Rural mental health providers overcome stigma, rugged individualism, and distance to provide care

In Michigan’s rural counties, the dozens of miles between a patient and a therapy session can mean they are navigating anxiety, depression, or a severe and persistent mental illness on their own. Stigma and small-town toughness can keep rural residents from asking for help in the first place, according to mental health professionals at Summit Pointe, OnPoint, and Sanilac County Community Mental Health.

The community mental health (CMH) agencies tasked with caring for rural residents through such difficulties have challenges of their own, with many of them constrained by limited staff to meet the needs of a growing patient base.

Providers serving rural areas can protect the mental health of their clients by counteracting stigma with positive messages, supporting efforts to increase transportation options, and partnering with other community leaders to provide wraparound care, say leaders of the three Michigan mental health organizations.

As CMHs work to reach and treat rural patients, communities can help by surrounding struggling people with encouragement, says Wil Morris, CEO of Sanilac County Community Mental Health.

“We all struggle at some point in our life,” Morris says. “We should support one another to get over those humps.”
Deb Messing oversees Sanilac County Community Mental Health communications efforts to the county's rural residents.
Stigma and partnerships 

Sanilac County is home to two traffic lights, no roundabouts, and acres and acres of farmland. The dozen or so miles between small towns can add up to loneliness in the rural Thumb county.

“If you don’t live on a main road, it can take a week before they plow you out,” Morris says.

Isolation exacerbated by rural separation contributes to the depression and social anxiety reported by many of the CMH’s patients. With too little human interaction in their daily lives, many go far too long without seeing a smile until they walk through the CMH doors.

“That’s what a lot of folks in rural areas are craving,” Morris says. “There’s just not that social connectedness.”

A pull-yourself-up-by-your-bootstraps mentality in many rural communities keeps others from asking for mental health help.

Wil Morris“Unfortunately, if someone’s struggling, people still see that as a sign of weakness,” Morris says. 

Overcoming negative stereotypes takes a determined effort on the part of mental health providers. As head of his rural agency, Morris makes himself the voice of mental health in the county. He records radio spots about issues related to mental health, hoping to stimulate and normalize conversation on the topic.

His communications department makes sure the agency has a presence at fairs, parades, school activities, and other events that draw rural people together.

Morris also prioritizes relationships with local police, the courts, and other community leaders, whose first-name relationship with Morris means they can pick up a phone and connect someone to mental health help before a situation gets out of hand.

Other partnerships allow Sanilac County CMH to take services out to rural clients. When Morris learned the state intended to cut funding to schools for on-staff mental health care workers, he called local superintendents to see how Sanilac County CMH could help cover gaps. That possibility is still in the discussion stage.

A local hospital that was trying to find work for a psychiatric mental health nurse practitioner could only provide part-time employment. Morris was able to hire the worker for additional hours, expanding the breadth of the Sanilac County CMH roster. 

“That’s why those relationships, especially in rural communities, are so important,” Morris says. “None of us have adequate resources by ourselves. But together, we can come together to meet the needs of our community.”
CMHs serving rural communities cover more territory with fewer resources.
Getting there

Transportation poses the most significant barrier between rural people and mental health help, says Mark Witte, executive director of OnPoint, the CMH in Allegan County.

Internet access has improved in the state’s less populated counties in recent years, making telehealth an option for many. Still, not all areas have strong internet, and some treatment works best in person. Those who can’t easily drive to therapy — because of a health condition, lack of a driver’s license, inability to afford a tank of gas, or other reasons — have to find another way there or miss out on treatment.

Mark Witte“‘What could be’ has already started in Allegan,” says Witte.

He commends county commissioners for approving new funding for expanded hours for Allegan County Transportation (ACT). ACT provides on-demand, app-based bussing countywide, allowing residents anywhere in the county to schedule a curb-to-curb ride wherever they need to go for a nominal cost, an option not available in many counties. A dependable route with scheduled stops in the more remote parts of the county would help even more. 

