Mental Health in Small Towns

I grew up in a small town. Corn fields surrounded our community. Each year, the park filled with neighbors and people who had left town coming back for the yearly homecoming. A beautiful place. At times, I felt like an outsider.

Country music often paints rural areas as a kind of eutopia of close-knit neighbors and self-determination. Sometimes these stereotypes hold some truth. Research shows that rural environments are associated with a higher level of psychological sense of community (PSOC) than urban areas (Obst et al, 2002). This makes sense, it is easier to get to know everyone in a small group than to every person in a larger group. A strong sense of community and social support is key to mental health.

Not All Paradise

Still, several serious psychological and social problems hide within rural areas. Substance use is common in rural areas, particularly abuse of prescription drugs (Peters et al, 2020) and alcohol (Mellinger, 2019). Death by suicide is significantly more prevalent in rural areas than in urban areas (Casant and Helbich, 2022).

Resources for mental health care in rural areas are limited. While telehealth services are filling some of this gap, it is more difficult to receive mental health care anonymously in rural areas. When there are only a few dentists and one grocery store within a certain radius it’s a bit more difficult for providers and clients not to run into each other. Further, when a higher level of care is needed such as hospitalization it is not uncommon for someone to spend days in a hospital Emergency Department or to be brought by ambulance hours away to the nearest psychiatric unit with an available bed.

Fears of judgment and perception of seeking help as weak are rampant in rural areas (Crumb et al, 2019). This stigma and belief that one ought to ‘take care of their own’ discourages help-seeking behaviors (Cheesmond et al, 2019). Further, distrust of outsiders makes it less likely that individuals in rural areas will reach out to virtual mental health services.

Sense of community is a significant predictor of psychological well-being among individuals in rural areas (Kutek et al, 2011) making social exclusion particularly painful. Lack of acceptance of sexual and gender minorities in these communities is prevalent (Elliott et al, 2022) and reflected in worsened mental health outcomes for these minorities in rural areas when compared to urban areas (Horvath et al, 2014).

In Conclusion

Small towns do have some advantages over larger areas in terms of fostering mental wellbeing, however, the picture is much more complicated. Mental health problems do exist in these communities. Rural culture encouraging self-reliance fosters high rates of stigma. Coupled with a lack of resources to begin with, this means a lack of help for people who need it.

Mental health initiatives ranging from targeted anti-stigma campaigns to integrate mental health care into primary care services have shown promise. In addition, strategies that leverage community support by training the public in mental health first aid have been shown to increase the detection of mental health concerns, positive attitudes toward seeking help, and willingness to do so in rural areas (Jorm et al, 2004).