Rural Nebraskans Leading Effort to Expand Mental Health Services

Rural areas feel the effects of the mental health care shortage far more than cities like Lincoln and Omaha. And many Nebraskans are leading the effort for more resources in their communities.

This story is part of our ongoing reporting project "Nebraska: State of Mental Health."

Dr. Catherine Jones Hazledine’s days start early – and usually in a different town every day.

I meet Dr. Cate, as her clients call her, in a tiny clinic in Rushville, Nebraska – population 890.

She leads a team of behavioral health providers at Western Nebraska Behavioral Health, traveling hundreds of miles a week to hold mental health clinics.The team spreads out each day to cover more ground.

"We have clinics in Crawford, Chadron, Rushville, Gordon, Valentine, Bridgeport, Alliance and Scottsbluff currently," she said.

Rushville is also her hometown – and the reason she’s so passionate about providing mental health care in rural areas.

"I think the distances involved can be a real challenge," Dr. Cate said. "You know, if we don't travel, our clients have to travel and our clients very often can't travel."

There’s a nationwide shortage of mental health care providers, often resulting in long wait times. That shortage is especially acute in areas like this.

People in rural areas experience mental illness at about the same rates as in urban areas. A recent NPR poll found 18% of rural adults say they "always" or "often" feel lonely or isolated. Those numbers go up for rural adults with low income or disabilities.

But mental health resources are much harder to find. Rural Nebraska counties have just three psychiatrists for every 100,000 residents, on average. The national average is five times that – and even that number is too low to meet the need.

Low pay contributes to the overall shortage of providers, but psychiatrist and director of the Behavioral Health Education Center of Nebraska Dr. Marley Doyle says rural communities offer even more challenges.

"Medicaid reimbursement is a lot lower. More people in rural areas have Medicaid," Doyle said. "So it makes it hard to kind of make ends meet, doing the career that you were trained to do."

Having to pay out of pocket is a big deterrent for rural Nebraskans who face a lot of other financial decisions. A report from the Robert Wood Johnson Foundation found four in ten rural Americans report problems paying for medical bills, housing or food.

Doyle says they used to focus attention on convincing trained professionals to move to rural areas – but now they’re taking a different approach.

"We know that there's more success if you can retain a provider that's from the area, rather than trying to recruit somebody to move to an area that they're not from," Doyle said. "And so we've really kind of shifted our focus on going to where people are from, where they live, and working with those schools, to try to kind of get people to kind of stay in the communities that they're from."

And that has other benefits, too.

The stigma of mental health seems to be a lot stronger in rural areas – so when the local therapist went to high school with you, you’re might be more willing to try something outside your comfort zone.

"I've even had physicians tell me that they've referred somebody who had never been to behavioral health services before," Dr. Cate said. "And the person had been kind of on the fence and very wary. And then they told them who it was. And they were like, 'Oh, yeah, we know her.'"

Even just one person seeking help can have a lasting impact in the community. Think about struggling kids who grow up to be struggling adults raising their own kids.

"We were trained to implement interventions with relatively straightforward problems," she said. "But instead, we had sort of these train wreck situations of generations and generations of people."

Gordon, Nebraska is about 15 miles east of Rushville. (Photos by Becca Costello, NET News)

Resources like Western Nebraska Behavioral Health give parents the chance to break that cycle.

Parents like Tiffany, who drives 30 miles round-trip from Gordon to Rushville to take her two daughters to counseling. Tiffany remembers the day her 11-year-old daughter confessed how she was feeling.

"I sat down with her in her room, and I said, 'You know what's going on, you can talk to me,'" Tiffany said. "And she was able to open up and said, 'Yeah, I was YouTubing how to commit suicide.' And so, as a mom, that's very hard to hear."

Her 9-year-old daughter has a form of ADHD that makes it hard for her to control her impulses.

"My second daughter actually has been going to counseling for over a year, and it's a world of a difference," Tiffany said. "She does have her days where she's very agitated, and I call it down days. But those are very far in between, from one to the next. She's more open about what's going on, she talks to us more and explains to us how she's feeling, what's going on."

Tiffany has been seeing a counselor herself – and she’s so grateful that help is a relatively short drive away.

"I believe the next step would be going to Chadron which is about 45 miles or 46 miles from here. So it's quite a distance," she said.

These small communities are coming together in a big way – including a school district committed to making mental health a priority.

"I do budget X amount of dollars every year for mental health care just like I budget for P.E. or music or whatever," said Lori Liggett, superintendent for Gordon-Rushville Public Schools - a district with just over 600 students.

Liggett has been working with Dr. Cate to provide in-school therapy for over a decade. Each building in the district has a counselor on-site once a week, adding up to 20 hours of counseling a week.

The school pays for whatever’s left over after billing insurance and Medicaid – that means families never get a bill.

And the longer the program goes on, the less stigma students seem to feel.

"Now the kids pretty much at all levels will broadcast the fact that you know, 'Hey, I'm going to go see the counselor, I'm going to go do this,' and they're not ashamed of it. They're not embarrassed by it," Liggett said.

She attributes their success to a secret weapon: a mental health professional with a passion to help her hometown.

Dr. Cate shares that enthusiasm, saying she's awed by the district's commitment to mental health. She's working to give that passion to the next generation, offering teens the chance to explore mental health careers.

Every summer, she hosts teens from across the state for FARM Camp — Frontier Area Rural Mental Health camp — funded by the Behavioral Health Center of Nebraska.

High school students can take a class for college credit, hear from professionals, and even practice leading a therapy session.

"And then we assign them a mentor, and we keep in touch with them on an ongoing basis," Dr. Cate said. "Our goal is to sort of trigger that understanding and interest and then support it and sustain it and, and provide sort of some other options for kids to get connected to those jobs early on."

Seventy-eight Nebraska counties have no practicing psychiatrists. Rural communities are leading the way in finding creative approaches to expanding services at home.

Editor's note: this story is part of our "Best of 2019" Signature Story report. The story originally aired and was published in August.