Nebraska native and licensed mental health practitioner Tara Wilson grew up in a town so small that her high school graduating class comprised only 10 people. When her young niece was diagnosed with cancer a few years ago, Wilson’s family organized a pancake breakfast and benefit auction to cover the growing medical bills. People traveled from across the county to attend the fundraiser, and the family received cards and words of support from people they didn’t even know.

“People bend over backward for you in a rural community,” Wilson says. “Whenever a big life event happens … everyone just bands together. We had people from the surrounding communities that I had never even known or heard of or met [who] all came together. The outpouring of support from that was just remarkable. The entire community came together. I think that’s very unique to a rural area. I don’t know if you’d find that [elsewhere].”

Wilson can attest that working as a professional counselor in a rural area features its fair share of challenges. But the rewards — such as witnessing the impact of an entire county pulling together to support someone in need — make it all worthwhile, she says.

In addition to the “we’re in this together” character often in evidence in rural areas, the setting can afford counselors the chance to see young clients grow up, succeed and start families of their own.

“Living in a small town, I see [students] when they come to kindergarten and I see them when they graduate,” says Christi Jones, a school counselor and American Counseling Association member in rural Alabama. “I measure my success by the graduation invitations that come [in the mail] or the college students who come back to visit. You know they have overcome a lot of adversity to get there.”

A long and winding road

According to data from the most recent census, 19.3 percent of the U.S. population lived in rural areas in 2010. This reflected a slight decrease from the 2000 census, when 21 percent of the population resided in rural areas. (The U.S. Census Bureau defines “rural” as any population outside of an urban cluster or area with 50,000 residents.)

Counselors working in rural communities can face potential obstacles that practitioners in suburban and urban areas may never know. These challenges can include professional isolation, a culture where “everybody knows everybody” and long hours spent traveling to faraway or widespread professional commitments.

Stacey Meehl begins serving as president of the North Dakota Counseling Association (NDCA), a branch of ACA, in July. Most of the professionals in Meehl’s town, from the paramedics to the local parole officer, have her cell phone number on hand, and her phone is apt to ring at any time of day. “I could change [my number] and throw the whole town in a loop,” she jokes. “You do it all [as a rural counselor]. … I learned early on in my career not to specialize because you never know what you’re going to get walking through the door.”

Wilson, an ACA member and assistant professor at Wayne State College in Wayne, Nebraska, agrees. “If you start to specialize, I think everything else [besides what you specialize in] will walk through the door,” she says with a chuckle. “[Clients] are going to come at you with anything and everything.”

Meehl is a licensed professional clinical counselor who has a private practice in North Dakota and also works at a mental health center just across the border in South Dakota. She currently has clients — individuals, couples and families — ranging in age from 3 to 60-something. In private practice, she covers a four-county area. Last year, she put 15,000 miles on her car driving to meet clients at satellite offices, schools, homes, medical facilities, nursing homes and other locations.

Rural counseling is anything but the neat-and-tidy model in which a practitioner sees each individual client one hour per week in a single office, Meehl notes. “It’s what’s expected. It’s just part of where you live,” she says.

When working in rural areas, a professional counselor or school counselor may be the only mental health practitioner for miles around. Counselors considering moving to rural areas should be aware that the only option available to them may be opening their own private practice because other agencies or clinics in the area may be sparse or nonexistent, Wilson says.

At the same time, Meehl, Wilson and the other counselors interviewed for this article urge practitioners to consider working in rural areas because the needs — and the rewards — are great.

“There’s a shortage of [rural] practitioners,” says Wilson, who co-presented about the experience of rural mental health counselors at ACA’s 2016 Conference & Expo in Montréal. “But it’s not an opportunity someone should go into blindly. You need to be aware of the challenges. We’d always welcome more providers though. There’s such an opportunity.”

Meehl, an ACA member, concurs. “Consider giving your gifts and talents to work in this area,” she says. “There is an opportunity — a rewarding opportunity — to work with people. Yes, it is challenging. There is nothing in graduate school that will prepare you for this. But we deal with the same [clinical] issues as anyone in a larger town.”

Blooming where you’re planted

The practitioners interviewed for this article agree that working in a rural area has its challenges. But they say those challenges are nothing that can’t be lessened or overcome entirely with a little creativity and collaboration. Consider the following insights and words of guidance.

> Prepare for the inevitability of dual relationships. When you’re a counselor practicing in a small town or rural area, Wilson advises, “It’s not a question of whether you’ll see a client at Wal-Mart today; it’s how many clients you’ll see at Wal-Mart.”

Or in other real-life scenarios common in rural areas, a client and counselor might find themselves playing in the same softball league, singing together in the church choir or encountering each other regularly because their respective children are involved in Scouting. The key, Wilson says, is to be prepared, think ahead and talk such scenarios through with clients ahead of time.

