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Above image credit: Amy Taft and Dr. John Hudson talk in their office located in the basement of the First Christian Church of Cameron, Missouri. The two licensed professional counselors have been providing mental health care to rural residents of Missouri over the last year via telehealth and socially distanced in-person sessions. (Jacob Douglas | Flatland)
CAMERON, Missouri — Amy Taft was in the middle of a special kind of trauma treatment called eye movement desensitization and reprocessing when word of the coronavirus first hit the news.
Beginning today, Flatland is publishing a three-week series of stories that will explore the issue of mental health during the COVID-19 pandemic as experienced by frontline health care providers. On April 8, Kansas City PBS will premiere “The Hidden Pandemic,” a documentary by acclaimed filmmaker Michael Price focusing on the lives of Kansas Citians navigating mental illness.
The phased treatment focuses on reconnecting the patient with images, self-thoughts, body sensations and emotions related to the trauma. Taft, a licensed professional counselor, had been developing this process with some clients for months. Last March, that treatment was disrupted as the pandemic forced those in the mental health field to move their services online via Zoom, or the telephone.
“That was really heartbreaking for them and for me,” Taft said. “(It was) difficult to know how to best care for them in the middle of all that.”
Mental health care workers have seen the number of clients with depression and anxiety symptoms surge in the past year. They’ve been forced to alter their entire profession and deal with labor shortages. Many have also faced personal struggles with their own mental health during the pandemic.
But adaptation often breeds progress. And just as the pandemic has exposed long-standing problems that have plagued the rural mental health system, it has also spurred the search for solutions.
“As we know, necessity is the mother of invention. It’s also the mother of innovation,” said Dr. Paul Thomlinson, executive director of Compass Health Research Institute. “And we’ve innovated in a whole bunch of ways.”
The foremost innovation has been the rapid expansion of telehealth, which has benefited rural communities over the last year.
Of all of the barriers to accessing mental health care in rural communities, telehealth has helped two in a major way: travel times and stigma.
In a REACH Healthcare Foundation/United Methodist Health Ministry Fund study on telehealth in Kansas, rural respondents said the greatest benefit of increased access was the elimination of travel times.
Some patients in rural areas travel more than an hour to access mental health care. That means they have to make an entire day revolve around seeing their therapist. With telehealth that issue has disappeared for many.
This has been an enormous change for members of the agriculture community, who according to the Centers for Disease Control and Prevention commit suicide at a higher rate than any other profession.
“These folks are able to call in to their counselors while they’re in their combines,” said Andy Brown, commissioner of behavioral health services for the Kansas Department for Aging and Disability Services. “They don’t have to give up a day of work in order to get their mental health services.”
In rural communities where the stereotype is “everyone knows everybody,” stigma and anonymity can be huge issues. Imagine your car is parked outside of the local mental health care clinic, and your neighbor drives by. They may begin to think something is wrong with you, your family or your marriage. That word can spread fast in a small town. This is a fear fueling stigma in rural areas.
However, telehealth allows you to reach out to a mental health professional from the comfort of your own home. That has broken down some stigma in rural areas, according to Dr. Doug Wright, the clinical director and CEO of the Southeast Kansas Mental Health Center.
“I think telehealth has been a very important factor in sort of reducing the stigma, because people like the fact that it’s more private because they can do it from their home,” Wright said. “But also people talk to their friends. So now for the first time in a couple of decades, people are starting to realize that getting mental health treatment is more mainstream than they realized.”
Wright noted that people increasingly sharing their experience on social media has also helped normalize mental health care in the last year, and raise awareness about accessing it.
A related issue that has been highlighted during the pandemic is the digital divide. BroadbandNow estimates that 352,000 residents in Missouri and 173,000 Kansans lack adequate broadband access. This has been a barrier to providing mental health services in rural areas.
While speaking with Flatland over Zoom for this story, Dr. John Hudson, a colleague of Taft’s at Trinity Professional Counseling Services, dropped from the video chat unexpectedly.
“So we just saw a case in point,” Hudson said. “I don’t know if you realized I froze, but I lost my internet access. So I switched to the hotspot on my phone to reconnect with you guys. That is very typical for a remote client.”
Multiple providers reported patients calling in from their cars outside of the local McDonald’s or public library, which are popular sources of broadband connections in rural communities. Some organizations got grants to provide hotspots to their more rural patients.Telehealth can also be done over the phone, however it’s much more difficult to provide service that way.
Whether it is discomfort with telehealth or the inability to connect, Taft and Hudson have both seen clients in person over the past year. In their shared office in the basement of the First Christian Church of Cameron, they have multiple bottles of hand sanitizer, new chairs that are easier to wipe down, and fewer pillows to clean.
Taft makes sure to mention the location of two trash cans on either side of the couch where her patients typically sit. She says encouraging them to dispose of their own tissues that they may use in more emotional moments of the session has become another routine reminder.
This hybrid approach made work more chaotic for providers.
Typically a therapist will have a 50- to 60-minute session, then a 10-minute period to gather their notes before they move onto their next patient. Now that 10-minute period includes deep cleaning an office before another person comes in, to ensure their safety. It’s been another stressor for providers over the last year.
“I get one person out the door, then I have to scramble and get my computer just right and do all of these things,” Taft said. “So the stress of that, going back and forth and juggling that was not what I thought it would be.”
She rectified that by splitting up her days based on the clients she would see, telehealth one day and in person on another. When meeting clients in person, cleaning has been another thing on a mental health provider’s mind.
Hudson has seen clients in person over the last year. An old school practitioner, he has had clients agree to meet at their farm or at a mutually agreed location. He has also done visits to prisons during the pandemic.
