Call to Action: Family Therapy and Rural Mental Health

Original Paper


Rural communities experience considerable disparities in mental health. Research about this topic is limited, however, especially in the family therapy field. What is known comes primarily from work in other disciplines, which points to three primary barriers that prevent rural communities from accessing high quality mental health care: availability, accessibility, and acceptability of services. A search for papers published over the past 20 years in family journals yielded only 18 articles. A review of these articles in presented here, alongside a call for family clinicians and researchers to advance further contributions. Specific directions for such research are discussed, including telehealth technology, collaboration with existing structures and institutions in rural communities, and the need for more precise definitions and measures of rurality. Family clinicians and researchers are uniquely positioned to conceptualize systemic challenges that rural communities face, and would be advised to join other disciplines in developing innovative methods to address them.


Rural mental health Rural communities Family therapy Call-to-action Stigma Telehealth 


  1. American Hospital Association. (2016). Small or rural hospitals. Retrieved from
  2. Andrykowski, M. A., Steffens, R. F., Bush, H. M., & Tucker, T. C. (2013). Disparities in mental health outcomes among lung cancer survivors associated with ruralness of residence. Psycho-Oncology, 23, 428–436. Scholar
  3. Beecher, B., Reedy, A. R., Loke, V., Walker, J., & Raske, M. (2016). An exploration of social work needs of select rural behavioral health agencies in Washington state. Social Work in Mental Health, 14, 714–732. Scholar
  4. Bischoff, R. J., Hollist, C. S., Smith, C. W., & Flack, P. (2004). Addressing the mental health needs of the rural underserved: Findings from a multiple case study of a behavioral telehealth project. Contemporary Family Therapy, 26, 179–198. Scholar
  5. Bischoff, R. J., Reisbig, A. M. J., Springer, P. R., Schultz, S., Robinson, W. D., & Olson, M. (2013). Succeeding in rural mental health practice: Being sensitive to culture by fitting in and collaborating. Contemporary Family Therapy, 36, 1–16. Scholar
  6. Burt, J. D., Andrew, S., Kupzyk, K. A., Frerichs, L., & Gathje, R. (2014). Examining the utility of behavioral health integration in well-child visits: Implications for rural settings. Families, Systems, & Health, 32, 20–30. Scholar
  7. Carlson, L. E., Lounsberry, J. J., Maciejewski, O., Wright, K., Collacutt, V., & Taenzer, P. (2012). Telehealth-delivered group smoking cessation for rural and urban participants: Feasibility and cessation rates. Addictive Behaviors, 37, 108–114. Scholar
  8. Carnes-Holt, K., & Weatherford, J. (2013). Intensive play therapy training for rural mental health counselors. The Family Journal, 21, 80–86. Scholar
  9. Choi, N. G., Hegel, M. T., Marti, C. N., Marinucci, M. L., Sirrianni, L., & Bruce, M. L. (2014). Telehealth problem-solving therapy for depressed low-income homebound older adults. American Journal of Geriatric Psychiatry, 22, 263–271. Scholar
  10. Correll, J. A., Cantrell, P., & Dalton, W. T. III (2011). Integration of behavioral health services in a primary care clinic serving rural Appalachia: Reflections on a clinical experience. Families, Systems, & Health, 29, 291–302. Scholar
  11. Cowie, K., & Quinn, K. (1997). Brief family therapy in the schools: A new perspective on the role of the rural school counseling professional. The Family Journal, 5, 57–68. Scholar
  12. Cremers, G. E., Cogan, N. A., & Twamley, I. (2014). Mental health and parenting in rural areas: An exploration of parental experiences and current needs. Journal of Mental Health, 23, 99–104. Scholar
  13. Eberhardt, M. S., & Pamuk, E. R. (2004). The importance of place of residence: Examining health in rural and nonrural areas. American Journal of Public Health, 94, 1682–1686.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Economic Research Service. (2014). Rural income, poverty, and welfare: Summary of conditions and trends. Retrieved from
  15. Erickson, S. H. (2001). Multiple relationships in rural counseling. The Family Journal, 9, 302–304. Scholar
  16. Franz, L., Carter, T., Leiner, A. S., Bergner, E., Thompson, N. J., & Compton, M. T. (2010). Stigma and treatment delay in first-episode psychosis: A grounded theory study. Early Interventions in Psychiatry, 4, 47–56. Scholar
  17. Goldfield, G. S., & Boachie, A. (2003). Case report: Delivery of family therapy in the treatment of Anorexia Nervosa using telehealth. Telemedicine Journal and E-Health, 9, 111–114. Scholar
  18. Gonyea, J. L. J., Wright, D. W., & Earl-Kulkosky, T. (2014). Navigating dual relationships in rural communities. Journal of Marital and Family Therapy, 40, 125–136. Scholar
