Rural Mental Health's Stressors, Barriers, and Protective Factors: Q&A with Dr. Dawn Morales

by Allee Mead

Dawn Morales, PhD, is the Program Chief of the Office of Rural Mental Health Research (ORMHR) at the National Institute of Mental Health (NIMH), one of 27 institutes and centers that make up the National Institutes of Health (NIH). Morales discusses the challenges facing rural mental healthcare as well as the importance of cultural competency and protective factors, especially in rural populations such as American Indian and Alaska Native communities and farmers and ranchers.

Tell me about your journey to ORMHR.

Professionally, I'm a statistician and methodologist. Before I joined NIH about seven or eight years ago, I worked in clinical research and program evaluation, most recently at a Veterans Health Administration hospital. And many of the projects I worked on were conducted in rural areas. I lived in a rural area and I loved it. I became passionate about serving the needs of rural communities in health science research.

I come from a long line of country people, and I was also the caregiver of a family member with serious mental illness. Amidst all my professional obligations, I also had to contend with the difficulties of living in an underserved rural area and trying to support someone with their health issues. My expertise and passion are driven by both my professional and personal experiences.

What stressors and barriers to mental healthcare are people in rural and tribal areas experiencing?

Rural residents and tribal members experience many of the same stressors that anyone might but, in some cases, they do experience greater amounts of such stressors. And then there are also stressors that are unique to rural residents or tribal members.

It's incomplete to just speak of stressors and barriers, because it's really important to talk about protective factors as well.

It's incomplete to just speak of stressors and barriers, because it's really important to talk about protective factors as well. I'll give you an example relevant to tribal members. We know losing a loved one, especially unexpectedly, is a stressor for anyone. However, during COVID-19, tribal members have lost many more loved ones than members of other communities have in many cases. And the pandemic affected tribes more severely because of pre-existing disparities. And this meant that there were many more people in tribal communities who could name one or more loved ones whom they had lost. This is an example of the quantity of a stressor being greater, but it's also the case that many tribal communities lost revered and respected elder members. In many tribal communities, these elders were the custodians of indigenous knowledge and important cultural traditions such as language.

And that older generation was so important because a lot of times the in-between generation was required to attend boarding schools or was exposed to other efforts to force them to adopt non-indigenous ways of knowing and culture. And that's an example of a unique stressor: the loss of the custodians of culture and language. An example of a barrier would be that an indigenous youth might have a lot of difficulty locating a mental healthcare provider with the necessary cultural humility or competency to help them cope with all that. So if this young person feels like now they're never going to be able to obtain the level of cultural knowledge and tribal identity that they had envisioned, they might be at greater risk for substance misuse or self-harm, if they feel like this hope for future self is irreparably lost.

But remember what I said about protective factors: Let's say some people set up a social media group and do the work of getting older and younger people who are interested in teaching and learning and practicing language to join — that's an example of resilience in action and that can very likely offer protection. It turns out that kind of thing is actually really common.

An example of a serious mental health disparity would be the increase in suicide among ranchers and farmers. There are some stressors that are common for farmers and ranchers: working in a family business and dealing with large-scale disasters such as flood and wildfires and pipeline explosions. Now, anybody — not just farmers or ranchers — might find working in a family business stressful, but it's just a more common stressor for those families. And, again, large-scale disasters are stressful for anyone, but they're a unique stressor for farmers and ranchers because of the complex and extended effects that these disasters can have upon farms and ranches that can expand beyond some of the effects they might have on a metro or suburban area.

And stressors can combine in ways that compound their effects. Suppose a farmer feels a great responsibility to pass a family farm along to the next generation, but they're struggling with family business issues, and they're also contending with the effects of a big disaster that affected the crops or the animals or the land. And they start to come to the conclusion that they're letting the family down, right? This is a person who might be at risk for very poor mental health outcomes. They feel like they failed to care for a family legacy, and that's a really important part of their identity. Let's say this farmer or rancher doesn't know a lot about mental health or they're very reluctant to seek care because of stigma. Or let's say there just isn't any care available in their community. Those are all barriers.

And I can't stop talking about protective factors and resilience. I just want to point out that, in many rural communities, farmers get together for coffee every month and talk and they're making social connections. That's a protective factor.

…when it comes to mental health, it's really important for people to understand that it's a really great idea to talk to people. Individual self-reliance only takes you so far.

I identify myself as a country person. I deeply understand "when the going gets tough, the tough get going." But the thing is, if you look back into the history of farming and ranching communities in the U.S., you'll see that people often embraced their interdependence, back in the era of when there was the Grange and people had collective use of farm equipment and stuff. I am enthusiastic about respecting that love of individual self-reliance. At the same time, when it comes to mental health, it's really important for people to understand that it's a really great idea to talk to people. Individual self-reliance only takes you so far.

