Psychotherapists should find empathy when rural ideas about COVID-19 safety vary

Psychotherapists should find empathy when rural ideas about COVID-19 safety vary

By S. Jean Caraway, Ph.D.
April 12, 2021

As psychologists, many of us are natural people watchers in public. As such, while stopped for gas and coffee at a local convenience store, I pass the time by counting the number of people exiting the store wearing masks.

How many would you guess in my home state of South Dakota? I counted two out of 10. Did I see this right? I re-sampled for the same count. I decided to go home and make my own coffee.

You may have heard that the Dakotas collectively had some of the highest COVID-19 transmission rates in the United States in the fall of 2020. My informal mask poll in February 2021 came to a somber conclusion: many in this rural area ignore this basic public safety practice.

At the end of that month there were 15 states without mandatory mask policies. Most have a high percentage of rural residents.

Who are these people not wearing masks? Have they already had COVID? Do they not believe in this deadly infectious disease?

As a faculty member in a clinical psychology graduate program, I started to get practical. How many of these people need mental health services? Can they link into telehealth or can they be seen face-to-face?

We have several placement sites for our graduate students. How can I help students connect and establish empathy for people who choose to deliberately engage in behavior that risks making themselves and others sick?

As psychologists, we understand from ethics codes and codes of conduct that we are to refer those we serve to another practitioner if we are compromised in our ability to provide them services. Does lacking empathy for someone count?

Yet, in rural areas there may not be another practitioner nearby. If we don’t work with someone who knocks on our door, who will? An urban psychologist through Zoom? Will they understand this rural population better than I do?

Developing positive relationships with clients is crucial to treatment outcomes. Basic Rogerian qualities of genuineness, empathy and unconditional positive regard have been drilled in to our heads since graduate school. Psychotherapy-outcome studies have demonstrated their effectiveness as part of non-specific, common factors approaches.

As someone who grew up on a farm and became a psychologist in a rural area, I want to understand my neighbors and clients better. So I read books about why rural people behave counterintuitively to their own self -interests.

I review rural values, cultures and norms that may contribute to this – a shared sense of community, resistance to change, self-reliance, rugged individualism, stoicism and a tendency toward conservatism.

Of course, attributes vary across rural dwellers and many would not have all of these. However, since many graduate programs and CEU courses do not focus on rural versus urban differences and much of the training we receive is urban centric, a closer look is warranted.

Certain creeds are part of belonging in rural settings. For example, even though my husband and I have lived here over 20 years we are still considered “transplants.” Someone is only considered a “townie” if their family of generations is “from here.”

Familiar with behavioral principles, psychologists understand that “old habits die hard.” Change takes time. There is stigma associated with embracing progressive beliefs and many resist acculturations to new ways, even those that may benefit them in the long run.

In the early ’90s, for example, rural residents across the nation resisted changing locally known street names such as “Greenfield Road” to the sterile 9-1-1 locatable rural addressing system. Even though visitors, mail, packaging services and emergency responders would find them quicker, potentially saving their lives, people protested.

Through empathetic ears, we now hear this outcry as residents desperately clinging to an already threatened identity from the ’80s Farm Crisis years of economic devastation and declining population.

Wearing masks can be uncomfortable and if not forced or enforced, many here choose to go without. When there is conflicting news about the importance of something like masks, the tendency is to go with known entities such as messages from elected officials they voted for or news sources they trust.

In rural America, people don’t want your help or for you to tell them what to do. They don’t want you to call them out. They aren’t in your business, why are you in theirs?
Rural people are descendants of immigrant settlers who needed to be stoic and to depend on themselves and their neighbors to survive. They come from generations of families with conservative religious values and are disturbed by what they see as a moral decline of society on several political issues.

My rural neighbors and clients have given thought to their mask wearing choices and it may draw stares from unfriendly faces in public. Perhaps their masks are internal; they have blocked themselves from this horrible change in their lives and believe in facing consequences head on.

An interesting twist in my home state in March 2021 is that, despite reluctance to “mask up,” people are rolling out to get COVID vaccinations at an amazing rate. Are these values and norms somehow complexly realigning and contributing to this phenomenon? I wouldn’t bet against it; rural people have found ways to survive a long history of tragedies.

We envision light at the end of this COVID-19 tunnel through vaccination rollouts. Many of us continue to diligently follow CDC guidelines, but some continue to ignore them.

I observe my own internal judgement on rural people who hold different views on this softening. I feel more at ease getting gas and am considering (now that I am fully vaccinated) going in for coffee.

However, as I review this, I notice I did not use the pronoun “we” when describing rural residents, even though I am one. Sigh.

Throughout this acceptance journey, I am reminded of a Richard Bach quote, “We teach best what we most need to learn.”

Jean Caraway, Ph.D., is an associate professor of psychology at the University of South Dakota where she has worked for more than 20 years. She is a clinical psychologist and is currently serving as the president of the South Dakota Psychological Association. She can be reached by email at

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