Rural Psychologists and Integrated Primary Care

By Jeff Leichter, Ph.D., Katherine M. (Kay) Slama, Ph.D., L.P.
January 21, 2016 - Last updated: January 20, 2016

Rural Psychologists and Integrated Primary CareThere are significantly few psychologists per capita in rural areas. Rural people may be the largest cultural minority about which there is little to no training. If students hear anything about rural practice, it is likely about its challenges rather than its rewards.

Unless students happen to be from a rural area or train in a rural area, they seldom learn about the unique cultural beauty of rural people and communities and the dimensions that make rural practice effective and rewarding. Nor do established practitioners get much easily accessible continuing education on working with rural people. So the scarcity of rural psychologists remains.

Rather than seeing psychologists, rural people generally seek care from their primary care practitioners. This “somatic superhighway” runs through primary practices in rural and frontier communities, which deliver the vast majority of behavioral health care.

C.J. Peek, Ph.D., defined integrated care as “a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.” Integrating behavioral and medical care meets the three A’s of accessibility, affordability and acceptability.

Sixty percent of patients with mental health concerns receive no care at all. Nearly 60 percent of those who do receive services get them exclusively from primary care physicians. Behavioral health concerns are highly prevalent in primary care. A majority of the 14 most common physical complaints have no known organic etiology, while depression and anxiety are among the most common concerns brought to primary care doctors.

Depression and anxiety go undetected in about 67 percent of cases in primary care. It is not surprising then that depression and anxiety are among the top five chronic diseases driving the overall cost of health care. Doesn’t it make sense for psychologists to ally themselves with those who are managing the majority of psychological problems – particularly in rural areas?

Research on the benefits of integrated primary care/behavioral health has been consistent and promising. In patients with comorbid psychological and physical health concerns (e.g., diabetes, hypertension, asthma, cardiovascular disease), one study showed medical utilization decreased 15.7 percent for patients receiving behavioral health care, while a matched group that did not have those services saw the cost rise 12.3 percent.

A variety of studies have also shown clinical indicators of chronic physical disease improve significantly when behavioral health services are added. Not surprisingly, this leads to improved patient satisfaction among those individuals getting care for chronic medical conditions. Here’s news – physicians like working with behavioral health professionals!

One study showed that 92 percent of physicians who piloted an integrated care approach felt it led to better communication with behavioral health professionals and nearly 93 percent felt it reduced stigma around mental illness. Improved outcomes, better stewardship of health care dollars and improved patient satisfaction accomplish the “Triple Aim” in population health.

However, it’s important to work with the other resources in a small town as well. Schools are perhaps the greatest opportunity to reach young people and their families, and we can do it in collaboration with the teachers and school administration, as well as with school counselors, psychologists and social workers. It works best to be clear that we respect the competencies of whoever is already in the schools and that we are willing to provide additional needed competencies wherever we can consult and serve them and their students.

Rural psychologists often find it useful to consult in the same way to local counselors, social workers and chemical dependency programs. It’s also common to consult to county social services, police, domestic violence advocates, lawyers and finance officers, all of whom want to know what to do when they are worried about a client.

Churches not only provide spiritual services, but are, in rural areas, one of the few social outlets besides school activities, an occasional service club and (let’s face it) bars. Knowing the area’s pastors lets us refer back and forth as needed and hold joint public education programs about topics such as suicide, grieving, depression, child rearing, etc. The best rural practice is truly “integrated” across the whole community.

What is needed to encourage more psychologists to consider rural practice? First it is important to recognize that rural populations are a unique cohort that has its own customs, language, expectations and clinical challenges.

Second, psychologists must become aware of rural practice and gain the skills to practice comfortably in rural areas. It’s encouraging that more graduate programs are either offering a course in rural psychology or integrating rural diversity into other courses.

Third, there is an urgent need for more practicum, internship and post-doctoral experiences in rural areas, as well as ways to reimburse for clinical supervision hours.

Fourth is the need for continuing education in rural culture and services both for rural practitioners and urban ones who extend telehealth to rural areas. One model of providing rurally accessible CE is to webcast the training both to small local groups of mixed behavioral health practitioners, who network as they view it together, and to practitioners webcasting individually into the training. The annual Rural Behavioral Health Practice Conference, hosted by the Minnesota Psychological Association and its partners, employs this model.

Fifth, there needs to be more research on rural populations, including on working in rural areas, to highlight the unique and enjoyable aspects of working with rural individuals.

Lastly, promoting the opportunities for rural practice that give voice to the life-quality aspects of the work. Living in geographically beautiful country replete with numerous outdoor activities, less traffic, more affordable housing and the potential to make a large impact on an underserved community can be particularly attractive for some psychologists and their families.

Jeff Leichter Ph.D., L.P., is a licensed psychologist in Minnesota, Michigan and Arizona who has been embedded in a primary care medical clinic in a rural community for nearly 25 years. He works closely with family medicine, internal medicine and OB-GYN physicians to collaborate on caring for adult patients. He was the founding director of MCARPT, a rural post-doctoral training fellowship. His email is

Katherine M. (Kay) Slama, Ph.D., L.P., has worked in clinical services, teaching, management, consulting and research. She holds adjunct positions at the University of Minnesota Medical School and at St. Mary’s University of Minnesota and has served on the Governing Council of the Minnesota Psychological Association and as president of the Minnesota Rural Health Association. Her email address is

Farmer photo available from Shutterstock

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