Thursday, February 24, 2011

Rural Mental Health – An Interview with George Doherty

Category: Conversations

George W. Doherty is the President of the Rocky Mountain Region Disaster Mental Health Institute. The institute delivers critical incident response training in Wyoming and throughout the region as well as a national yearly conference and proceedings for crisis response managers and the mental health professionals who work with them. His upcoming book called Crisis In The American Heartland: Disasters & Mental Health In Rural Environments (Loving Healing Press 2011) is about services in rural areas after a disaster, to ensure early recovery and prevention of aggravation of psychological conditions resulting from disaster and/or trauma. In the following interview, George answers some of my questions about mental health issues among the elderly population of rural areas in America. 

Ernest: George, in Crisis In The American Heartland you talk about becoming old as a phase of transition and changing roles. What are the main psychological problems in this phase?

George: Adjustments to changes in physical abilities; acceptance of changes in self-concept and even mental abilities in some cases; job roles, especially in rural areas, can affect how a person adjusts to changes in how jobs are done and by younger people who may have different ideas and approaches; adjusting to changed life-styles, fading of traditional ways of life, loss of life-long friends, neighbors and family members (especially a spouse); increasing health problems, ability to maintain independence, losses of home and/or cherished possessions due to a disaster; predatory actions taken by fraud criminals who prey on the elderly; finding meaning in life when the world seems to be changing in new ways. Dealing with possible nursing home placement can be a major life adjustment. Social contacts and interactions change. In some, feelings of self-worth are affected.
Overall, adjustment to a changing life remains primary. Some adjust better than others. With longer life spans in the United States, finding ways to use the experience, education and abilities of older adults in the workforce will be a critical issue to address as the population ages. In some situations, respect for and maintenance of older adults health and economic security are very poor. The value of respect for elders is not one that is as well-developed as it appears to be in other societies. Depression is an additional problem faced by many seniors. This can be due to many causes, mostly related to the above mentioned issues and losses. Support by family members and friends may not be the same as it had been in younger years.

Ernest: And are these problems similar among the aging groups in rural and urban areas?

George: There are some significant differences between rural areas, especially farm and ranch environments. Family involvement, support, and togetherness have been traditionally more obvious and influential in how older people are accepted in farming/ranching environments. In the past more often than the present, older family members have been respected for their experience, wisdom, expertise, judgment, foresight, planning, and knowledge. In many cases, they represent a somewhat patriarchal or matriarchal system. Farming/ranching families often have deep spiritual values, strong commitments to the land and their style of life, are hard-working and have life-long commitments to their way of life. They value life-long friends and fellow farmers/ranchers. In many cases they help and support one another during times of crisis and/or disaster. Most are very independent and prefer to address adversity on their own and/or with the help and assistance of their neighbors. Seeking assistance from welfare groups, government, or other outsiders is often rejected.

Agrarian groups (e.g., Grange, 4-H, Future Farmers of America, etc.) are major educational and support groups. With the growing development of corporate farms and ranches, often owned by national business organizations and corporations, many of these values and strengths are falling by the wayside in favor of corporate profits. This is a major part of the Farm/Ranch Crisis facing the country and has major effects on how the aging rural population adjusts and is treated. Additionally, there is a major lack of medical and mental health professionals in all rural areas, but quite apparent in the frontier states (e.g., Wyoming, Montana, Utah, Nevada, Alaska, and others where there is a lack of medical and mental health professionals). The lack of these resources in rural areas has major affects on the aging rural populations. Long distances to travel to access such services, if available, hamper treatment and help as well. This is even true for our veterans who reside in such areas. 
In urban environments, medical, mental health, educational, and other services are available and much more easily accessed. The acceptance and availability of these services is also greater, and often expected by residents. While there are certainly some problems in urban areas in these regards, there are far more services available, either public or private, than in rural areas, especially in frontier states. Most medical and mental health professionals prefer urban to rural settings primarily for such things as professional development opportunities, economic security, much higher salaries, and a more preferred life style. For older populations, such services are definitely more available and responsive than in rural/frontier areas.

Ernest: You mention that older adults, particularly in rural areas, are reluctant to move from their home, even if living in a disaster prone area. What psychological factors account for it? 

George: In many situations, farm/Ranch families have been living in the same home on the same land for a number of generations. For example, in western states, many ranch families originally homesteaded their land. The ties to the home and land are strong and long-lasting. They not only feel tied to these, but also a responsibility. They are the caretakers of their land and home. After having lived in their same home their whole lives, they do not wish to leave or abandon them. Additionally, family, friends, neighbors, and others are important parts of their lives. The adjustment of leaving can often be far more detrimental to their wellbeing than staying. Following a major disaster, they often want to stay where they have always been and re-build and continue. With the help of family, friends, and neighbors, they prepare to deal with and overcome these adversities. The strengths and ties they have to these and to their stewardship of their lands are important factors in their wanting to stay.

In major disasters, the loss of some or all cherished possessions and/or even lives, often the only important part of their lives to give meaning, support, and ties comes from their lifetime home and land. These are what have made their lives full of meaning and value. All areas in this world are disaster-prone in one way or another. The stability of the land provides strength. In most situations, farmers/ranchers, especially those who have done this for generations, have dealt with adversity before (either themselves or previous generations – e.g., dust bowl) and do not wish to give up. The land and home are familiar, long-time parts of their fabric and not to be given up in old age. Being born on the farm/ranch and working it their whole lives, they wish to see it through and eventually die as part of it – hopefully passing it on to a family member. Disasters, crises, losses have always been integral parts of farming/ranching. Drought, floods, wars, economic problems, crop failures, wildfires, other disasters have always occurred. The land and home are the major constants. 

