Volume 49 Number 2 
Spring 2016

Rural Interest Group

Edited by Susana Helm
Co-Editors Cheryl Ramos and Suzanne Phillips

The Rural IG column highlights rural resources as well as the work of community psychologist, students, and colleagues in their rural environments. In this issue, we are pleased to provide a “brief report” from Courtney Cook, a fifth-year doctoral student in clinical psychology at East Tennessee State University (ETSU). For future issues, please email Susana ( if you would like to submit your own brief rural report or if you have resources we may list here. 


APA Committee on Rural Health. The APA Committee on Rural Health recently updated its vision and mission, which is now posted (retrieved 1/14/16: The CRH mission is “achieving optimal health and well-being for rural and remote populations” through a number of strategies which can be viewed online, and the vision is:

The vision of the APA Committee on Rural Health is to achieve the full and optimal benefit of the science, education, practice, and advocacy of psychology for all rural and remote populations. To this end, the Committee envisions the equal protection and respect of the human rights of all people, including the residents of rural and remote regions, the integration of rural perspectives in APA policy and the removal of barriers to comprehensive health care for rural and remote populations.

Project ECHO (Extension for Community Healthcare Outcomes). According to the Project ECHO website (,  this “collaborative model of medical education and care management”…“increases access to specialty treatment in rural and underserved areas by providing front-line clinicians with the knowledge and support they need to manage patients with complex conditions such as hepatitis C, rheumatoid arthritis, chronic pain, and behavioral health disorders among many others.” 

Brief Report:

In reviewing the 2015 roster of Rural IG members, we realized that Tennessee represents! In a quick calculation, we determined that 10% of the active members with known institutional locations in the US are located in Tennessee. Our roster shows that of the 162 active members of the Rural IG, seven members are located at institutions in the State of Tennessee: Tennessee, East Tennessee, and Vanderbilt. It should be noted that of the active members, our records include institutional locations for less than two-thirds of the total (96 people, or 59%). So there may be other members who are in Tennessee, and we just don’t have that info. Please feel free to send your location info so we can update our records. Based on this large representation, we invited submissions from Tennessee, and are pleased to present a brief report by Courtney Cook and her colleagues at East Tennessee State University. ETSU sits within the Buffalo and Cherokee Mountains in Johnson City, Tennessee, serving approximately 15,000 students. The Clinical Psychology graduate program provides doctoral training with an emphasis in both rural behavioral health and integrated primary care. 

Brief Report:  Rural Parents’ Perceptions of Mental Health Services: A Qualitative Study

 Submitted by Courtney Lilly Cook, Jodi Polaha, and Stacey Williams

Author Note: This research was supported in part by a grant from National Institute of Mental Health (R21MH090539). Special thanks to Dr. Melissa Schrift, Department of Sociology, East Tennessee State University, for her guidance in analyzing data according to thematic analysis. 

Rural residents encounter multiple barriers in accessing mental health services including a lack of mental health professionals and stigma associated with mental health diagnoses and treatment (Merwin, Hinton, Dembling, & Stern, 2003; Boydell et al., 2006). Distance to a healthcare site, transportation, and poverty have also been identified as barriers to care in rural areas (Boydell et al., 2006). While rates of mental disorders may be similar among rural and non-rural groups, there is evidence that rural people receive fewer mental health services than their urban counterparts (Goldsmith, Wagenfeld, Manderscheid, & Stiles, 1997; Kessler et al., 1994).

While systemic barriers to care in rural populations are evident within the literature, this is only one piece of the rural help-seeking experience. Several studies have attempted to elucidate rural individuals' experiences with mental health, yet these studies focus on barriers and facilitators of care which compose only a portion of the rural help-seeking experience. Knowledge of rural individuals’ perceptions, desires, and past experiences are vital to understand fully how and why rural individuals seek help. 



Adults accompanying children to primary care were recruited in eight pediatric primary care waiting rooms across Tennessee and Virginia to complete a demographic questionnaire and the Pediatric Symptom Checklist (PSC; Jellinek, Murphy, & Burns, 1986). Those with PSC scores indicating significant or borderline significant psychosocial concerns were asked to complete a larger set of measures (see Williams & Polaha, 2014), including five open-ended questions/statements used in the analysis presented here. Data were collected via paper-pencil self-report format.


A total of 347 adults participated in the full study, including the qualitative component, with 79.8% being the child’s mother, 7.8% father, and 12.4% other (e.g., grandparents, siblings). The average child age was 9.2 years (SD = 3.43 years), and male (57.9%). The sample was predominantly white (94.2%), consistent with the racial demography of clinic locations. 


Inductive thematic analysis was used in reviewing and interpreting data. A team of three graduate students analyzed data. To reduce potential biases, faculty within psychology and sociology, one of whom has extensive experience in qualitative analysis, reviewed data classification and a finalized thematic classification system was chosen.

