Resilience and Community in Rural Social Work
With few providers and fewer resources, social workers must innovate and work with their neighbors to face the challenges of their rural communities.
By Jesse Berney
“I was frustrated,” says Jan Dunn, LCSW. Working with members of the Osage nation and others in her rural Oklahoma community, Dunn saw “people who were motivated to change, to break their generational trauma.” They wanted to improve their lives but had too many barriers to access the services they needed. Practitioners were few and far between. Hourly workers couldn’t spare the time away from their jobs to drive an hour, sit for an hour of therapy, and then drive another hour to return to work.
“The need became apparent,” continues Dunn. “We can’t meet everyone where they’re at, but we can start with these communities.”
If they couldn’t come to therapy, maybe therapy could come to them. That’s when Dunn and her husband Andy came up with the idea for Feels on Wheels. They outfitted an Airstream trailer with comfortable furniture, warm lighting and decor, and everything they needed to take Dunn’s practice on the road. Now instead of navigating expensive office leases in multiple towns, Feels on Wheels takes Dunn where she’s needed, relying on the help of her community for space and resources. On Tuesdays and Thursdays, for example, she drives the Airstream to the parking lot of the First Assembly of God Church in the small town of Pawhuska, population approximately 3,000 people, bringing her skills to an area in desperate need of them.
Lack of Accessibility, Resources
Dunn’s strategy of taking her therapy on the road is a unique approach to one of the primary challenges facing social workers in rural areas. Accessibility where populations are spread thin and providers spread even thinner can make it impossible for people to get to the services they need. There are nearly twice as many social workers per capita in metropolitan areas than there are in rural ones. That means individual practitioners like Dunn face an outsized demand for their services in an environment that makes it more difficult to deliver them. Social workers in rural areas must often come up with creative solutions like hers to meet their clients where they are, not only physically, but socially and emotionally as well.
The lack of supportive services can make that work even more difficult. Jess Bowers, MSW, CAPSW, an associate professor in the Department of Sociology and Social Work at the University of Wisconsin Stevens Point, says there are shortages of resources like primary care physicians and dentists.
“People will drive two hours just to get to a methadone clinic for opioid treatment,” she says. Bowers points out that as people move away from rural areas—especially those with the kind of educational attainment necessary for social work— it is getting harder to recruit and retain social workers. “Providers face isolation and limited peer support,” she says. “They’re working with very few beds, and clinics and birthing centers are closing.”
Sense of Community
Social workers who practice in rural areas have a unique advantage as well. The lower population density of rural areas along with economic and social challenges necessitates a near-universal community spirit where neighbors depend on neighbors for help through difficult times. Rural social workers can find success by integrating themselves deeply into their communities and becoming a pillar, the person that everyone knows they can turn to when they need help. Visibility is a key part of social work and mental health practice in rural areas.
“You have to brand yourself as a helper,” says Martha Schultz, NPP, LCSW, PMHNP-BC. Schultz wears a lot of hats in the area she serves: Franklin and Clinton counties situated at the northeastern tip of New York state. Fulfilling multiple roles means understanding how to fulfill the needs of her community. “What makes rural areas unique is that you have to problem-solve,” Schultz says. “If it’s Saturday at 2 a.m., I have to know who to call, how to get someone the support (they) need.”
Filling multiple roles like Schultz does is often a requirement for anyone working in rural areas. According to the Rural Health Research Gateway, as of 2021 more than a fifth of rural counties in the United States lacked a single social worker, while just 5.4 percent of more populated counties didn’t have any. When you are often the only person people can turn to for mental health services in multiple counties, you have to be a generalist. School counselor, mental health care provider, liaison to government services and nonprofit organizations, child welfare advocate, crisis interventionist—the rural social worker must be prepared to fill all these roles and more.
That requires creativity, innovation and resourcefulness. For Schultz, that means learning everything about her community and how to get resources to the people she serves. In an urban setting, while social workers certainly face heavy caseloads and funding shortages, they are more likely to have long lists of resources and partner organizations. For social workers practicing in an urban area like New York City, there are hospitals, mental health practitioners, substance abuse centers, city and state agencies dedicated to delivering services to residents, and a wealth of nonprofit organizations. A social worker who wants to refer a client to a higher level of care, bring in a specialist, or help them obtain food or housing has options a short distance away. Public transportation is available to help clients get to appointments at various locations throughout the area. And social workers in urban areas are likely to have the opportunity to specialize in an area of their particular interest.
Barriers to Rural Care
Rural social workers rarely have that luxury. Schultz’s jobs include working as a psychiatric nurse practitioner and an emergency room crisis counselor. She works in the medical department of a local addiction and recovery center’s inpatient program and serves as a Committee on Preschool Special Education counselor helping 3- to 5-year-old children with special needs and their families. Everyone in the area knows “Miss Martha” is the person you turn to when you’re in need. But when she refers someone to care, she says, “they may have to go two or four hours one way to find someone who accepts their insurance.” Even telehealth is often not an option, as Internet access can be unpredictable thanks to the mountainous terrain.