Meehl has a conversation with each of her clients — children and adults — at the beginning of the therapy relationship. “I stress that we live in a small town. If you don’t want to say anything to me when we pass in the street, I won’t be offended,” Meehl says.

As the mother of an 11-year-old daughter and a 9-year-old son, Meehl also understands some additional complications that can arise. “In a small town, having kids, they become friends with your clients or their families. You might be sitting next to them at church or at your child’s ballgame. You may be fine, but [your clients] might feel uncomfortable,” she says.

Wilson has learned the value of asking her clients what their preference is ahead of time. In one instance, in trying to prepare ahead of time for any chance encounters, she told a female client that she wouldn’t acknowledge her in public unless the client said hello and initiated contact. The client took offense, interpreting this to mean that Wilson was embarrassed to be seen talking with her in public.

Wilson took the client’s reaction to heart. “The client felt fine about it, so why not?” she says. “What would have helped there is to approach it with ‘How would you want this to go?’ instead of saying, ‘This is what will happen.’ Be prepared [for client encounters outside of session], but let the client have a say in it. Ask them ‘How do you want to handle [meeting in public]?’”

Early in the therapeutic relationship, it is also helpful to have a discussion with clients about boundaries and what is — and isn’t — appropriate to talk about outside of session, Wilson adds.

Family members are also part of the equation, Meehl notes. “My kids learned the word confidentiality at a very early age,” she says. “They know that when mom gets a phone call and has to go to another room, it’s work and they understand. … They learn that boundary.”

> Be mindful of appearances. In a small town or rural area, the stigma of being seen going to therapy can weigh heavily on clients. “Not only does everybody know everybody, but everybody knows everybody’s car,” Wilson says.

Counselors should be mindful of this when choosing office space, Wilson advises. When she worked at a rural clinic in the panhandle of Nebraska, the facility shared space with a medical practice. This lessened the stigma for clients because passers-by wouldn’t know whether the person was there for a medical appointment or a therapy session, Wilson says.

In addition, if a counselor is aware that two different clients know each other — for instance because they’re neighbors or have children at the same school — it might be helpful to avoid scheduling their appointments back to back.

The “everybody knows everybody” rural culture can also affect how clients and potential clients reach out to the counselor, Meehl says, noting that people sometimes call her at home or pull her aside in social or public situations rather than calling her at the office.

“You have to make them feel comfortable. That’s the big thing — making them feel like there’s nothing that they can’t share with you or work with you on,” Meehl says. “Everything is case by case. What does [the client] need, and how do I put it together?”

> Carefully consider whether a little self-disclosure can help build trust. In rural areas, many clients will have spent their entire lives in the same town, growing up around the same neighbors and extended family members. For these clients, it can mean something for a counselor to share a few details about his or her background and family connections, Wilson says.

That might be particularly true when the counselor did not grow up in the immediate area where he or she is now practicing. “Name is huge — what family you belong to, who you’re connected to … Be prepared for [these clients’] curiosity of wanting to get to know you,” Wilson says. “They’re not being nosy or harmful. It’s a curiosity to help identify you.”

In Wilson’s case, she found that offering some limited self-disclosure — what part of town her family lived in, where she grew up — helped her forge relationships with certain clients, especially among the older generations.

Wilson also suggests that counselors practicing in rural areas — and especially those who are new to the area — build connections by getting involved in the community. This can be as simple as participating in an adult sports league or book club. Getting out and mingling in the community is the best way for counselors to get a better understanding of the local culture, while also letting people get to know them, she says.

Meehl says that counselors who move into rural areas should consider joining a professional organization such as the Rotary Club. This provides an outlet for these counselors to get ideas, network with other professionals and figure out whom they can call for referrals or support services for their clients.

At the same time, Wilson adds, counselors should keep in mind that word of mouth is a powerful tool in rural areas and small communities. Every client contributes to building the counselor’s reputation or could lead to a referral. “[Maintain] a very ethical practice, and keep boundaries with your professional and private life,” she says.

> Get creative. Rural counselors may have to think outside the box to find resources for clients, Meehl says. For example, she might connect a client who is a military veteran with services and support from a local American Legion or Veterans of Foreign Wars post because a Department of Veterans Affairs facility is too far away.

In another example, Meehl says the nearest psychiatrist or other practitioner who can prescribe medication is more than an hour away from her practice. If a client would have trouble making that trip, she sometimes works with the local senior center’s bus service to ensure that the client has transportation, even if the client is not a senior citizen.

“You get pretty creative to try and find the services you need,” Meehl says. “It just means you have to know your community very well. It becomes very collaborative. … You just have to get a little more creative in your treatment process.”

