Cover Two

Barriers and Bridges

Mental Health Care for Rural Communities of Color

BY Mitra Milani Engan AND Marnie Werner

Nationwide, there is an acute shortage of mental health providers and services in rural areas, and in Greater Minnesota this shortage is very real. Setting up further potential shortages and complicating access to care, more than half of rural providers are over the age of 55. There is a reluctance among new providers to practice outstate related to lower income potential. Additionally, bottlenecks in the training and licensing systems combined with other factors are barriers for young people choosing to become mental health care providers and thereby easing the serious issues posed by the coming wave of retirements. Lack of access to care is part of the reason rates of mental illness and suicide are higher in rural areas. “We can provide suicide hotlines to farmers all day long, but that doesn’t address the root cause,” said a member of the Upper Sioux Community in southwestern Minnesota who has worked with Minnesota farmers.

The greater distance between communities and the sparse population of smaller towns create adverse economies of scale that increase the cost of providing services, which in turn has led to clinic closures and health care consolidation, further squeezing the supply of services, and resulting in even longer drives to receive services.

For people of color, becoming licensed is even harder.

Cost of care is, of course, a major issue. Whether people have health insurance through their employer, buy it themselves or receive it through a public option, costs continue to rise. “I can recognize when a kid is really struggling,” said a school administrator and social worker in Willmar, but on more than one occasion, when she recommended to a parent that their child be seen by a doctor for depression, the parent replied, “Okay, but we don’t have health insurance.”

A lack of transportation also limits mental health care access in rural areas, where people are more likely not to have their own vehicles or are unable to drive because of age or disability. Public transportation is usually not available. According to a 2024 Minnesota Department of Health report on the state of rural health care, patients seeking inpatient mental health and chemical dependency treatment must travel three times farther than their urban counterparts. These barriers are significant for all rural families and are even greater for people of color.

Contributing Factors

Other factors affecting people of color in rural areas can be lower incomes, an inability to speak English or speak it well, or they simply don’t believe there is such a thing as mental illness and/or that anything can be done about it. These circumstances all make the standard rural barriers to access even higher. Additionally, there are significant issues around trust brought on by past social and medical experiments imposed especially on African Americans and Native Americans that would today be unethical. As a result they see the health care system as a continuation of these past experiences, while fear of encounters with the law make people reluctant to call for help when a family member is in crisis.

The aspect of the issue that is easiest to measure is the lack of licensed mental health care providers who are also people of color. Erik Sievers is the executive director of Hiawatha Valley Mental Health Center, which serves a population of about 160,000 in five rural counties in southeastern Minnesota. “We’re an agency of about a hundred or so. We have one provider who’s not a white person. One,” he said.

A common understanding of a community’s experiences and culture is important, especially when it comes to mental health. Steve, whose heritage is both African American and white, hears similar things from the students he works with at a local college. “Representation, I think, is what’s stopping a lot of students [from seeking help]. It’s hard to be able to connect with people that you don’t think will understand what you’ve experienced.”

An example of the differences among cultures can be seen in attitudes toward individualism and collectivism among America’s various ethnic and racial groups. Mental health professionals from Latin American, Asian, African and Middle Eastern backgrounds understand from their own experiences that multigenerational households are quite normal in those cultures.

On the other hand, a mental health professional of northern European descent, a culture that emphasizes individualism, might see extended family and multiple generations living together in one home as not normal or even healthy.

According to Gabriel, a long-time school social worker in rural West Central Minnesota, it’s important that school social workers build trust with students, but the trust part often comes only when students see social workers who share their racial or cultural background.

“As a person of color, you’re looking for someone you can relate to, someone that maybe can understand your culture, because a lot of times, you know, in smaller towns, you feel isolated,” he said. “The problem of putting [BIPOC people] all together is that you don’t recognize that the Somali community has specific traumas, Latinos have different traumas, Karen have different traumas in history,” says Juan, a community leader in Willmar, originally from Peru. “Our journeys have been different.”

This is the case for Native Americans. “Native people from Upper Sioux aren’t going to seek out mental health resources that are not provided by Upper Sioux,” says Brooke, a Dakota tribal member, health care provider, artist and activist. “So if I’m going to go see a person of color as a therapist, there’s a tendency [for that therapist] to categorize the indigenous experience as racial rather than as socio-political, which then is a whole other level of like, ‘Okay, now I get to educate you on this during therapy hours that I’m paying for? Great.’”