Ernest: And older adults in rural areas, as you tell in your book, are also more hesitant in seeking help because they think it’s like asking for charity? Does it mean the concept for help varies for rural elders than urban ones?

George: Help is just as important for both populations. The major difference is where it comes from. Farmers/Ranchers have always been having an independent lifestyle. They do accept help, but usually from their own. These resources mostly include family members, friends and neighbors, agrarian groups such as Grange and others. To accept help and assistance from these incurs a responsibility to be there when they need assistance. This has developed over the generations when the only assistance in adversity came from others who were exposed to and understood similar situations. It is a bond developed from these situations and personal relationships. To accept assistance from government and/or, in some situations, from charitable organizations suggests possible failure to provide, an obligation to strangers, a possible moral question, and other factors.

As family farms/ranches slowly change or disappear and corporate farming/ranching expands, the reliance on government and charitable organizations is becoming more of a response following disasters in rural environments. The concept of help for rural elders is expanding, primarily in response to health and mental health issues. The lack of easily available medical and mental health services in rural/frontier areas is increasingly important, but is hampered by shortages of such professionals willing to make long-term commitments to such areas. Religious and church groups in rural areas also provide strong support and values for many elderly farm/ranch persons. In many cases they provide important support for these populations. Generally, the provision of services for rural elderly that is often taken for granted in urban environments is lacking.

Ernest: What are the specific means of psychological support available to rural elders that might help in case of a disaster? 
George: These are often limited in rural environments, often requiring outsiders and strangers to come to help alleviate immediate needs. Without questioning the good intentions and expertise of the helpers, their assistance is often time-limited and generalized. Fitting the best-intentioned helpers with the values and culture of a specific rural area has some problems. Unfamiliarity with these can hamper appropriate response. Development of support resources familiar to local populations prior to any event may help to more adequately respond. These resources may include neighbors, agrarian groups, churches and other local resources. Again, the presence of medical and mental health and educational personnel, readily and reliably available on a regular basis in rural areas prior to such events, will be more adequate in assisting rural elders and others in responding to and recovering from disaster/crisis events. Education of local populations about disaster/crisis response and recovery is important. This can be accomplished by educating folks through local groups, including churches, public health, schools, agrarian groups, and others. Peer support is another important resource. 

Ernest: Currently, in America’s rural areas, do we have any special support services, government or non-government, directed at the needs of the elders?

George: Such support generally comes from agrarian groups (e.g., Grange, 4-H, Future Farmers of America, Extension Services – County Agents, etc.). Land Grant Universities have representatives (e.g., County Agents) who have resources that address many of these areas and are usually quite accepted by farmers/ranchers. They often present educational opportunities for rural populations that address these areas. The growing awareness of the developing needs of rural seniors is one area that many university agricultural colleges study and provide assistance on. The US Department of Agriculture, often in partnership with Land Grant Universities, has a significant amount of resources in these areas. Most have a presence through county government and local educational institutions. Emergency Management Coordinators for counties are an additional resource.

Ernest: And would you like to offer any suggestions for improving the status of psychological support available to aging people in rural areas?

George: Here are some that I would like to mention:

A. Increase the reliable, ongoing and permanent availability of adequate numbers of medical and mental health professionals who are committed to serving rural/frontier populations. Initially such development would include a commitment by governmental groups to help guarantee such permanence and reliability. Some ways this could be accomplished could include internships, VISTA, Americorp, and other volunteer professionals. A required service commitment for a two year period by such professionals prior to completion of their final medical or mental health credentialing. Such service could also be a requirement for a percentage of payment of student loans incurred in their training. Without getting political, a look at the Cuban system of training medical and mental health professionals, their commitments required for their free education, and their specific approaches to treatments and preventive medicine, etc, and other areas might be instructive. It is critical to the future that such services as adequate medical, mental health and education be made readily available in rural/frontier areas to ensure that aging people in such areas continue to be relevant and important as well as to learn ways to help prevent future health and mental health problems.

B. Develop adequate economic resources, quality of life and other areas for medical and mental health professionals in order to keep them involved and reliably on the job in rural/frontier environments.

C. With the development and implementation of computer-based approaches, expansion of education, medical, and mental health services can be expanded to many rural/frontier settings. Such approaches can include individual consultations (e.g., utilizing such approaches as using Skype for personal consultations), educational programs with group interactions via conferences live online), ongoing educational programs both live and recorded for personal as well as educational development – these are and can be made available through such groups as Agricultural and Land Grant Colleges, County Agents, etc.

D. Provide training for local persons who are or are interested in working with elder rural persons via computer courses, conferences, consultations and live in-person presentations. This can provide a variety of trained peer opportunities, team development for local disaster/crisis responses, and many other related opportunities. Partnership with Land Grant and other groups can provide additional expertise. Such trainings via computer assisted approaches can also be implemented by utilizing training and consultation opportunities provided by groups and governments and agencies nationally as well.

E. Provide telecounseling and medical consultation discussions in rural/frontier areas. 

Ernest: George, thank you for sharing your knowledge with my readers!
George: Thank you for the opportunity. 

Interested readers can follow the activities and events of George Doherty’s Disaster Mental Health Institute at the website http://www.rmrinstitute.org .

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