> Network and collaborate. In rural areas, counselors must learn to collaborate with professionals of all kinds, from those in social service agencies and law enforcement to schools and other medical professions. In turn, those professionals will routinely call on counselors for support, Meehl says.

With clients’ permission, Meehl has collaborated on client issues with domestic violence agencies, child services, local doctors and hospital personnel. On one occasion when a client was having back pain related to stress and anxiety, she even collaborated with the client’s chiropractor to set up a treatment plan.

“You learn to work with them all,” Meehl says. “The community of professionals becomes very tight-knit.”

Collaborating with those outside of the counseling profession is also a good way to learn about issues with which a counselor may be unfamiliar, Meehl adds. “I had several clients come in with eating disorders, and I hadn’t done too much with that in [graduate] school. I did any research I could, and I worked with other specialists in the area to figure out a treatment plan, simply because that’s a very specialized field. … You call people you may know and ask, ‘Where can I get training? How do I work with this?’ You learn to count on others to walk through things, or you figure it out on your own,” she says.

> Be flexible and navigate the learning curve. Jean Baird, NDCA president-elect and a school counselor in a very rural part of North Dakota, says much of what she does over the course of a typical workday falls under “other duties as assigned.” This may include helping to administer standardized tests, managing Section 504 plans for special education students or, in one instance, picking head lice out of students’ hair because her school does not have a nurse.

“We deal with whatever comes along,” says Baird, who is one of two school counselors at a high school with 500 students in the northern part of the state. “We are a jack-of-all-trades and do everything.”

Baird switched careers to school counseling after working as an elementary school music teacher. At the time she was hired, she was the only counselor at her high school, and she was in the midst of finishing graduate school. Within her first three weeks on the job, a student died by suicide outside of school. Baird also was the first to intervene in another student’s suicide attempt in a school bathroom.

Her on-the-job training was “baptism by fire,” she says. “It was a steep, steep learning curve — a very eye-opening experience.”

Many counselors in rural areas are isolated and may have few, if any, colleagues who do exactly what they do. In those situations, counselors must be disciplined about engaging in as much professional development as they can on their own, Baird says. Fortunately, webinars and other online continuing education opportunities are much more prevalent than they were even a few years ago.

“With every new thing that came up, I would consult with the social worker [in Baird’s school district] and read and read and read,” says Baird, a member of ACA. “I went to every conference and workshop that I could find. … The more basic information a [counselor] has, the better. You don’t know what you’re going to need. Prepare for anything and everything.”

> Use time spent in the car to your advantage. Rural counselors often spend many hours behind the wheel commuting and traveling between professional engagements. That time can be spent on the phone returning calls or consulting with colleagues, Wilson says. It can also be a chance to dictate notes into a recorder. Sometimes, it simply serves as much-needed time alone to decompress or engage in mindfulness or gratitude exercises.

Before Wilson was licensed, she did co-therapy training with another counselor. They rode together and used the 40-minute commute home after sessions to talk through the day’s experiences and discuss personal growth and self-care. Those car conversations proved particularly helpful and enhanced the learning experience, Wilson says.

> Stay connected. Meehl, Baird and Wilson agree that memberships in professional organizations, both at the national and state levels, are a good way for rural practitioners to stay connected to others in the profession. These memberships also open up opportunities to participate in conferences, trainings, workshops, webinars and other learning opportunities.

NDCA offers a monthly meeting via phone conference, which is much easier than meeting in person because its members are so spread out, Baird says.

Jones, an elementary school counselor in rural Alabama, meets periodically with a consortium of school counselors of all grade levels from across her district. The meetings offer not only a chance to share resources and ideas but also serve as an antidote to the isolation that can come with working in a rural area, Jones says.

The other school counselors in the group “know exactly what it’s like to walk in your shoes,” Jones says. “That support helps. It really is a form of self-care. It’s important to have someone you can reach out to and consult with. We all deal with similar issues.”

> Make time to be off the clock. Being the only mental health practitioner in a community can become all-consuming. You are not only constantly in demand but likely will also encounter clients around town when you’re not working, Meehl says. Before she scaled back her private practice, Meehl says she could put in a 12-hour day and still get work-related phone calls at night when she was home with her family.

On the flip side, Wilson points out that outdoor activities (her favorite is fishing) are often an easily accessible form of self-care in rural areas.

Meehl urges rural counselors to be deliberate about scheduling time off, whether it’s a date night with their spouse, attending their child’s sporting event or getting out of town for vacation. Provide clients with a number to call in an emergency, but otherwise, keep your cell phone turned off during personal time, she advises.

“One of the things I had to learn very quickly is to make sure I had time with my family,” Meehl says. “My son reminds me when I’m getting crabby. That’s my cue [to take a break],” she says. “You have to make sure to take some alone time, time to go out on a date with your husband. If you don’t, you will get consumed by [the work].”

