How to enhance access to mental healthcare in rural America

Rural America has a higher proportion of people who are at risk for mental health disorders and state offices of rural health have identified suicide, depression, anxiety disorders and lack of access to mental  healthcare, as major rural health issues.   A particularly sobering statistic is that suicide is the second leading cause of death in states with primarily rural populations. There is a shortage of mental health professionals practicing in rural areas so rural populations face significant disparities in accessing care, especially with regards to the provision of highly specialized services.

Add to this the fact that rural culture itself places emphasis on self reliance, independence and conformity to social norms (whether positive or negative toward mental health treatments) and we have a situation that is ripe for the delayed identification of mental health problems and subsequent utilization of mental health services.

Whilst telehealth and other technological interventions are being utilized as a successful strategy to address some of these issues, geographical inequities in the availability and distribution of mental health professionals are unlikely to change in the near future and there remains a pressing need for innovative ways to enhance access to mental healthcare in rural America.

Peer support counselors represent innovation in mental health treatment

Hiring peer support counselors represents innovation in the delivery of rural mental healthcare. Peer support consists of a peer support provider, who has a lived experience with mental illness, and having experienced significant improvements in their own condition, offers services to a peer considered to be not as far along in their own recovery process. Consistent with this definition, and integral to the peer support process, is that the peer support counselor shares and self-discloses regarding his/her own experiences with mental illness and, specifically, focuses on what skills, strengths, supports, and resources he/she has used in his/her own recovery. Another crucial point to understand about peer support is that it is viewed as a form of healthcare with peer support providers acting as members of the mental health team.

 A radical concept?

On the face of it, this appears to be a rather radical concept and it likely sets off alarm bells  for many mental health professionals.  This is probably because the concept of what a peer support counselor does is, in many ways, contrary to the principles mental health professionals, like me, hold sacred: preserving professional boundaries (between ourselves and our patients); not routinely self- disclosing personal details to our patients and  maintaining objectivity in the way we see our patients.

Then, of course, there are the many practical issues that are raised. How do we integrate peer support counselors onto our teams?  Most of us are very comfortable working as part of multidisciplinary teams with nurses, psychologists, social workers but peer support counselors do not fit into the neat category of a “licensed mental health professional”. So then, how do we assess their practice? How should they demonstrate their competency? What is their role on the team? What if they make errors in the care they provide? What if they have a setback of their own mental illness?

To these concerns I would remind skeptics of the following:

1. The utilization of “peers” in mental health care settings is not a novel concept. They have been utilized in many clinical settings, not just in rural areas, and most often in settings where disparities in healthcare are prominent issues.

2. Whilst a slightly different concept to that of the peer support model described above, “peers” have, for decades, served as paraprofessionals on mental health  teams  to enhance the reach of the existing mental health taskforce. 

3. In recent years, the concept of using such paraprofessionals, recruited from the local community of the target population, to delivery psychological treatments for depression and anxiety disorders has gained robust momentum as exemplified by the work of Patel and colleagues.  This process called, “task shifting” addresses, at its’ core, the need in communities with low or negligible traditional mental health resources for mental healthcare that is accessible and sustainable.

4. Whilst the use of peer support counselors for individuals with mental health disorders such as major depression, PTSD and other anxiety disorders is a relatively new concept the use of peer support to provide services to individuals living with SMI (serious mental illness), such as bipolar disorder and schizophrenia, has been well investigated.

5. Many healthcare systems are now formalizing a role for peer support counselors and have provided the necessary infrastructure to define their roles and responsibilities, required trainings, certifications and mechanisms to ensure they demonstrate certain competencies.

Peer support counselors offer a particular promise in rural America

The promise of peer support counselors in rural America lies in their potential to play a key role in supplementing mental health care offered by mental health professionals. The idea is not that peers replace the evidence based psychotherapies and pharmacotherapies offered by trained mental health professionals, but rather provide innovative supplemental services that aim to engage those living with mental illness in treatment

But more than this supplemental role, I believe that peer support counselors can bring a unique element to treatment that many mental health professionals simply cannot offer. Peers come from the same rural community as the patient they are serving and this fact, along with the shared history of experiencing mental illness, could be helpful with regards to combating some of the stigma associated with the decision to seek mental health services.  Simply put, their “peer status” grants them a higher level of credibility, with the person seeking help, when compared to non-peer mental health professionals.

Are peer support counselors effective?

An innovative idea does not obviate us from the responsibility to apply the same critical thinking to evaluating its effectiveness as we would to any other new intervention or treatment approach.  Early evidence about the effectiveness of peer support counselors is encouraging, for example, in the case of peers in recovery from SMI, employed to provide services to others with SMI, randomized controlled trials comparing the effectiveness of these peers compared with non-peers, found at least the same degree of effectiveness on outcomes such as patient social functioning, quality of life and treatment adherence.

Still, many questions remain unanswered.  What factors predict positive outcomes of this peer support intervention? What are the unique and useful elements of this relationship?  Are there harmful aspects of this relationship? Which interventions can be delivered safely and effectively by peer support counselors?

Ultimately, it would be evidence from such scientific studies that would help inform the development of robust peer support models and it would be these, evidence based models that could truly offer the bold innovation needed to enhance access to mental healthcare in rural America.

Shaili Jain is a psychiatrist who blogs at Mind the Brain on PLOS Blogs, where this article originally appeared on June 27, 2013.

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