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Volume 51 Number 3 Summer 2018
Edited by Susana Helm, PhD, University of Hawai`i at Mānoa, Rural.IG@scra27.org, Cheryl Ramos, PhD and Suzanne Phillips, PhD
The Rural IG column highlights rural resources as well as the work of community psychologists, students, and colleagues in their rural environments. Please email Susana Helm (Rural.IG@scra27.org) if you would like to submit a brief rural report or if you have resources we may list here. In this issue, we highlight the work of two recently retired professors with decades of experience working in rural Pennsylvania. Professors Murray and Keller reflect on their academic-community careers, which emphasize the importance of access to health care in rural communities, among other important contributions.
Rural Resources: Rural Health Care Access
The Journal of Rural Health announced its inaugural “article of the year” awarded at the National Rural Health Association annual meeting, entitled, “The Rising Rate of Rural Hospital Closures” (Kaufman, Thomas, Randolph, Perry, Thompson, Holmes, & Pink, 2016, 32-1, 35-43). As a rural resource, Murray and Keller describe hospitals and hospital closures in the brief report below. Although peer-reviewed journals, such as JRH, may be difficult to obtain unless you are affiliated with large universities, JRH also has a virtual library that appears to be open access, and which includes a number of articles on health care access.
Brief Report: A 40-year Perspective on Serving Rural Communities
Written by J. Dennis Murray and Peter A. Keller, Professors of Psychology (emeriti), Mansfield University, Pennsylvania, firstname.lastname@example.org; email@example.com
We both have worked and lived in rural communities for over 40 years. For a great majority of that time, and until our recent retirements, we were colleagues at Mansfield University, a small public institution in rural north central Pennsylvania. During our careers, we have spent a great deal of time studying and serving our regional community. We were each trained in clinical psychology programs where we had the good fortune to integrate the precepts and values of community psychology into our emerging professional identities. That identity shaped all our academic and community work including over two decades leading and teaching in a master’s degree program in community-clinical psychology that Peter started in 1975. At one point, the program was NIMH funded because of our focus on training students to work in rural settings (e.g. Keller & Murray, 1987; Keller, Murray, et al, 1983; Murray & Keller, 1991).
We helped graduates enter appropriate careers in diverse rural clinical settings and in a variety of leadership and policy roles in rural agencies, both within our region and across the U.S. While we advocated to preserve the value of master’s level psychologists to underserved rural communities, forces within APA and our state redefined what it meant to be a psychologist. A reduced commitment to master’s training at NIMH and changes in state licensing laws led us to close that program in 2001 as opportunities for its graduates faded. On the positive side, our commitment to understanding and participating in efforts to improve rural communities and services continued unabated. In what follows, we first reflect on the past and current situation in rural America. We also describe some of the meaningful experiences we’ve had as community psychologists working in partnership with others to affect our students and community.
Rural America: “The more things change, the more they stay the same” (or perhaps get worse)
The situation in rural, relative to urban, America has been relatively constant over the past 40 years. A short list of ongoing challenges includes: lower per capita incomes and relatively higher rates of unemployment and poverty; slower recovery from economic recession; relatively fewer human services, fewer health and behavioral health workers per capita, less access to comprehensive health care services; higher percentage of the population over 65 and under 18; and struggling public schools, including significantly lower per student spending compared to many metropolitan areas. (See for example, U.S. Department of Agriculture, 2016). Janet Fitchen (1981), a pioneering anthropologist and rural sociologist, documented the intractability of rural poverty over 35 years ago, and her work remains salient today.
From some economic and educational perspectives, rural communities look more like impoverished inner cities than thriving middle or upper middle-class communities. In recent years, the challenges facing rural communities have accelerated as larger economic and policy forces have stressed commercial centers, core education, health and human services, and physical infrastructure. Notably, the loss of manufacturing jobs, the consolidation of agricultural enterprises and loss of traditional family-run farms, the steady rise in health care costs and related rural hospital closures (Ellison, 2016), and the continuing flight of capable young people to more metropolitan settings negatively affects the vitality of many rural communities. We recognize that these are broad generalizations regarding rural communities and that there are exceptions to these trends, such as those occurring in areas suddenly buoyed by an energy extraction boom. We experienced one such boom in the form of natural gas fracking in our northern Pennsylvania region, but it was short-lived: the ensuing bust left the region little ahead economically and perhaps worse off in terms of the residual problems and disruptions to community networks and institutions.
Interestingly, a great deal of attention is being directed to rural America’s role in the recent presidential election. Cramer (2016) presciently documented the political consequences of a “rural consciousness” that reflects the frustration and pain of many rural people who believe themselves left behind by the larger, urban, society. Monat (2016) has shown that Donald Trump’s success in 2016 (relative to Mitt Romney in 2012) was greatest in economically distressed counties with large working-class populations, high unemployment, higher loss of factory jobs; and the highest drug, alcohol, and suicide mortality rates (“deaths of despair”). Those are all significant factors in America’s rural counties. We would like to think that this kind of political attention will result in efforts to address these problems, though early signs do not suggest authentic concerns from a policy perspective.
The strengths of many rural communities are also evident. From our perspective, most communities survive and sometimes thrive on the strength of gemeinschaft networks of family and neighbor support and volunteerism that create an informal safety net and counterbalance to the challenges noted above. In our experience, rural people often embrace community problem solving and support. Community members accept difficult circumstances and make the best of the fewer resources they have and work together to find creative solutions. We highlight some of our experiences in this regard.
