Academic journal article Journal of Mental Health Counseling

Building a Practice in Rural Settings: Special Considerations

Academic journal article Journal of Mental Health Counseling

Building a Practice in Rural Settings: Special Considerations

Article excerpt

Private practice in rural areas presents special challenges. Rural communities often hold more stigmatizing views about psychotherapy and have fewer economic resources, yet rates of mental health problems are comparable to those in metropolitan areas. Rural practice can be particularly rewarding for clinicians who can build collaborative networks, adjust to visibility, negotiate boundaries, and successfully integrate into the community. This article offers recommendations for mental health counselors on building a practice for branding, marketing, collaborating, and exercising self-care. It also discusses challenges associated with counseling in rural areas and gives suggestions for building a thriving practice.


Because rural areas across the United States and Canada struggle to attract and retain qualified mental health counselors, establishing a private practice in a rural setting can both meet a critical need in underserved areas and provide a rewarding, though challenging, career. When counselors consider rural practice, they must have realistic expectations about rural work and life, consider the cultural values permeating different rural communities, and understand the impact of geographic isolation on themselves as well as their clients.

Rural areas may be very different from one another in terms of geography, cultural heritage, ethnic makeup, and history, but certain factors shape the lives of all who live in rural areas in significant ways. These factors speak to a dimension of diversity, often overlooked in the mental health literature, but it is essential that counselors working in rural settings understand them.

Rural residents often rely on tight-knit community relationships supported by kinship ties extending back generations (Curtain & Hargrove, 2010). The social support provided by family, and often by the church, leads to high levels of satisfaction among those who adhere to community standards (Childs & Melton, 1983), but the reliance on family and friends often means that outsiders are viewed with suspicion (Bradley, Werth, & Hastings, 2012). Gender roles in rural settings are often traditional, with cultural standards encouraging hetero-normative behaviors for both men and women (Boswell, 1980; Campbell, Bell, & Finney, 2006; Salamon, 1992). Community standards also promote conservative traditional values and advocate self-sufficiency and hard work (Harowski, Turner, LeVine, Schank, & Leichter 2006; Helbok, Marinelli, & Walls, 2006).

Drawing on anecdotal and empirical support, this article discusses both the problems and the promises of rural practice. We provide recommendations for building a successful rural mental health practice in terms of branding, marketing, collaborating, and exercising self-care.


The prevalence rates of mental illness in rural areas are equivalent to those in metropolitan or urban centers (Robins & Regier, 1991; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994), with approximately 20 million rural adults having experienced mental illness in the previous year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). However, rural residents are more likely to die from suicide (Hirsch, 2006). Because they are also less likely to perceive a need for care (Rost, Fortney, Fischer, & Smith, 2002), they access care at lower rates than urban peers (Rost et al., 2002).

A number of structural barriers also inhibit access to care: lack of insurance, transportation, and available providers; poverty; and stigma. Poverty is particularly challenging. In urban areas, 12% of residents live below the poverty line; in rural areas that is true of 15% of residents (DeNavas-Walt, Proctor, & Smith, 2008). The federal Agency for Healthcare Research and Quality (AHRQ) under the U.S. Department of Health and Human Services (U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality [HHS] 2006) reported that one in five individuals who are uninsured reside in rural areas. …

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