Rural social workers face own set of challenges

Red barn and a siloThe National Rural Social Work Caucus has a sense of humor about joining their group.

Their membership page poses questions such as “What kind of tractor do you own?” to gauge if you have kinship with their cause.

Social workers who practice in rural areas face challenges different from their counterparts in urban-based cities. Some of these include less pay, limited access to specialty services and dealing with crisis situations more often, because prevention and early intervention services are not readily available.

All jokes aside, the caucus well understands that despite the charm of quiet life in the country, social workers practicing in isolated areas face more complex challenges than their counterparts in urban cities.

Social workers in rural communities are paid less, have limited access to specialty services and deal with crisis situations more often, because prevention and early intervention services are not readily available.

There are many people who need services too, with nearly 50 million Americans (17 percent) living in rural areas, and too few practitioners to adequately serve rural populations.

Eighty percent of social workers are employed in metropolitan areas, and large states have a relatively low number of licensed social workers per capita. Furthermore, there are 2,157 health professional shortage areas in rural and frontier areas as defined by the U.S. Department of Health and Human Services.

Sam Hickman, secretary of the caucus and executive director of the NASW West Virginia Chapter, said even though the caucus has had some success in keeping rural culture at the forefront of people’s minds, “ ... it’s a continuing battle.”

“We want people to look at rural issues in the same way as minority issues, like a specialized practice,” he said.

One of these issues is the dual relationship — or having more than one relationship with a client, Hickman said.

“If you’re one of only a few practitioners in an area that people have to turn to for help, you’re bound to run into them or their children and relatives at the grocery store,” he said.

The caucus successfully influenced urban colleagues to better understand the cultural aspects of dual relationships in rural communities during a revision of the NASW Code of Ethics, Hickman said.

It was recognized that dual relationships are common, sometimes unavoidable and maybe even helpful in small towns. (See Code 1.06(c) at

“It was determined the social worker was responsible for any dual relationship that was unavoidable and this relationship must not be exploited or used to hold power over a client,” he added.

Lack of transportation is another issue in rural cultures, Hickman said. “I was at a meeting in Alexandria, Va., and just looking out the hotel window I could count about 13 different modes of transportation. If you look out the window in rural West Virginia you have to walk, bike or use an automobile — and nothing else.”

While rural and urban-based cultures differ, the prevalence of mental illness is similar in both environments, according to the Rural Assistance Center. ( But the outcomes can be far worse for people when services are a great distance away or not available at all.

For example, suicide rates rose faster in rural areas, according to data from the Centers for Disease Control and Prevention. From 2004 and 2013, small towns and rural counties experienced a 20 percent increase in the suicide rate while the large metropolitan counties showed a 7 percent increase, the data show.

Also, stigma persists in small towns — where everyone knows their neighbor and health care providers struggle to offer mental health services because of poor reimbursement and high no-show rates. Despite these challenges, there are solutions that are making an impact on social work practice in rural communities.

Effective Solutions

Technology has changed the landscape of social work practice, with electronic health records, social media, apps and video conferencing all playing a key role in breaking down geographic barriers and providing mental health care in a creative and cost-effective manner.

The impact of this technology is of special importance in rural communities, where creating access and availability to mental health care is a dire need. The growing popularity of telehealth and telemedicine promises to narrow the gap between a clinician and client who may be miles apart.

According to the American Telemedicine Association, there are about 200 telemedicine networks, with 3,500 service sites in U.S. hospital systems, clinics, private practices and government agencies using telehealth. Even private companies are jumping into the industry.

In the social work profession, there are schools and community-based organizations making inroads to using the benefits of telehealth, in part to meet a goal set by President Bush’s New Freedom Commission on Mental Health in 2002 to use technology to access mental health care.

One example is the University of Southern California School of Social Work’s USC Telehealth, which opened in early 2012. Since the launch of this program, licensed social workers — in partnership with health care settings and social service agencies — have delivered 17,000 to 20,000 successful live interactive sessions and served approximately 1,200 clients in California, some of who live in underserved areas.

It was no easy task to launch USC Telehealth, as described by the program’s director of operations and communications, MaryAnn Frattarole.

