determinants of health) specialist services, lack of, 9 training models, 777–781 Rural, remote, and very remote settings, 94 Rural Support Networks, 429 Rural Support Trusts, 420

S Salutogenesis, 608 Schizoaffective disorder, 470 Schizophrenia, 465, 467, 712 Aboriginal and Torres Strait Islander Australians, 719 bio-psycho-social’ framework, 714–716 case study, 729 clinically recovered, 478 community mental health team, 713 effective service models, 720 ideal models of care, 716 management in rural and remote communities, 717–722 practice implications for practitioners in rural and remote settings, 722–725 symptoms of, 713 in Zanzibar, 473 School-based health centers (SBHCs), 583 School-based intervention, 582, 587, 589, 590 School-based mental health services, in rural and remote settings, 582 challenges, 590, 591 EBP, 589 effectiveness of, 584, 585 family engagement, 589, 590 interdisciplinary collaboration, 585, 586 PBIS and MTSS, 587, 589 SMH programs, 583, 584 SSBHCs, 583

793 telehealth and telepsychology, 584 university-community partnerships, 586, 587 School-based prevention, 587, 589, 590 School mental health (SMH) programs, 583, 584, 586 Scientist-practitioner model of training, 778 Screening, 302 Secure housing, 26–27 Selective serotonin reuptake inhibitors (SSRI’s), 471 Self-care, RRvR mental health service provision, 507 atypical career trajectories, 494–495 challenge, 504 control problem, 502 follow-up evaluation, 506 goal conflicts, 503 goals, 500–501 health, control in, 499 income and job security, 495–496 intra-personal conflict, 502 nature of mental health work, 494 negative feedback, 497–498 phenomenon of control, 497 post-workshop evaluations, 506 Self-continuity, 78–80 Self-harm, 514, 515, 518, 520, 524 Self-Help Network of Kansas, 649 Senate Committee Report, 760 Session Rating Scale (SRS), 264 Severe and persistent mental illness (SPMI), 114–116, 128 Shared decision-making, 363, 364, 368 Shared medical appointments (SMA), 74, 75 Shomaj Shongi model, 57–58 Smoking, 296 Smoking cessation, 306 Social advocacy, 408 Social and emotional wellbeing (SEWB), 5, 6, 10–11, 352, 353, 370, 601–603, 608–609, 614 Australia’s historical, political and social contexts, 612–613 effective communication, 612 genuine relationships, 612 historical and social determinants, influence of, 603 human-rights based approach, 613 listen and inquire, 611 process and outcome, 613 risk and protective factors, 609–611 self and cultural identity, 605

794 Social capital, 25 Social cohesion, 519 Social connectedness, 401 Social determinants of health (SDOH), 10, 779 Social determinants of mental health, 71 access to services, 24 circuit model, 22 community level, 31–33 country level, 29–31 employment, 24–25 individual-level, 33–36 material factors, 22 mechanisms, 21 principles and actions, 28–29 psychosocial factors, 22 rurality, 27–28 secure housing, importance of, 26–27 social capital, 25 social-political exclusion, 25–26 Whitehall I study, 20 Social exclusion, 26, 197–198 Social inclusion, 113, 116, 125–130, 299, 715 and community participation, 310 Social justice, 407, 408, 430 Social media, 650 Social participation, 309 Social positioning, 425 Social Return on Investment (SROI), 452, 453 Social selection, 22 Social stratification, 30 Social stress, 21 Social support, 25, 642–644 community building, 646–648 community groups as, 645–646 and gender differences, 644–645 and rural communities, 645 social media and mobile phones, 650 support groups as, 648–650 Social work, 418, 423–424 and anti-oppressive practice, 425–431 competence, 418–419 Socioeconomic factors, 198 Soteria Project, 467 South Australia Health and Medical Research Institute (SAHMRI), 357 Southern New South Wales Local Health District (SNSWLHD), 447 Stakeholder engagement, 104 STAR*D study, 5 Stepped care, 257 model, 738 Stepped mental health care model, 312 Stigma, 627–629, 740 Strength-based approach, 602, 605–609, 611–613

Index Stress, 34 inoculation, 686 Substance abuse in Australia, 536 definition, 534 in Europe, 538 health disparities in, 540–542 in New Zealand, 537–538 perceptions of, 535 prevention and treatment of, 542–545 racial vs. ethnic minorities, 547–549 remote therapies, rural and remote populations, 546–547 in rural and remote areas, 535 scope of, 535 in United States, 535–536 in urban and rural areas, 534 Substance use, 308 Suicidality, 755 Suicide, 69, 76, 78, 79, 83, 295, 514, 516, 735 assessment, 515 in farming communities, 519 global suicide rate, 515 male, 514 rates, 200 risk factors, 516 Suicide prevention, sustainable community solutions, 521 capacity building, 522–523 communication, 525 community development/strategic plans, 523 community leadership/elders, 523 cultural appropriateness, 524 education, 524 service collaboration, 524–525 Support and advocacy, 303 Support groups, 648–650 Systemic change, 744

T Targeted communications, 744 Task-sharing, 47–48 Telehealth, 398, 584 initiatives, 207 substance abuse and, 546–547 Telemedicine, 335 Telemedicine-based collaborative care, 335 Telemental health, 635 access and acceptability, 235–236 Australia, 234 in rural and remote communities, 237 videoconferencing (see Telepsychology) workforce, 235–237

Index Telepsychiatry, 73, 335 assessments via videoconference, 335 Telepsychology, 584 case study, 243–245 empowerment, 239 funds, 240–241 lack of training, 241 optimization, 242–243 practical benefits, 238 professional concerns, 242 technical glitches, 241 therapy, 238–239 videoconferencing, 245–246 work burden, 242 The Lancet, 3 Therapeutic relationships, 376, 384, 387 Thorn program, 725 Training, psychology, 745 content, 778 models, 777 primary care, 778–781 structure of, 777–778 Transdiagnostic mental health interventions, 56 Transdisciplinary collaboration, 148 Trauma model, 330

U Unemployment, 519 Unipolar depression, 470 United Nations Convention on the Rights of Persons with Disabilities, 559 University-community partnerships, 586, 587

V Vertical integration, 311 Very remote area nurses (vRANs), 9 Victorian Mental Illness Awareness Council (VMIAC), 447

795 Videoconferencing, see Telepsychology Video phones, 650 Video therapy, 241, 242 champions, 245 psychological risk, 245–246 in rural environments, 237 sustainable funding, 245 Visiting rural and remote mental health services advantages and disadvantages, 220 competencies, 221–224 FIFO/DIDO model, 219 hub and spoke model, 219 orbiting model, 219 practitioners and organisations, considerations for, 225–226 recruitment and retention opportunity, 227 short term locum/agency models, 219 support needs for, 225 training and supervision, 226–227

W Wajampa, 781 Warlpiri, 781 Weight gain, 298 Western model of depression and anxiety, 699 WHO Commission on Social Determinants of Health, 31 Wholistic treatment, 193 Workplace programs, 756 World Health Organization (WHO), 22, 30, 198, 443, 515, 559

Y Years of life lost (YLL), 179 Youth Experiencing Success in Schools (Y.E.S.S.) Program, 592 Youth mental health, 581, 582