“It’s not uncomfortable for me,” Hudson said. “You get used to it. I met with a new couple last night. They came with masks. I asked them what they wanted to do. They said, ‘Can we take them off?’ I’ll do whatever you want me to do. You have to respect the client and be aware of what their needs are.”
Masks have made the job difficult for people like Taft. She had a hard time doing therapy with something blocking so much of her and the patient’s face.
“I just totally undervalued how much wearing a mask changed the dynamics of a session,” Taft said. “Because I think what it did is, when they saw me wearing a mask, then they would start talking about the pandemic, and you know, it just brought all the trauma of the pandemic into the room.”
Another part of the job of a mental health care provider is outreach, which has been difficult to do when meeting people in the community is restricted.
According to Brown with the Kansas Department of Aging and Disability, early in the pandemic there was a drop-off in people reaching out to access care. Part of the drop-off was due to the confusion of what to do in the pandemic, but also in figuring out if mental health services were even available to them. It has been the job of providers to make sure people know they are open for business and want to see people.
“I’m always amazed that we have been here since the ‘60s and there are still people in surrounding areas, maybe 20 miles outside of town, that still don’t know we exist,” Wright said. “So we are doing more community outreach, we have an awareness campaign, just trying to let people know that we’re here.”
One group that has struggled mightily during the pandemic, and in particular need of outreach, is substance abuse patients.
Brown said that a lot of the referral systems for substance abuse patients come through their interactions with law enforcement as well as their friends and family. But as isolation began, those interactions decreased.
“We believe that there are a lot of folks out there that probably increased their substance use during COVID,” Brown said. “But a lot of that substance use is happening during isolation, and is probably going untreated. So our numbers for Substance Abuse Disorder services really have taken a dip in 2020.”
A CDC study found 13% of Americans increased their substance abuse during the pandemic.
“One very prominent model of addiction views it as a failure of connection,” Thomlinson said. “What we know is not having deep, meaningful, nourishing social connections can be a risk factor for the development of substance abuse disorders.”
Providers have been innovative, using telehealth as a way to gather groups to talk about their issues with substance abuse. They have also taken the risk of meeting people to talk about their issues with substance abuse.
The federal government uses the Health Professional Shortage Area statistic to measure workforce shortages in the mental health care field.
In Kansas, 32.1% of the percent of the need for mental health workers is met. In Missouri, only 3.7% of the need is met, according to the HPSA.
Greg Hennen, executive director at the Four County Mental Health Center in Independence, Kansas, said the shortage has been felt by his organization. The problem was felt before the pandemic, and has only worsened with it.
“Recruiting has been very difficult in the last year,” Hennen said. “In the middle of a pandemic, people aren’t looking to geographically relocate and do a lot of moving around.”
Hennen has actually lost staff during the pandemic. He lost psychologists to other states that are paying higher wages, or have existing laws in place that expand telehealth and Medicaid and Medicare.
One solution being considered in the Kansas Legislature is Certified Community Behavioral Health Clinics. These clinics would provide a range of mental health services through Medicaid.
Brown said the new provider type would help with workforce development by allowing more flexibility on the payment system, and would allow more service to be given out with fewer workers.
Perhaps the biggest impact the pandemic has had on mental health care providers in rural areas is the same thing that has been affecting their patients.
They too are dealing with a pandemic.
“It was a lot of me trying to figure out my own life, and my own self, and feeling a lot of the same trauma and impacts that my clients were feeling,” Taft said. “But I’m trying to keep that separate so I can focus on caring for them.”
The added stress of changing how you operate, of taking on more clients, of having restricted face-to-face access to patients — all while isolating like the rest of the world — has led to a great deal of burnout among mental health workers.
“It’s much more draining,” Wright said. “Especially early on therapists found televideo to be a lot more of a strain because now I have to make sure this client shows up for Zoom, and if they didn’t, let me call them and make sure they got the invite, and all of those little things.”
Dennis Mohatt is the vice president for Behavioral Health at the Western Interstate Commission for Higher Education. His wife is a clinical psychologist. He’s seen the fatigue of the pandemic on providers first hand.
“She’s been doing telehealth day in, day out for almost a year on her little computer screen,” Mohatt said. “She’s been sitting in her office downstairs with the door closed, seeing one patient after another.”
Mental health care providers such as Four County Mental Health Center have systems in place for their therapists to fight off compassion fatigue that can set in over long periods of time. Hennen said that the pressure to develop outcomes that can positively impact their patients’ lives has created fatigue among his colleagues, and that focusing on self-care has been vital.
“I think it’s important for therapists to do more self-care than ever, because they are being affected by this just as much as their clients,” Wright said. “You know they’re talking to clients about the loss of parents, siblings, cousins and friends to COVID while they themselves may also be dealing with the loss of a family member to COVID.”
Mental health experts don’t believe this is going to just magically go away when herd immunity is achieved.
“I would expect we will still be dealing with the aftermath in 2023 or 2024,” Brown said.
“I mean, they don’t call it post traumatic stress disorder for nothing,” Mohatt said. “A lot of the problems here are going to emerge later.”
People in the mental health field are cautiously waiting to see if PTSD will be a common symptom of a post-pandemic world. Most believe we will see an increase in PTSD symptoms, but some believe the pandemic may actually build some resiliency among people and their mental health.
Resilience is a keyword, as it’s something that providers like Taft and Hudson have had to show over the last year. It’s something the system itself has had to show, morphing into something completely different than it was just a year ago. Rural communities are filled with resilient people, and they will rely on the system and those who work in it to be equally resilient in coming years.
“The most frequent modal response to trauma and adversity is in fact, resilience,” said Thomlinson. “It’s not illness, it’s not PTSD, it’s resilience. Our patients are showing incredible resilience in the face of this pandemic.”
Jacob Douglas covers rural affairs for Kansas City PBS in cooperation with Report for America.