Successful Partnerships: Three case examples
The Institute. For a decade, starting in 1984, Denny helped create, direct, and support our University’s Rural Services Institute, whose mission was to use the resources of the University to address the needs of the community. Faculty and students participated in many data-driven projects including creation of a rural county-level data base, needs assessments, and program evaluations. The institute also hosted several grant-funded initiatives including projects assisting small business and industry development, providing consumer credit counseling, and outreach to rural parents to help guide their children’s plans for higher education.
An evolving health-care system. Denny also has been fortunate to serve for over 30 years on the boards of the primary health care organizations serving our county and region. He participated in three significant organizational mergers designed to better meet the health needs on the community. The first occurred in 1989 when an umbrella health and human services agency (North Penn Comprehensive Health Services), including five federally funded health centers, joined the local hospital to create a single county-wide health care system (The Laurel Health System). The success of that new organization and the increasing financial pressures on rural hospitals then led in 2012 to a strategic merger with the larger three-hospital health care system in the county south of us (Susquehanna Health). Denny led the local system board during that process. Recently (2016) Susquehanna has affiliated with the largest not-for-profit health care system in Pennsylvania (University of Pittsburgh Medical Center, UPMC) to further strengthen and grow health care services in our two counties. These three “up-link” experiences were all guided by a few key principles: keeping the needs of the local community at the forefront of all decisions, increasing access to locally offered services, increasing the breadth and quality of services (while cognizant of the financial realties in the increasingly difficult national health care environment), and ensuring that the merging organizations shared compatible values and cultures to ensure success. All these changes required the commitment of visionary board members and administrative leaders to set aside personal and parochial anxieties and to fearlessly embrace the need for change to meet community needs.
The Partnership. Both of us have played leadership roles in a remarkable “Partnership for Community Health” that was initiated 23 years ago through a collaborative effort of our rural community health system, the county human services department, and our university. This enterprise was initiated based on a comprehensive study of health needs and services, including mental health, that was undertaken with the support of the university’s psychology faculty and, over time, contributors from other academic programs ranging from social work to health sciences and dietetics. Students as well as faculty have been engaged from the early years, and continue to be involved, particularly in needs assessment and outcome studies of partnership initiatives. Studies and interventions have ranged from identification and treatment of diabetes to drug abuse prevention and intervention. Need and outcome assessments have included alliances with the state department of health and surveys of students and families through the county’s school systems.
The strategic goals of the Partnership have focused broadly on health promotion and disease prevention. One of us (Peter) has served on the executive or planning committees since the inception of the partnership. The other (Denny) provided leadership to ensure a data-focused foundation for the varied initiatives of the partnership. The Partnership was chosen, as one of only 25 sites from a diverse range of communities across the United States, to participate in the Kellogg National Community Care Network Demonstration Program. A variety of substantial grants from local, state, federal agencies, and companies have helped to sustain the continuing work of the partnership.
It seems remarkable to both of us in retrospect that this health partnership, which we helped initiate and nurture from our perspectives as community psychologists, continues to function and receives broad support and recognition within the community. It is a testimony to what is possible within a rural setting when there is respectfully shared leadership across a wide range of community sectors that ignites a passion for serving the varied health, human, and environmental needs of rural community members.
The activities we’ve described highlight the importance of coalitions and partnerships built on shared values and vision. We have seen the power of value-driven systems thinking and strong organizational and community leadership. All these efforts required effective community listening and data-driven analysis and action. These values and collaborative efforts are powerful antidotes to the isolation and helplessness often seen in under-resourced rural communities.
As you might guess, we are pleased to reflect on the work we’ve done and very grateful to have had the opportunity to collaborate with so many remarkable people in our university and in the community. We doubt that neither our faculty mentors nor we would have guessed how these experiences would have unfolded because of our community psychology identities, but it seems that focused theory and intentionality do lead to engagement and positive outcomes over the long term. We would welcome discussion with anyone interested in the topics or experiences we’ve touched on.
Cramer, K.J. (2016). The politics of resentment: Rural consciousness in Wisconsin and the rise of Scott Walker. University of Chicago Press.
Ellison, A. The rural hospital closure crisis: 15 key findings and trends, February 11, 2016. http://www.beckershospitalreview.com/finance/the-rural-hospital-closure-crisis-15-key-findings-and-trends.html
Fitchen, J.M. (1981, 1995 reissue). Poverty in rural America: A case study. Waveland Press.
Keller P.A. & Murray J.D. (1987). Handbook of rural community mental health. Human Sciences Press: NY, NY.
Keller P.A., Murray J.D., Hargrove D.S., Dengerink, H.A. 1983. Issues for training psychologists for rural settings. Journal of Rural Community Psychology, 4(1), 11‑24.
Monat, S.M. (2016). Deaths of Despair and Support for Trump in the 2016 Presidential Election. http://aese.psu.edu/directory/smm67/Election16.pdf
Murray, J.D. & Keller, P.A. (1991). Psychology and rural America: Current status and future directions. American Psychologist, 46, 220‑231.
U.S. Department of Agriculture (2016), Rural America at a Glance - 2016 edition. https://www.ers.usda.gov/webdocs/publications/eib162/eib-162.pdf?v=42684