“That’s many years away, just because of the population distribution in Allegan,” says Witte.
OnPoint is located at 540 Jenner Drive (M-40) in Allegan.
Witte worked in Kent County and other urban areas before joining the Allegan team. In a big city, a constellation of nonprofits share the burden of care. Community mental health agencies have numerous private providers with whom to contract. Rural agencies have to cover more territory with fewer partnerships and each with fewer personnel.

“If I have a problem to solve that involves another agency, I know exactly who to talk to,” Witte says. 

From the health department and police agencies to hospital administrators, he connects with other agency heads quickly and solves problems efficiently.

OnPoint is also the county agency serving the unhoused — the only CMH in the state to take on that dual role, as far as Witte knows. Handling both mental health needs and housing needs makes sense because the two often go together.

“I daresay over 50% of the people who are homeless also have behavioral health needs,” Witte says. “And we’re able to address it at the same time.”

CMHs serving rural areas can support clients' mental health by counteracting stigma, supporting transportation options, and partnering with other community organizations to provide wraparound care.
Dual roles and staffing challenges 

Summit Pointe, the CMH serving Battle Creek and Calhoun County, addresses a growing concern among mental health practitioners in Southwest Michigan — substance use disorder (SUD).
Sean Field
“We still struggle with substance use. That is something I have seen growing in our rural communities and our smaller towns,” says clinical director Sean Field. “[The southwest corner of Michigan] has been plagued, particularly by opiates. We see that appear as a rural mental health problem. It’s probably our biggest one.”

As the county’s primary substance use disorder treatment center, treating about 300 SUD patients a year, Summit Pointe was one of the first CMHs in the state to provide such services and the largest provider of medication-assisted treatment in the area. 

Most clients who come in for substance use services also have mental health needs. 

“We’re naturally suited to address both challenges,” Field says. “If we’re addressing the substance use needs and mental health stuff comes up, it’s easier ... than if we were relying on a bunch of other providers to try to coordinate or connect to.”

On the far east side of the county, a Summit Pointe clinic in Albion brings help closer to  rural residents there. Summit Pointe can’t fully staff it, however. Like Sanilac County, Calhoun County is a federally designated mental health care professional shortage area. Providers in these two counties say it’s harder to hire staff in rural areas than in cities, especially at CMHs, which typically pay less than private practice. And all agencies are competing for a dwindling pool of workers in what the Community Mental Health Association of Michigan (CMHA) calls a behavioral health care workforce shortage.

Summit Pointe's 24/7 First Step Psychiatric Urgent Care Center CMHA recommends expanding that pool by increasing starting wages and
benefits, assisting with tuition for students studying to become clinicians, and adjusting requirements for worker certification, among other tactics.

Recent state efforts to incentivize mental health workers to take rural jobs have a good chance of working in some areas. 

“For us in Battle Creek, we wouldn’t qualify for any of those programs despite having rural communities that have all the same demands of us as a provider,” Field says — the county’s overall population is too high.

Until staff numbers increase, telehealth helps fill the gap. Summit Pointe’s Albion clinic may not have a full range of professionals, but if patients can make it there, they can connect via Zoom with the main clinic and at least see a provider’s face.

Jennifer Myles, clinical supervisor of youth care management at Summit Pointe, has seen her network of contracted home-based clinicians dwindle from about 20 to zero. Her team does what it can to fill the gaps and help as many people as it can.

Myles says communities, including rural ones, can do their part by changing the narrative around mental health.

“We all have struggles,” she says. ”And we do better when we have support from those around us.”

These three Michigan CMHs provide that support.

Julie J. Riddle is a freelance journalist based in Jackson, Mich. and the editor of Jackson Magazine. She writes about quirkiness, connections, and the transformative power of informed compassion in her blog, withmarshmallows.blogspot.com. Learn more at juliejriddle.com.

Photos by Leslie Cieplechowicz

The MI Mental Health series highlights the opportunities that Michigan's children, teens, and adults of all ages have to find the mental health help they need, when and where they need it. It is made possible with funding from the Community Mental Health Association of Michigan, Center for Health and Research Transformation, LifeWays, Michigan Health and Hospital Association, Northern Lakes CMH Authority, OnPoint, Sanilac County CMH, Summit Pointe, and Washtenaw County CMH.