  19. Hall, S. A., Kaufman, J. S., & Ricketts, T. C. (2006). Defining urban and rural areas in U.S. epidemiologic studies. Journal of Urban Health, 83, 162–175. Scholar
  20. Handley, T. E., Kay-Lambkin, F. J., Inder, K. J., Attia, J. R., Lewin, T. J., & Kelly, B. J. (2013). Feasibility of internet-delivered mental health treatments for rural populations. Social Psychiatry and Psychiatric Epidemiology, 49, 275–282. Scholar
  21. Hart, L. G., Larson, E. H., & Lishner, D. M. (2005). Rural definitions for health policy and research. American Journal of Public Health, 95, 1149–1155. Scholar
  22. Hasson-Ohayon, I., Levy, I., Kravetz, S., Vollanski-Narkis, A., & Roe, D. (2011). Insight into mental illness, self-stigma, and the family burden of parents of persons with a severe mental illness. Comprehensive Psychiatry, 52, 75–80. Scholar
  23. Hauenstein, E. J., Petterson, S., Rovnyak, V., & Wagner, D. (2006). Rurality, gender, and mental health treatment. Family and Community Health, 29, 169–185. Scholar
  24. Heflinger, C. A., Wallston, K. A., Mukolo, A., & Brannan, A. M. (2014). Perceived stigma toward children with emotional and behavioral problems and their families: The Attitudes about Child Mental Health Questionnaire (ACMHQ). Journal of Rural Mental Health, 38, 9–19. Scholar
  25. Hendryx, M. (2008). Mental health professional shortage areas in rural appalachia. The Journal of Rural Health, 24, 179–182. Scholar
  26. Herbst, N., Voderholzer, U., Stelzer, N., Knaevelsrud, C., Hertenstein, E., Schlegl, S., Nissen, C., & Kulz, A. K. (2012). The potential of telemental health applications for obsessive-compulsive disorder. Clinical Psychology Review, 32, 454–466. Scholar
  27. Hertlein, K., Blumer, M., & Smith, J. (2014). Marriage and family therapists’ use and comfort with online communication with clients. Contemporary Family Therapy, 36, 58–69.CrossRefGoogle Scholar
  28. Hooper, L. M., & DePuy, V. (2010). Mediating and moderating effects of differentiation of self on depression symptomatology in a rural community sample. The Family Journal, 18, 358–368. Scholar
  29. Hovestadt, A. J., Fenell, D. L., & Canfield, B. S. (2002). Characteristics of effective providers of marital and family therapy in rural mental health settings. Journal of Marital and Family Therapy, 28, 225–231. Scholar
  30. Human, J., & Wasem, C. (1991). Rural mental health in America. American Psychologist, 46, 232–239. Scholar
  31. Inder, K. J., Handley, T. E., Fitzgerald, M., Lewin, T. J., Coleman, C., Perkins, D. et al. (2012). Individual and district-level predictors of alcohol use: Cross sectional findings from a rural mental health survey in Australia. BMC Public Health, 12, 586–597. Scholar
  32. Kataoka, S., Langley, A. K., Wong, M., Baweja, S., & Stein, B. D. (2012). Responding to students with posttraumatic stress disorder in schools. Child and Adolescent Psychiatric Clinics of North America, 21, 119–133. Scholar
  33. Kermode, M., Bowen, K., Arole, S., Joag, K., & Jorm, A. F. (2009). Community beliefs about treatments and outcomes of mental disorders: A mental health literacy survey in a rural area of Maharashtra, India. Public Health, 123, 476–483. Scholar
  34. Larivaara, P., Väisänen, E., & Wynne, L. C. (1996). Developing a family systems approach to rural healthcare: Dealing with the “heavy-user” problem. Families, Systems, & Health, 14, 291–302. Scholar
  35. Larson, E. J., Corrigan, P. W., & Cothran, T. P. (2012). The impact of mental health stigma on clients from rural settings. In K. B. Smalley, J. C. Warren & J. P. Rainer (Eds.), Rural mental health: Issues, policies, and best practices (pp. 49–64). New York: Springer.Google Scholar
  36. Letvak, S. (2002). The importance of social support for rural mental health. Issues in Mental Health Nursing Practice, 23, 249–261. Scholar
  37. Lichstein, K. L., Scogin, F., Thomas, S. J., Dinapoli, E. A., Dillon, H. R., & Mcfadden, A. (2013). Telehealth cognitive behavior therapy for co-occurring insomnia and depression symptoms in older adults. Journal of Clinical Psychology, 69, 1056–1065. Scholar
  38. Mann, A. K., & Heflinger, C. A. (2016). Community setting-specific and service-seeking stigma toward children with emotional and behavioral disorders and their families. Journal of Community Psychology, 44, 199–213. Scholar
  39. Mohatt, D. F., Bradley, M. M., Adams, S. J., & Morris, C. D. (2006). Mental health and rural America: 1994–2005. Washington, DC: United States Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy. Retrieved from
  40. Morris, J. (2006). Rural marriage and family therapists: A pilot study. Contemporary Family Therapy, 28, 53–60. Scholar
  41. Morris, J. (2007). Characteristics and clinical practices of rural marriage and family therapists. Journal of Marital and Family Therapy, 33, 439–442. Scholar