Why is cultural humility or cultural competency important to specific populations like farmers, American Indian and Alaska Native people, or LGBTQ+ individuals? What are the top mental health concerns for these populations in rural and tribal areas?

There is a need for providers who understand what it's like to be in this culture. I talk to people who are in agriculture, for instance, who can be uncomfortable if they're talking to a provider who has no idea what it's like to be a farmer or a rancher.

Cultural humility or cultural competency is applicable widely, I would say. Let's say you want to discuss means restriction (limiting someone's access to lethal methods of suicide) with somebody who lives in a rural community. They might have a lot of access to means, and they might really need that to live where they live and to do what they do. You don't want to just apply metropolitan-style approaches to means restriction in a situation like that, right? You try to think carefully and you need somebody who is knowledgeable about what it's like to live in a rural place and to work at the kinds of jobs that rural people have in order to manage that successfully. So cultural competency or humility goes broadly, I'd say.

…when people live in areas where they can find social supports and when young people can find a caring adult to talk to, those are very, very valuable protective factors.

Suicide is a serious concern for American Indian and Alaska Native people living in rural areas and for people who are minoritized sexual or gender identities. I would say that's probably the #1 concern for both of those groups. As far as the sexual and gender minorities in rural areas, I think that, when people live in areas where they can find social supports and when young people can find a caring adult to talk to, those are very, very valuable protective factors. And you see that in some places in rural America.

What are some ways we can improve equity and representation when it comes to research, workforce, and care?

I tackled this question on two levels. Personally, I think we can all encourage each other and lift up our voices as we tell our stories and advocate for rural communities. I used to be a caregiver in a rural area, and I lived this experience of struggling to find care for someone. I spoke about that openly, and other people can do that too. You can also talk about your own mental health openly and make an effort to try to improve mental health literacy and to reduce stigma. Those are actions that can be taken on the individual level.

…healthcare research jobs are created in these communities, and professional development is supported, and research capacity is developed in these rural places, and children are able to enroll in clinical trials that may offer the very best in innovative treatment.

On the structural level, from the perspective of the National Institute of Mental Health, NIMH has participated in the NIH ECHO ISPCTN program. The ECHO part stands for Environmental Influences on Child Health Outcomes, and the ISPCTN part is the IDeA States Pediatric Clinical Trials Network. The network that supports these clinical trials has the goal of increasing research capacity in rural and underserved areas and increasing the number of NIH-funded clinical trials recruiting children from rural and underserved areas. And the sites for recruiting are mostly near or in rural communities where significant health disparities exist. And they're deliberately in states with historically low NIH funding success. What this means is that healthcare research jobs are created in these communities, and professional development is supported, and research capacity is developed in these rural places, and children are able to enroll in clinical trials that may offer the very best in innovative treatment. And families have the pleasure of knowing that the results from these trials are likely to generalize to a wide range of children across the country. That's a more structural view of what kinds of things we need to do and are doing to foster equity.

Can you share any work going on in rural and tribal areas improving health equity?

I wanted to talk about some things that are just developing or just very currently in the mix. We have a major award to Vanderbilt University Medical Center in Tennessee for research that aims to figure out how to improve screening for autism in young children who live in rural places, and they're developing a parent-administered and clinician-guided tele-assessment tool.

And this is so important because children with autism who live in rural areas have relatively worse health outcomes compared to peers who live in urban areas. The likely driving factor here is that children living in rural areas have a later age of diagnosis for autism. Improving screening is important, but requiring a family to drive to an urban medical center that has an autism specialty clinic is a big ask. So this idea that we're going to be able to do this through telehealth and the parent will be able to administer it with the clinician guiding them — it looks like it's going to be a really practical, useful solution.

Another award is to Mississippi State University for research looking at how to better help older people with hoarding disorder, with specific focus on older adults in rural communities. Rural-dwelling older adults with hoarding disorder can be an especially difficult-to-treat population. There's a variety of reasons driving this, but basically municipal officials, neighbors, and family in rural areas are all less likely to make formal complaints. And this means that the older adults in question are at greater risk of issues related to fire safety and other health concerns.

The research project is specifically looking at an intervention called motivational interviewing — which is an evidence-based practice and very respected — and how it can be used to help older adults living in rural places engage in more sorting and discarding behaviors. And this particular research award uses a special kind of funding mechanism that encourages the scientists to build research capacity at the institution, in this case Mississippi State University, and to provide research experiences to undergraduate students at more rural-serving institutions.

What is your favorite part of your work?

I love to listen to people in rural communities and to investigators who are committed to rural health talk about how they're addressing mental health challenges in their communities and their hopes and ideas for the future.

I think that there are gaps in our knowledge about what works in rural communities. I think that it's fair to say that we, meaning NIMH or NIH, have more work to do, but at the same time we can recognize the things that are already successful and working well in these communities.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.