(Story Credit to Kelly Page for IowaWatch.org)

DES MOINES, Iowa – Iowa does not have enough psychiatrists, psychologists, therapists or other mental health care providers to handle an increasing need to care for farmers dealing with relentless flooding this year, several mental health experts IowaWatch interviewed warned. Many health care specialists don’t want to work in small, rural areas for reasons ranging from a lack of local resources to seeing few options for personal growth that comes from cultural events or entertainment, the interviews revealed.

The result is that people who need mental health care immediately have a difficult time getting it, a problem in the parts of rural Iowa hit this year by devastating flooding. “We turn people away every day because we don’t have available appointment slots. We do a lot of referring to other agencies,” said Susan Ecker, director of Waubonsie Mental Health Center, which has locations in Fremont, Page and Montgomery counties in southwestern Iowa, all hit hard by the flooding.

“There is no competition between service agencies in our community because all of us combined cannot handle the volume of people that are seeking service. “Fifty of the 59 Iowa counties designated as disaster areas because of flooding this year also have been designated by the U.S. Health Resources and Services Administration as having inadequate mental health care. In all, 86 of Iowa’s 99 counties are designated mental health professional shortage areas because they do not have an adequate number of providers for the number of people living in those counties.

Some of the counties hit hardest by flooding are not targeted by national programs that encourage young healthcare professionals to work in the rural U.S. with incentives like student loan forgiveness, scholarships and grants. Many mental health professionals still feel a strain on mental healthcare resources in heavily-flooded counties even when provided these incentives, interviews revealed.

For many, their caseloads become too large to handle adequately, leaving them with an ethical dilemma of taking on more clients at the expense of others they already are seeing. Meanwhile, patients in these underserved areas rely on therapists who get shuffled to multiple locations during the week. Patients have to wait five to six weeks to be seen if not needing urgent care – one to two weeks if they do, health care professionals said in interviews.

Alecia Dougherty, clinical supervisor at Plains Area Mental Health Center, which covers a wide patch of northwest Iowa, said some patients are on their second or third therapist in one to two years. She said switching therapists, especially after building a therapist-client relationship over the course of years, can be traumatizing. “Turnover is probably the biggest barrier to getting good services to people in this area,” Dougherty said. “It affects community coalitions, it affects clients.”

Clinicians at Plains Area Mental Health Center move to places like Sioux City or Des Moines after starting in the smaller, rural areas Plains Area serves, Dougherty said. “I have actually two clients on my caseload right now who saw their previous therapist – one of them saw her for nine years, the other one saw her for 13 years – who were honestly traumatized by having to start seeing me. So it was a major setback for their treatment.”

Ecker works in Clarinda but lives on a farm near Elmo, in northwest Missouri just south of the Iowa-Missouri border near where she grew up on a rural Big Lake, Missouri, farm. Both areas sustained serious flooding this year. She said she feels connected to her community. Her husband, Terry Ecker, is a farmer. “I’ve lived here all my life. This is home to me. It makes me really sad that there’s this disaster in the community, and there’s such a great need, and I don’t know how to employ therapists to meet those needs,” Ecker said.

Unmet demand for mental health care services in disaster-ridden, rural regions in the state are part of a larger problem in Iowa, mental health care advocates said. “We don’t have psychiatrists, psychologists, nurse practitioners, therapists, clinical social workers,” Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness, said. “It goes all the way down the line. We just don’t have enough.”

Even if enough care providers were available, barriers exist in linking farmers, whether they are in flood zones or not, to mental health care services, the IowaWatch interviews revealed. Financial difficulties, transportation issues, time constraints and limited internet access, but also many therapists’ lack of understanding of agriculture and a stigma attached to mental healthcare in farm communities also make it difficult for farmers to get the help they need when confronting stress and behavioral health issues.

“I guess that agriculture’s a tough job anyways, but this year is probably a hundred times more stressful than a typical year,” said Corey McIntosh, a fifth-generation farmer near Missouri Valley, Iowa, on the western side of the state, which has had some of the worst flooding from the Missouri River. “I’d say a lot of the people around here are probably experiencing, you know, certain levels of depression.”

McIntosh’s farm has flooded twice this year. Although he is not seeking counseling, he said it would be difficult if he were because he would not have time to do it.

He sees more flooding in the future. “It can’t be denied that we’re experiencing more extreme weather events,” he said. “The Corps of Engineers recognizes that climate change is happening but they have yet to start planning for it.”

MENTAL HEALTHCARE DILEMMAS IN SHORTAGE AREAS

Eight of the counties hit by flooding have not received designation by the national Health and Resources Service Administration as mental healthcare provider shortage areas (Cass, Dallas, Fremont, Mills, Montgomery, Page, Polk and Pottawattamie). This designation can have importance for healthcare providers in rural areas because the National Health Service Corps uses the administration’s designations to decide where to help clinics provide financial recruiting incentives to bolster rural healthcare systems.

Though a recruiter at one clinic IowaWatch spoke with said the clinic used the National Health Service Corps program as part of a more robust recruiting strategy that produced helpful results, many others said the program is not the complete answer when attracting mental healthcare providers to rural areas.

Ecker, from the heavily-flooded southwest of the state, practices in counties that previously had been declared a shortage area but lost their designation for reasons she said she does not fully understand. She said National Health Services Corps helped Waubonsie Mental Health Clinic for many years but that has changed. “Every few years, they rewrite the different areas. And our rating scale changed somewhat by a point or two,” she said.

Dougherty said Plains Area Mental Health Center employees continually feel understaffed and are fighting high turnover rates, even with Service Corps funding and employment benefits such as numerous health insurance policy options and pay that is 7% higher than the state average.

Dougherty blames high turnover and a perceived unattractiveness of rural communities, in part, on colleges failing to prepare students for the specific needs in rural areas. She said she has seen employees straight out of school quit the profession within their first few weeks because the work was too challenging.

“A lot of treatment models are set up for urban areas – I would say most of them, to be honest – and then we try to implement them in rural Iowa, because they have such good outcomes,” Dougherty said.

Despite widespread challenges with recruiting mental healthcare professionals to rural America, employees at one clinic IowaWatch spoke to said they have doubled their staff in the past year and are expanding services. The clinic is Crossroads Behavioral Health Center in Creston, Iowa, in a region that also has experienced heavy flooding. Last November, it hired human resources and marketing director Macie Blazek, who has a recruiting background.

Crossroads provides employees some of the same financial incentives as other clinics: service corps backing and what Blazek called a good retirement program. The clinic additionally pays for an independently-licensed therapist to supervise a clinic therapist’s first two years in practice. This process can be a financial drain on therapists if they have to pay it.

Many mental healthcare clinics do not have full-time recruiters. “We’re still hiring several positions, currently,” Blazek said. “And so even though we feel like we’re in a good place right now, it’s something we still kind of have to keep working at.”