  42. Mukolo, A., & Heflinger, C. A. (2010). Factors associated with attributions about child health conditions and social distance preference. Community Mental Health Journal, 47, 286–299. Scholar
  43. Park, S., & Park, K. S. (2014). Family stigma: A concept analysis. Asian Nursing Research, 8, 165–171. Scholar
  44. Phelan, J. C., Bromet, E. J., & Link, B. G. (1998). Psychiatric illness and family stigma. Schizophrenia Bulletin, 24, 115–126. Scholar
  45. Polaha, J., Williams, S. L., Heflinger, C. A., & Studts, C. R. (2015). The perceived stigma of mental health services among rural parents of children with psychosocial concerns. Journal of Pediatric Psychology, 40, 1095–1104. Scholar
  46. Pullmann, M. D., Vanhooser, S., Hoffman, C., & Heflinger, C. A. (2010). Barriers to and supports of family participation in a rural system of care for children with serious emotional problems. Community Mental Health Journal, 46, 211–220. Scholar
  47. Reynnells, L. (2016). What is rural? Retrieved July 27, 2017, from
  48. Robinson, D. W., Springer, P. R., Bischoff, R., Geske, J., Backer, E., Olson, M., Jarzynka, K., & Swinton, J. (2012). Rural experiences with mental illness: Through the eyes of patients and their families. Families, Systems, & Health, 30, 308–321. Scholar
  49. Ryan-Nicholls, K., & Haggarty, J. (2007). Collaborative mental healthcare in rural and isolated Canada: Stakeholder feedback. Journal of Psychosocial Nursing and Mental Health Services, 45, 37–45. Retrieved from
  50. Slovak, K., & Singer, J. B. (2012). Engaging parents of suicidal youth in a rural environment. Child & Family Social Work, 17, 212–221. Scholar
  51. Smalley, K. B., & Warren, J. C. (2012a). The current state of rural mental health. In K. B. Smalley, J. C. Warren & J. P. Rainer (Eds.), Rural mental health: Issues, policies, and best practices (pp. 3–16). New York: Springer.Google Scholar
  52. Smalley, K. B., & Warren, J. C. (2012b). Rurality as a diversity issue. In K. B. Smalley, J. C. Warren & J. P. Rainer (Eds.), Rural mental health: Issues, policies, and best practices (pp. 37–47). New York: Springer.Google Scholar
  53. Smalley, K. B., Yancey, C. T., Warren, J. C., Naufel, K., Ryan, R., & Pugh, J. L. (2010). Rural mental health and psychological treatment: A review for practitioners. Journal of Clinical Psychology, 66, 479–498. Scholar
  54. Stain, H. J., Kelly, B., Lewin, T. J., Higginbotham, N., Beard, J. R., & Hourihan, F. (2008). Social networks and mental health among a farming population. Social Psychiatry and Psychiatric Epidemiology, 43, 843–849. Scholar
  55. Starr, S., Campbell, L. R., & Herrick, C. A. (2002). Factors affecting use of the mental health system by rural children. Issues in Mental Health Nursing, 23, 291–304. Scholar
  56. Swinton, J. J., Robinson, W. D., & Bischoff, R. J. (2009). Telehealth and rural depression: Physician and patient perspectives. Families, Systems, & Health, 27, 172–182. Scholar
  57. Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., & Acierno, R. (2010). A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology. Journal of Traumatic Stress, 23, 116–123. Scholar
  58. U.S. Department of Health and Human Services, Health Resources and Services Administration. (2017). Designated health professional shortage areas (HPSA) statistics, Retrieved from
  59. United States Census Bureau. (2010). Frequently asked questions. U.S. Department of Commerce. Washington, DC. Retrieved from
  60. Uphold, C. R., Rane, D., Reid, K., & Tomar, S. L. (2005). Mental health differences between rural and urban men living with HIV infection in various age groups. Journal of Community Health, 30, 355–375. Scholar
  61. Wei, Y., Szumilas, M., & Kutcher, S. (2010). Effectiveness on mental health of psychological debriefing for crisis intervention in schools. Educational Psychology Review, 22, 339–347. Scholar
  62. Weigel, D. J., & Baker, B. G. (2002). Unique issues in rural couple and family counseling. The Family Journal, 10, 61–69. Scholar
  63. Wendel, M. L., Brossart, D. F., Elliott, T. R., Mccord, C., & Diaz, M. A. (2011). Use of technology to increase access to mental health services in a rural Texas community. Family & Community Health, 34, 134–140. Scholar
  64. Williams, S. L., & Polaha, J. (2014). Rural parents’ perceived stigma of seeking mental health services for their children: Development and evaluation of a new instrument. Psychological Assessment, 26, 763–773. Scholar
  65. Ziller, E. C., Anderson, N. J., & Coburn, A. F. (2010). Access to rural mental health services: Service use and out-of-pocket costs. Journal of Rural Health, 26, 214–224. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Family Social ScienceUniversity of MinnesotaSaint PaulUSA

Personalised recommendations