Open-Ended Questions/Statements

1.  Please list all of the factors that might be helpful to you if you were looking for help for your child’s behavior, development, and emotional well-being.

2.  If you were to get help in a way that was “perfect” for your situation, needs, and interests, what would happen?

3.  If you have sought services in the past, please think over those experiences and list the positive aspects.

4.  What aspects were negative?

5.  If you were asked to list the main reason why you have not/will not seek help for an ongoing problem with your child’s behavior, development, or emotional well-being, what would that reason be?


Analysis of study data revealed seven primary themes. Participants responded to items in two ways:  reports of past experiences and perceptions or desires related to services.

Perceptions of Mental Health Services

Numerous participants endorsed a desire for collaboration amongst primary care providers, teachers, parents, and behavioral health providers in caring for their child. One participant reported a desire for “everyone (parents, teachers, doctors) working together for the benefit of the child.” Along this same line, several participants reported ideas for innovative service delivery facilitating collaboration, including in-home behavioral treatment and services within the school setting. Several participants also recounted past experiences in which parent-provider collaboration was difficult or nonexistent, reporting their concerns were “ignored,” they “weren’t taken seriously,” and providers discounted their concerns.


One common manifestation of stigma was fear of consequences associated with a child’s diagnosis or treatment. In response to why a participant has or will not seek help for their child, one participant wrote, “Impact on his future – would it affect college enrollment, jobs or other things he would wish to do. I do not want him to feel like he has or is a ‘problem.’ How would he feel? He is only 5.” Several participants also reported that seeking help would evoke feelings of inadequacy as a parent or change how others view them. 


While some participants reported efficacy of a child’s medication regimen, others reported negative experiences with medication or disproval of psychopharmacological treatment. One participant reported "a doctor that actually seems to care what's best for my child instead of thinking medication fixes everything" would be a helpful factor in seeking services for the child.

Desire for Guidance and Resources

A number of study participants reported minimal knowledge about how to seek mental health services. Many were unaware of available resources and unsure of where to seek guidance. Many participants reported a referral from a healthcare provider or a pamphlet delineating resources within the area would be helpful in addressing this concern.

Logistical Barriers

Commonly endorsed barriers included long distances to care sites, insurance and financial concerns, inconsistent transportation, provider shortages, and lack of convenient appointment times. Several participants reported a desire for evening or weekend appointments due to concerns about missed school and work. 

Willingness to Seek Help

Many participants provided responses indicating resistance to help seeking. Several caregivers reported their child’s behavior did not warrant professional treatment, despite significant scoring on the PSC. Other participants reported they have not or will not seek help because their child’s problems are normal for their age range, because of caregivers’ hopes that the concerns will improve naturally, or because of their desire or ability to manage the issue independent of professional help. Several other participants cited their child's resistance to treatment as a reason for not seeking help.

Provider Characteristics

Participants frequently cited a number of desirable and undesirable characteristics in a potential pediatric mental health provider. Participants frequently reported a desire for a relatable provider who could communicate in a relatable fashion (e.g. without using jargon) as well as a desire for a child-friendly provider and environment. One participant reported “children’s counselors that are ‘appealing’ to children, meaning, not a stuffy office with a stiff-joint professor of psychology,” would be helpful in seeking treatment for the child. 


This study sought to elucidate the needs, desires, and experiences of rural caregivers in seeking care for a child with significant psychosocial concerns. While some findings uncovered within this study are consistent with previous research (stigma, logistical barriers), several new factors were uncovered (desire for collaboration, desire for specific provider attributes). Such information can be used to direct the delivery of mental healthcare services in individual clinical practices as well as broader policy initiatives. While all study findings have potential implications for service delivery, unanticipated findings in particular have likely been neglected in rural mental health service delivery to date. Future research should implement new findings and evaluate the effects on acceptability and uptake of mental healthcare services in rural areas.


Boydell, K. M., Pong, R., Volpe, T., Tilleczek, K., Wilson, E., & Lemieux, S. (2006). Family perspectives on pathways to mental health care for children and youth in rural communities. The Journal of Rural Health, 22(2), 182-188.

Goldsmith, H. F., Wagenfeld, M. O., Manderscheid, R. W., & Stiles, D. (1997). Specialty mental health services in metropolitan and nonmetropolitan areas: 1983 and 1990. Administration and Policy in Mental Health, 6(6), 475-488.

Jellinek, M., Murphy, J. M., Burns, B. (1986). Brief psychosocial screening in outpatient pediatric practice. Journal of Pediatrics, 109, 371-378.

Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., . . .Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Study. Archives of General Psychiatry, 51, 8-19.

Merwin, E., Hinton, I., Dembling, B., & Stern, S. (2003). Shortages of rural mental health professionals. Archives of Psychiatric Nursing, 17(1), 42-51.

Williams, S. L., & Polaha, J. (2014). Rural parents’ perceived stigma of seeking mental health services for their children: Development and evaluation of a new instrument. Psychological Assessment, 26(3), 763-773.

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