Reprinted from the "Rural, Remote and Northern Communities" issue of Visions Journal, 2020, 16 (1), pp. 5-7
I live about 12 kilometres northwest of Princeton, a typical small, rural BC town. We have a supermarket, two banks (one is a credit union), a hospital, a medical clinic, an arena, a golf course, a community centre and a range of small businesses that serve a population of about 5,000.
In my experience, mental health issues in rural BC are essentially the same as they are in urban BC. For example, Princeton is currently experiencing an opioid crisis similar to that being experienced in large urban centres, and like other regions of the world, we are also coping with the new realities of COVID-19.
But the primary difference between rural BC and urban BC is access. In Princeton, we have several “access issues,” including an insufficient number of mental health care professionals and a lack of information about how and where to get help. Then there are travel barriers: mental health care practitioners and services are often located far from where people live, and transportation options are limited or non-existent.
When we consider mental health services in rural and remote BC, we have to take into account other factors as well—factors that also result in barriers to access. The value placed on self-reliance in rural and remote BC is high: “I don’t need anyone’s help.” The stigma faced by those seeking help is also significant: “I always knew he was nuts.” These and other factors contribute to access issues in small towns, and to the number of people who avoid seeking help.
Eight years ago, my wife and I, along with several other Princeton residents, formed the Support Our Health Care (SOHC) Society, a grassroots advocacy organization dedicated to the improvement of health care in Princeton and the surrounding areas. In September 2017, SOHC joined five other like-minded organizations to form the BC Rural Health Network (BCRHN). As President of the BCRHN, I am pleased to see the growth of the network to include 38 health care advocacy organizations and individuals across the province.
Early in its development, the BCRHN identified access to mental health services as a common concern among its members. Today, one of the goals of the network is to improve access to mental health services for all rural British Columbians.
One of the realities of “living rural” is that the further you get from urban centres, the fewer services there are—and less of each service is available. This results in increased suffering, for both rural patients who require mental health care and the community as a whole. Over the past several years, rural communities have seen a gradual reduction in health care services due to regionalization, an organizational change in which health services are “centralized” in urban centres to reduce costs for the health authority of the region.
Of course, the term is a misnomer from the point of view of rural residents: with centralization, many health care services are no longer “central” for rural BC. Instead, the organizational change has increased the personal costs of rural residents, who must now travel to urban centres for needed care.
At the same time, we have seen a decrease in transportation options, most notably the recent discontinuation of Greyhound bus services. These factors have had a huge impact on our communities. The most vulnerable populations—the infirm, the impoverished and the elderly—are impacted the most.
The difficulty in accessing mental health care services and transportation services means that mental health issues may not be dealt with in a timely manner. This can lead to or exacerbate addiction, family dysfunction, marital breakdown, chronic health problems and other personal and social challenges. Ultimately, this places an increased burden on other health care service areas, such as primary care, social services, public health services and community services.
Princeton is fortunate to have an excellent team of mental health professionals providing a broad range of services, including a mental health and substance use clinician, a registered psychiatric nurse and two community rehabilitation support workers. Karen Fulton, our community’s registered psychiatric nurse, agrees that the main challenge in providing mental health services in a rural community is the issue of accessibility. As she pointed out in a personal email exchange, “In rural communities, we don’t tend to have access to [a high] level of specialized care. When treatment programs are available in a small town, we are presented with other challenges, such as stigma, which creates a barrier to successful outcomes, where a client refuses to engage in treatment based on feelings of shame and blame, and their own internal struggle.”
To deal with other issues, such as providing care over a very large geographic area, Fulton said that the clinician “must find creative ways to support clients with limited programming available.”
When asked what things might look like if there were unlimited funds for mental health care services, Fulton said she could envision a mental health centre with access to a variety of specialized programs: “I would see open doors, welcoming everyone who is willing to learn and engage in treatment.”
When we consider rural and remote populations in BC, it is particularly important to look at the needs of Indigenous communities, since they constitute one of the largest isolated populations in Canada. The Canadian Collaborative Mental Health Initiative affirms that “Canada’s Aboriginal Peoples, who constitute a large proportion of those in isolated areas, are burdened with some of the highest rates of mental illness and often have the least access to appropriate care.”1
The way forward must take a culturally safe approach that responds to specific needs of all rural residents. Cultural safety is “an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the healthcare system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care.”2
I’ve identified several strategies that would improve mental health services in rural, remote and Indigenous communities. These include
- providing mental health access information through a variety of communication channels, including the Internet, the newspaper and pamphlets that would be available locally in key locations, such as primary care clinics, hospitals, town offices and grocery stores
- working with community stakeholders and Indigenous community members to develop education and self-help programs aimed at prevention
- improving access to transportation through increased private and public bus service, taxi vouchers for people with limited income and, where appropriate, a community-organized volunteer driver program
- developing programs to enhance culturally safe and trauma-informed diagnosis and treatment of mental illness (which takes into account how an individual’s experience of trauma might adversely affect their ability to function and their mental, physical, social, emotional and spiritual well-being)
- using videoconferencing and other virtual care options to help overcome the challenges of distance and isolation
The COVID-19 pandemic has had significant impacts on mental health and mental health care in rural, remote and Indigenous communities. Some of these impacts have been negative and some have been positive. The negatives include things like a general increase in fear, frustration and anxiety. On the positive side, as a friend who has chosen to live in a remote location puts it, when it comes to socializing, “COVID has taken the pressure off.” This is an interesting observation: for many people who are dealing with mental health issues, including anxiety, self-isolation is a treatment of choice. For some, COVID-19 has increased their isolation, which has been helpful. Isolation for them does not mean complete lack of contact. It simply means they can choose their contacts to meet their needs.
The COVID-19 crisis has made me realize how easily mental health can become negatively affected. For my wife and me, the most significant change has been the loss of in-person contact with friends who are important sources of support in times of stress and anxiety. It has shone the spotlight on the need to improve access to mental health services, developing preventative programs, removing stigma and working together collaboratively for the good of the community. As we emerge from these challenging times, the true test will be in how well we apply what we’ve learned in order to do what we do differently and better.
About the author
Edward is a retired teacher living in the Tulameen Valley, near Princeton. President of the BC Rural Health Network and Director with the BC Health Coalition Steering Committee, Edward believes in equitable access to health care services for rural BC residents. He and his wife, Nienke Klaver, formed the Support Our Health Care (SOHC) Society of Princeton, dedicated to improving Princeton’s health care model. Edward was also instrumental in establishing the Princeton Health Care Steering Committee
- Canadian Collaborative Mental Health Initiative. (2006). Establishing collaborative initiatives between mental health and primary care services for rural and isolated populations: A companion to the CCMHI planning and implementation toolkit for health care providers and planners (p. 1.). www.shared-care.ca/files/EN_CompanionToolkitforRuralandIsolated.pdf.
- First Nations Health Authority. (2020). Cultural humility. www.fnha.ca/wellness/cultural-humility#learn.