Characteristics of rural communities
There are two aspects of working with young people in rural
areas that are important for professionals to keep in mind.
First, access to services in rural areas - particularly
specialist mental health care - is limited, and this has
implications for young people with mental health problems (Boyd et
al., 2006). For instance, young people may either be
uncertain as to whether help is available in their town or they may
have to travel great distance to access quality care (Aisbett et
al., 2007).
They may also be reluctant to seek care because of a perception
that the services available in their town are not youth-friendly
(Boyd et al., 2007; Francis et al., 2006). While there may be
a GP in town, it is likely that the GP is an older and established
member of the community, making him or her less likely to be
considered by young people as approachable (Boyd et al.,
2007). As public transport in rural areas is scarce, the need
to travel to services outside of the town is a threat to the young
person's anonymity and confidentiality if he or she is not licensed
to drive a car (Boyd et al., 2006).
The second aspect of working with young people in rural areas
may be less obvious but in many ways is more important - the
social characteristics of rural communities (Boyd
et al., 2008). Several researchers have described rural
communities as socially proximate or close-knit (Parr & Philo,
2003). A paradox exists between the closeness of social
relationships in rural communities and the distance that separate
community members.
Members of rural communities can often possess intimate
knowledge of each other's lives and this makes it very difficult
for rural youth to keep personal information quiet. Social
visibility and rural gossip networks mean that a young person
needing to access mental health services might fear being seen as
well as fear being talked about (Aisbett et al., 2007). Young
people who seek help in rural areas may also experience stigma and
social exclusion (Aisbett, 2007).
Stigma of mental illness
There are two forms of stigma of mental illness - social stigma
and self-stigma (Corrigan, 2005). While social stigma is imposed by
the community, self-stigma is a judgement imposed on a person with
mental illness by themselves, as an internalisation of community
attitudes.
In small rural communities there is often a 'culture of
self-reliance' which means that community members are expected to
'soldier-on' and not talk about their problems to anyone (Parr
& Philo, 2003). Stoic attitudes among rural men are the
norm, and mental illness can be considered a sign of weakness
(Francis et al., 2006). As such, the experience of
self-stigma for a young person in a rural area can be particularly
profound, especially for males (Boyd et al., 2008).
All young people with mental health problems are at risk of
experiencing social stigma of mental illness. In small rural
communities, however, this experience is exacerbated by the social
characteristics of rural communities (Aisbett, 2007). Members
of a close-knit community typically engage in a range of caring
practices if a fellow community member experiences a physical
illness; however, these same caring practices may not extend to a
person with a mental illness (Parr, Philo & Burns, 2004).
Therefore, a young person with a mental health problem can
experience feelings of rejection and isolation, ostracism or
exclusion when the usual caring practices of the community are not
forthcoming (Aisbett et al., 2007; Boyd et al., 2007).
Furthermore, stigmatisation in rural communities can be seen to
serve a social distancing function whereby community members limit
their social obligations to people with mental illness in a context
where access to services is poor (Boyd & Parr, 2008).
Recommendations for working with rural young
people
With an awareness and appreciation of the characteristics of
rural communities, we recommended that professionals working with
young people in rural areas do the following, in addition to their
usual practice:
- Talk to young people about their experiences of accessing the
service, e.g., what obstacles did they experience in their pathway
to care?
- Consider whether these obstacles are likely to have an on-going
impact on the young person's care and think of ways that they might
be minimised
- Explicitly raise and discuss the young person experiences of
social stigma and self-stigma as well as the culture of
self-reliance in rural communities
- Explain the notion of social proximity - i.e., "everybody knows
everybody else" - and the phenomenon of rural gossip as a
consequence of social proximity. Discuss feelings of rejection
or social exclusion associated with these phenomena
- Give the young person strategies to cope with negative
community attitudes
- Help the young person identify sources of social support within
their community
- Assist the young person, over the course of the therapeutic
interaction, to develop a strong sense of self and to reject
self-stigma.
References
Aisbett, D.L., Boyd, C.P., Francis, K., Newnham, K., &
Newnham, K. (2007). Understanding the barriers to mental health
service utilization for adolescents in rural Australia. Rural
and Remote Health, 7 (online), no. 624.
Boyd, C.P., Aisbett, D.L., Francis, K., Newnham, K., &
Newnham, K. (2006). Issues in rural adolescent mental
health in Australia. Rural and Remote Health, 6 (online), no.
501.
Boyd, C.P., Hayes, L., Sewell, J., Caldwell, K., Kemp, E., Harvie,
L., Aisbett, D.L., & Nurse, S. (2008). Mental health
problems in rural contexts: A broader perspective.
Australian Psychologist, 43, 2-6.
Boyd, C.P, Francis, K., Aisbett, D.L., Newnham, K., Sewell, J.,
Dawes, G., & Nurse, S. (2007). Australian rural adolescents'
experiences of accessing psychological help for a mental health
problem. Australian Journal of Rural Health, 15,
196-200.
Boyd, C.P., & Parr, H. (2008). Social geography and
rural mental health research. Rural and Remote Health, 8
(online), no. 804.
Corrigan, P.W. (2005). On the stigma of mental
illness. Washington, DC: American Psychological
Association.
Francis, K., Boyd, C.P., Aisbett, D.L., Newnham, K., &
Newnhmam, K. (2006). Rural adolescents' perceptions of barriers to
seeking help for mental health problems. Youth Studies
Australia, 25, 42-49.
Parr, H., & Philo, C. Rural mental health and social
geographies of caring. Social and Cultural Geography, 4,
471-488.
Parr, H., Philo, C., & Burns, N. (2004). Social
geographies of rural mental health: Experiencing inclusion
and exclusion. Transactions of the Institute of British
Geographers, 29, 401-419.
Resources for Healthcare professionals
The
Greens NSW
Mental
Health in Rural and Remote Communities
ActNow.com.au: The Barren Landscape of our Mental Health
Multicultural Mental
Health Australia
Transcultural Mental Health Centre