Additional Barriers

There are many barriers for people who want to become licensed mental health providers. Student loans and the prospect of limited income are significant deterrents that keep people from entering the field. This may contribute to why only half of people who graduate with a degree that leads to becoming a licensed mental health care provider role actually attain a license.

For people of color, becoming licensed is even harder. Jessica Estrada is a mental health therapist practicing in Spicer, Minnesota, (population 1,081), while also pursuing her doctorate in social work. “It’s hard for anyone to go to college with so much debt…,” she said, “but it’s even harder for those like Hispanics and Somalis, who are already struggling financially, to even try to think of going to school to get more BIPOC providers out there.”

The licensing process has its issues, too. In 2022, the Association of Social Work Boards (ASWB) reported that a test taker’s demographics are the strongest predictor of whether that social worker will pass the exam required to become a licensed mental health care professional: 80% of white female examinees passed the ASWB clinical exam, while pass rates for other groups were lower, sometimes much lower.

Stigma and fear

A major and common barrier to seeking care for symptoms of mental illness, regardless of race, is stigma. Mental health and mental illness can be difficult to talk about, especially in communities where these concepts may not be seen as relevant, or that a path to care is clear.

“In working with families of color, I think that’s one of the biggest things,” says Gabriel, the middle-school social worker. They feel isolated in a community where most people don’t look like them. “It’s kind of like, ‘I’m not gonna put myself out there to get hurt.’”

Many of the people of color interviewed said there is a perception in their communities that mental illness does not exist in their culture. Language barriers are another major isolating factor. With mental health care, patients need to be able to accurately relate their thoughts, feelings, perceptions, and physical symptoms, but the many dialects of a language can become a problem. Miranda, a Spanish-language interpreter, found with one patient, “They were speaking Caribbean Spanish. That is not my Spanish.”

Medication is another common barrier. “The whole piece about medication that you hear is, ‘Well, I’m not putting my kids on meds,’” says a school social worker. The parents may have experience with a family member who was a drug user, and they fear their own child could become addicted. “It’s kind of unrealistically based sometimes, but it’s real to them,” she said.

As a person of color, you’re looking for someone you can relate to.

Expanding Access

When it comes to developing mental wellness programs for people of color, it is important to incorporate a group’s heritage and culture into those programs. The initiatives need to be designed and delivered by the cultural communities they are intended to serve. Research from the National Institutes of Health on suicide prevention programs for Indigenous people, for example, found that initiatives that were developed with and by the community, drawing on local culture, knowledge, need and priorities, had “substantial [positive] impact on suicide-related outcomes.…”

The Role of Mentorship

Being mentored by a professional with a similar background is vital for career development in the mental health care field. Estrada, the mental health therapist and doctoral candidate from Spicer, was mentored by a BIPOC supervisor through the National Association of Social Workers, but the funding for that program is limited, “so it’s not everyone that gets it,” she said. “I’m just lucky I got it…. Finding a mentor who understands the unique challenges of being a person of color in the mental health field can be difficult. Aspiring clinicians of color may feel they need to navigate the professional world alone, which can be discouraging and contribute to burn out.”

Licensure reform

The unbalanced passing rates for standardized licensing tests have not gone unnoticed, and those who write the tests are encouraging social work licensure reform. Some of their recommendations include:

• More input from mental health providers of color in the development of standardized tests.
• Replacing standardized multiple-choice exams with alternatives such as competency-based evaluations, portfolios or supervised practice assessments.
• Reducing cost and structural barriers. For example, remove retake waiting periods; provide free and low-cost test preparation resources; lower or remove exam fees; and offer language accommodations, including ESL support.

In 2024, Minnesota passed legislation giving people in groups that have traditionally had difficulty with the licensure test a pathway around the test.

Based on a successful pilot program with Hmong immigrants and others for whom English is a second language, licensing candidates now have the option to either take the traditional exam or complete additional supervision hours to receive their license.

Direct-Entry Mental Health Practitioners

Allowing mental health care providers to get more on-the-job training as a supplement to, or even replacement for, academic education would create faster expansion of the mental health care workforce.

With plumbers and electricians, there’s a training process where a person is paid while learning on the job. A system of education could help in which new mental health care providers could come into the field directly in some capacity and be paid.

Supervised hours are also an issue for clinics. Currently, to become licensed, a graduate must amass a certain number of hours where they see clients while supervised by a licensed provider. Those hours cost the clinic money. Licensed providers are paid for their time spent seeing clients, but not always when they are supervising interns. As a result, many rural clinics can’t afford to supervise students, despite the fact that hosting a student is one of the most effective ways to attract — and keep — a student at a rural clinic.