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Senate Judiciary Subcommittee on Immigration
May 22, 2001 Hearing
"Immigration Policy: Rural and Urban Health Care Needs"

Healthcare in Rural and Frontier Areas
By Douglas M. Wear, Ph.D.
Chair, Committee on Rural Health
American Psychological Association

Chairman Brownback and Senator Kennedy, the American Psychological Association appreciates the opportunity to testify today at this hearing on rural and urban health care needs. I am Dr. Doug Wear, a clinical psychologist from Seattle, Washington, formerly a practitioner in Buffalo, Wyoming, and I chair the APA Committee on Rural Health, which coordinates work on this association priority.

The APA has committed resources to addressing the behavioral health care needs of individuals residing in rural and frontier communities where behavioral health care providers and services are often in short supply. For example, at this time there are almost 800 Mental Health Professional Shortage Areas in the United States, and 70% of them are located in rural and frontier areas. This designation entitles communities to participate in a Federal program called Loan Repayment, administered by the National Health Service Corps. This federal agency has responsibility to operate various programs, including Loan Repayment, to encourage health providers to practice in underserved communities. These include rural communities that have immigrant groups who have arrived recently. Examples of these groups include Southeast Asians and Central Americans who have emigrated to escape political oppression and severe economic hardship.

This year the Senate Health, Education, Labor & Pensions Subcommittee on Public Health will be taking up the reauthorization of the National Health Service Corps. We recommend the reauthorization of this valuable program and the expansion of the capacity of the Corps to recruit and place psychologists and other behavioral health practitioners through the provision of both scholarships and loan repayment.

Psychologists can provide prevention and treatment services for mental health and substance abuse problems, as well as services that address the behavioral components of acute and chronic physical disease. Recent immigration to rural and frontier areas of the U.S. has introduced new challenges to the provision of healthcare in these communities. In addition to the adjustment problems of adapting to a new culture, recent immigrants often have special needs that need be addressed. These include anxiety, depression, and substance abuse problems that are the sequelae to these disorders. It is significant that mental disorders are often accompanied by co-occurring disorders that include addictions. It is known that 70% of individuals treated for substance abuse have a lifetime history of depression.

Some immigrants I have worked with as a psychologist are experiencing language difficulty, culture shock, isolation, and stress which exacerbates any existing mental or substance disorders they might have and sets them up for failure if they are vulnerable. An appreciation and understanding of cultural issues on the part of the psychologist is essential to really be effective. Developing a system of social support is an essential step. In the best of circumstances, there are mentors from the immigrant's own country that have preceded him or her to serve this important role. So often, though, this is not the case, especially in frontier communities where the numbers are very small. Then, it might be a local family, a school class, a church group, or a community organization that will end up attempting to help the new immigrant family acclimate to their new home. Often, group sessions are very helpful to begin helping people get comfortable with each other and find common ground.

Thus I'm gratified that the APA Council adopted a resolution in 1999 finding, in part, "Mental health-related issues, particularly stress associated with trauma, acculturation to language, economics, health care, education, religion, as well as encounters with both individual and institutional bias, are faced consistently by foreign-born residents of this country; and differential degrees of acculturation within immigrant families can negatively affect family communication and even evoke conflict, particularly between parents and their adolescent offspring."

I have often found a need to work with not only the immigrant and his/her family but also with members of the typically very heterogeneous community where the immigrant persons or families reside. They too are stressed, sometimes prejudiced, and unfamiliar with other cultures and value systems. Likewise in the schools or work and community settings, rural psychologists often can take an educative and facilitative role in bridging cultures and finding ways to bring people together.

The APA Rural Health Initiative works in conjunction with state psychological associations, federal and state agencies, national health professional organizations with an interest in rural populations, and the U.S. Congress and state legislatures to advance the cause of improved behavioral healthcare for rural Americans.

The APA Office of Rural Health is responsible for the expansion of practice opportunities for psychologists to provide behavioral healthcare in rural areas. It staffs and works closely with the APA Committee on Rural Health to administer projects to accomplish this responsibility. Much of the work that has been accomplished by the Rural Health Initiative appears on the Web site RuralPSYCH (, a resource center that provides information on policy, practice and training on rural behavioral healthcare. This is accomplished through storing (for easy download) important reports, cross-links to other worthwhile sources of behavioral healthcare, and announcements of projects that have been completed.

In order to ensure that sufficient numbers of psychologists are trained and prepared to meet the behavioral healthcare needs of rural and frontier populations, including those of recent immigrants, the APA conducts a periodic survey of psychology training programs and internships. The result of the survey is displayed on RuralPSYCH. The APA Rural Initiative cooperates with academic institutions developing new psychology doctoral training programs to serve rural communities. The newest one is located at Marshall University in Huntington, West Virginia. It is a program totally dedicated to training psychologists who will practice in rural West Virginia by having all of the clinical practica for students conducted in rural settings reinforces this objective.

The APA Rural Initiative has also addressed the shortage of psychologists in rural areas by encouraging the participation by psychologists in the Loan Repayment program of the National Health Service Corps. The program enables psychologists to provide services in communities located in Mental Health Professional Shortage Areas. Many of these areas have migrant workers in addition to recent immigrants. This is an imperative for healthcare providers to deliver care in a culturally competent manner.

To achieve cultural competence, behavioral health providers in rural areas must have an understanding of and an appreciation for cultural differences and similarities within, among and between groups. This requires the acquisition of academic and interpersonal skills that will increase understanding and willingness and an ability to draw on cultural and community-based values, traditions, and customs to work with people from the community in developing interventions, communications, and other prevention and treatment options that address behavioral health problems. The goals of cultural competence include:

" identifying social, economic, political, and religious influences affecting immigrant and ethnic minority populations:

" understanding the impact of interaction between social institutions, culture, and ethnicity on the delivery of behavioral health services:

" understanding the importance of language, culture, and ethnic influences in rural communities and the importance of the oral tradition in some cultures;

" recognizing the impact of the provider's own culture, sensitivity, and awareness as it affects his or her ability to deliver health care, especially with recently arrived immigrants; and

" understanding alternative treatment sources (e.g., Curanderes in Hispanic culture) in some immigrant and ethnic cultures.

The theme of cultural competence and the ability to provide behavioral healthcare services to recently arrived immigrant groups in rural communities is one of the underlying themes that is found in every chapter of a new publication titled Behavioral Healthcare in Rural and Frontier Areas: An Interdisciplinary Handbook that has recently been completed by the APA Committee on Rural Health. APA Books will publish this volume in late 2001 or early 2002. In addition to the work of the Rural Initiative, the APA has developed Guidelines for Providers of Psychological Services to Ethnic, Linguistic and Culturally Diverse Populations.

In September 2000, the APA and National Rural Health Association jointly conducted a Congressional briefing on an important report completed by the APA Rural Initiative titled The Behavioral Healthcare Needs of Rural Women. This report covered many healthcare problems encountered by recently arrived women immigrants and called for action to provide the behavioral healthcare services they need. See

The APA Rural Health Committee and Office of Rural Health are sensitive to the need to provide behavioral healthcare services to rural and frontier residents in the U.S. and are mindful of the special circumstances newly arrived immigrant groups encounter on their arrival. In approaching the task of ensuring high quality mental and behavioral healthcare for rural and frontier populations in the United States, we will continue to develop and advocate for programs that are culturally competent and sensitive to the special needs of immigrant populations who have arrived recently.