“We had to ensure the technology offered the latest in privacy and security according to federal standards and HIPAA compliance, she said, “duplicate the on-ground client experience to be safe, effective and confidential, and pass the extensive USC legal and compliance process.”

While USC Telehealth has enjoyed success, other places have not been able to effectively implement similar programs. There are many operational factors to consider, and organizations must determine if they have the infrastructure available to deliver services through telehealth.

“Access to broadband Internet in rural areas is still a problem,” Hickman said.

Also, if counseling is being provided by licensed social workers to clients across state lines, special attention must be paid to individual state licensure requirements.

Dennis Mohatt, vice president for behavioral health at the Western Interstate Commission for Higher Education, shared his telehealth observations too.

“I have been to clinics and seen really expensive equipment sitting in the corner with the dustcover over it,” he said. “When we discuss telehealth, we don’t think about who is going to fix it when it breaks. Who is going to work with a client to get them to feel comfortable? Who is going to pay for all that? I think the jury is still out on telehealth, but it holds potential.”

The potential has been researched. A 2011 American Telemedicine Association paper states, “… patients can be reliably assessed, diagnosed and treated with pharmacology and psychotherapy in outpatient clinics with a variety of video conferencing equipment and communication protocols.”

A Helping Hand

As technology creates more access to services, trained social workers are needed to deliver that care. Loan-forgiveness programs hold promise and provide opportunities for social workers to alleviate their student loan debt and make a difference in isolated communities.

Three loan-forgiveness programs are available to social workers: the College Cost Reduction Act of 2007; the National Health Service Corps Loan Repayment Program; and the Higher Education Act. All have service requirements that vary from two to 10 years. Specifically, the College Cost Reduction Act requires 10 years of service, which can be a difficult requirement to fulfill.

NASW has been vocal about decreasing the required years of service a social worker would need to commit for loan repayment assistance.

“There is no benefit for the criteria to be this strict,” said Melissa Johnson, executive director of NASW’s Kentucky Chapter. “Also, staying at one organization for a long time could kill your career opportunities if you don’t have the option for advancement.”

Social workers often carry large student loan debt relative to their modest salaries, so the ease of loan forgiveness is imperative to retain a skilled workforce. Eighty-one percent of baccalaureate graduates, 80.5 percent of master’s graduates, and 65.5 percent of doctoral graduates have loan debt. The mean amount of loan debt ranges from $31,880 to$42,149, according to 2013 report from the Council on Social Work Education.

And 19 percent of licensed social workers who work in rural areas earned lower salaries than those in metropolitan areas, which leaves them in a tougher position to pay off debt, according to 2006 data from the NASW Center for Workforce Studies.

Many rural mental health experts stress the importance of training practitioners who love their rural communities and are already committed to staying. This grow-your-own strategy, as WICHE’s Mohatt points out, is not followed enough.

“We need to make sure professionals are place-committed, not placement bound,” he said. This will be key to growing the social work workforce in high-need areas.

Moving Forward

It’s evident new technology advances will be at the forefront of how social workers serve rural communities. Technology trends coupled with loan forgiveness, better awareness about the cultural aspects of rural communities and training people in their communities instead of recruiting those from other areas will be transformative for mental health service delivery in small towns and other rural areas.

The benefits of telehealth, like alleviating clients’ long-distance travel by bringing services to them via the Internet, will improve care. Social workers armed with iPads — ready to access electronic health records or do a med check with a swipe and a click — will become the norm not the exception.

Continuing the fight for better reimbursement rates for social workers will even the financial playing field for those dedicated to the profession and strengthen the rural workforce.

National social work caucus keeps it rural

The National Rural Social Work Caucus, created in 1976, is an informal organization dedicated to keeping the needs of rural residents top of mind.

Caucus President Scott Sorensen described its mission as keeping a pulse on trends and crises in delivering mental health services in rural areas.

Its largest activity is an annual conference — held this year July 15-17 in Vermillion, S.D. — which is estimated to gather 130 mental health and health care practitioners.

“This loose-knit organization of individuals truly has a rural focus in their hearts and minds,” Sorensen says.