But the barriers to care in rural areas aren’t just physical. “Historically, we don’t talk about our mental health,” Schultz says of the people in her region. She describes a litany of common issues, including substance abuse, intimate partner violence, and generational trauma, but says seeking care for behavioral and psychiatric issues can be taboo. Schultz sees people who internalize the lessons that their problems are their own fault, and finds them using maladaptive coping skills that deepen their mental health symptoms instead of seeking treatment. She says people often don’t seek treatment until they’re in a crisis. Dunn has seen similar resistance to care in her community in Oklahoma. “There is something about the culture within a culture,” she says. “You have to accept that and meet them where they’re at.”
With her therapy-equipped Airstream trailer, Dunn meets the population where they are both figuratively and literally. She says providing that mobile private space provides another advantage. “It has to be a real science to figure out how to have people not run into a cousin or an enemy who doesn’t know they have therapy,” she admits. In small towns with small populations, everyone knows everyone, and it can be difficult keeping private business private. Confidentiality, the foundational ethical obligation of all mental health care providers, faces unique challenges in a place where you’re likely to run into clients in the only grocery store in town. Dunn makes sure to tell every client in their intake that “I’m not snubbing you if I don’t acknowledge you,” emphasizing the importance she places on client privacy. “And if you don’t acknowledge who I am,” she adds, “I will not be offended by that.”
Ethical Conflicts
Schultz says that in her area, it’s important to be friendly and build relationships with everyone. But when you’re known for being the person everyone can turn to, potential ethical conflicts are everywhere. The chances that someone she’s worked with in an addiction center has a relationship with someone she sees in the emergency room are high. She may work with a child as a school counselor and see an adult in their family for therapy. And of course Schultz and Dunn, like the majority of rural social workers, are themselves members of the community. “When you live in a rural community,” Schultz says, “you have to have strict boundaries to prevent dual relationships.” Being one of just a few providers of mental health services in a rural area means you are likely to see someone for services that you know from church, community organizations, or even your own neighborhood. In an urban setting, it’s simple to refer someone to another provider when a conflict arises, but in rural communities, the questions of how to handle those dual relationships are more complicated.
Bowers, the University of Wisconsin professor, says when she was practicing as a social worker, she remembers seeing kids in her children’s class photos who were on her caseload. Bowers teaches a course on ethics in rural social work, and she emphasizes how important it is to set boundaries with clients and to be proactive any time those boundaries are crossed. “Don’t go to a fish fry or county fair if you’re going to run into clients,” she says. “There’s not a lot of ability to be anonymous.” She says it’s especially important for social workers in rural areas to be cognizant of their public image and urges her students to be careful about what they post on social media.
Strength and Resilience
As difficult as navigating that ethical terrain can be, those close community ties also are a source of strength social workers can draw upon in their work. Bekah Dunaway, MSW, MPA, LGSW, grew up in an unincorporated town in Preston County, W.Va., and now works as a clinical instructor in the School of Social Work at the University of West Virginia. She talks about the interconnection present in rural communities forged by the struggles for human rights by working people who helped build America’s labor movement. These communities are resilient, she says, and “they see that you’re there to help someone, not to rescue them. We’re coming in as part of their toolkit.” Bowers recognizes that same resilience in her communities in Wisconsin. “People are so hardy and hard-working,” she says, “and their real heroes are their neighbors who pitch in when there are snow and ice storms.”
You can hear the admiration Schultz has for her community when she talks about the people she serves. “I love my patients,” she says. “I care about them deeply, and I believe in being a resource for them to help themselves.” She urges people considering a career in social work to consider working in rural areas. In a small, tight-knit community, it’s easy to see the difference you’re making in a way that just isn’t possible in an urban setting. “If you’re motivated and you care, it’s a great place to work.” Schultz says “satisfaction is hard to find in behavioral health. If you can take a step back and look at the impact on your community, that’s where the satisfaction is.”
From her softly lit Airstream, Dunn can see the difference she’s making to her clients and her community in Oklahoma. “Trauma is in every corner of the communities we serve,” she says, and she finds fulfillment helping the people around her break the cycles that have been perpetuated for generations. “It can bring me to tears, working with some of the most resilient, kind, loving people who have been through the most despicable things.” She joins Schultz in urging people to consider working in rural areas. “You are going to learn so much.”
Jesse Berney is a masters student at the University of the District of Columbia studying clinical mental health counseling. He has worked as a writer and communications strategist in politics, advocacy, and labor for more than two decades.
Resources
NASW Advocates Extra: “Rural Social Work Faces Scarcity of Resources, Ethical Concerns”: socialworkers.org/News/Social-Work-Advocates/Advocates-Extras/Rural-Social-Work-Faces-Scarcity-of-Resources-Ethical-Concerns
NASW News (2015): Rural social workers face own set of challenges: socialworkers.org/News/NASW-News/ID/182/Rural-social-workers-face-own-set-of-challenges
The National Rural Social Work Caucus: ruralsocialwork.org