Thinking outside the box

Collaboration is a watchword for rural and small-town counselors that can include everything from partnering with noncounselors in the community to participating in regular communications with mentors or colleagues in other parts of the state.

For Jones, collaboration comes in the form of an innovative program that brings a mental health counselor to her school, which is located in a very rural, high-poverty area, once a week. Jones is the only counselor in an elementary school of roughly 600 students in prekindergarten through fifth grade. The mental health counselor travels to a different school within the district each day.

The setup allows for intensive, long-term mental health care beyond what Jones can provide to students. The mental health counselor often works with students who have experienced abuse or trauma or who have ongoing issues such as difficulties with a blended family or a parent’s military deployment.

In many cases, the program provides treatment for children whose parents wouldn’t be able to provide transportation to regular counseling sessions outside of the school building. Jones’ school serves three communities, and many of its students are bused long distances to attend. In addition, a large number of parents in the area work two jobs and are already stretched to the limit, she explains.

Prior to the program, students wouldn’t always get the extra help they needed, Jones says. “This provides a way for students to get treatment. It’s a win-win,” says Jones, who has been a school counselor for 14 years. “I’m a school counselor with 600 students in my building. I try very hard to serve them and meet their needs, but that’s a lot of students for one school counselor. This [program] has provided extra, long-term support for students’ issues. To me, that’s an invaluable resource.”

The three-year-old program grew out of an idea from the school nurse in Jones’ district. After gaining support from the school board, the district set up a contract with the mental health counselor. Costs are covered by students’ insurance coverage through Medicaid. Eventually, Jones says, she’d like to see the program expand to accommodate students who aren’t under Medicaid. Jones co-presented a poster session about the program at ACA’s 2016 Conference & Expo.

A key factor in the program’s success is that all the involved providers established clearly defined roles for each participant before the program launched. The school counselors in Jones’ district refer students to the mental health counselor whenever a student presents with a mental health concern or other issue that would benefit from intensive, long-term therapy beyond what the school counselors can provide, Jones says. The mental health counselor is also able to meet with students and families year-round.

In return, Jones serves as a bridge between the mental health counselor and the teachers and students within her school, whom she knows very well. She also works with the mental health counselor to introduce families to resources in the community, such as charities that provide school supplies and clothing to those in need or support for families whose power has been cut off.

School counselors who serve students in rural areas often need to step outside of their basic, expected roles, Jones emphasizes. “The most important role of the school counselor is to be an advocate,” she says. “I feel like I give my students a voice when they have needs. A counselor cannot be successful if [students’] basic needs aren’t met, if they come to school and they’re hungry or cold. You have to deal with that first, and then you can sit down and have a counseling session.”

Jones is involved in organizing “wraparound” services for students at her school, which she says is a necessity in rural, high-poverty areas. For example, the school keeps a closet of extra clothes available for children who arrive at school with ill-fitting or worn-out clothing or who aren’t dressed appropriately for the season’s weather. Jones also helps with the school’s backpack program, in which a backpack full of snacks and easily prepared foods is sent home with children in need over weekends and school breaks.

“This is the hardest work and the best job I’ve ever had. When you come to a school and you see all this need, you can’t ignore it,” Jones says. “This job has changed me in ways that I thought weren’t even possible. To see what poverty really is … It’s hard work, but when you see students or a family turn a corner, it makes it worth it to come to work every day.”

 

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Guidance for rural counselors from the ACA Code of Ethics

Counselors in rural and small-town settings are often called on to play many roles and deal with multiple relationships with current, former and prospective clients. The more intimate settings common in rural areas present counselors with professional and personal challenges related to competence, effectiveness and self-care. The ACA Code of Ethics (counseling.org/ethics) provides some guidance to help address issues related to the following:

• Understanding the diverse cultural backgrounds of clients (Section A, introduction)
• Engaging in counseling relationships with friends or family members (Standard A.5.d.)
• Risks and benefits of accepting clients with whom the counselor has had a previous relationship (Standard A.6.a.), extending current counseling relationships beyond conventional parameters (Standard A.6.b.) and entering into nonprofessional relationships with former clients or their family members (Standard A.6.e.)
• Providing counseling services to two or more individuals who have a relationship (Standard A.8.)
• Establishing means of payment for services and accepting gifts (Standards A.10.c., A.10.e., A.10.f.)
• Working within the boundaries of competence (Standard C.2.a.)
• Counselors monitoring their own effectiveness, maintaining self-care and preventing burnout and impairment (Standards C.2.d., C.2.g.)

— Source: Deborah H. Drew, Mikal Crawford and Cheryl Crabtree’s education session, “Multiple Roles in Rural and Small Settings: Personal Impact/Professional Response” at ACA’s 2016 Conference & Expo in Montréal

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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