Because she’s a fan of small towns and the people who populate them, psychologist Kristi K. Phillips wants to talk openly about the mental health issues that plague rural communities.
As chair of the American Psychological Association’s (APA) Committee on Rural Health, Phillips, who lives with her family in Litchfield and works for Meeker Memorial Hospitals and Clinics, has a front-row seat to the unique impact that modern political and economic crises have on the mental health of rural residents.
“The stressors of life have had a devastating impact on farmers and farm families,” Philips said. “In rural communities, we’re seeing higher rates of depression, anxiety and suicide. It’s a disturbing trend.”
Phillips chalks up those increased rates of mental illness in part to a general reluctance among small-town residents to talk openly about their mental health — or to seek care from a mental health professional. Though Phillips observes a growing willingness among urban folk to talk about their mental health, in small towns across America, people still tend to keep their psychological struggles close to the vest. The pressure caused by this level of secrecy can be the source of other negative consequences, including physical maladies like hypertension, muscle pain and intestinal distress.
In an effort to get word out about the state of rural mental health — and the benefits of seeking mental health care — Phillips recently hosted “Improving Mental Health Care by Understanding the Culture of Farming and Rural Communities,” a webinar sponsored by the APA. Some 1,040 people — mental health professionals, agricultural workers and rural residents — registered.
“We tried to reach as many farmers and farm families as possible,” Phillips said about the webinar. “We wanted to provide up-to-date information about what is going on in the rural communities that pertains to the mental health of farmers. We were hoping to get people talking about ways they could make positive change.”
Recently, Phillips and I talked about her practice — and about her efforts to encourage small-town folks to open up about the state of their mental health.
MinnPost: What are some of the most pressing mental health issues in rural Minnesota?
Kristi Phillips: We know that suicide completion rates and depression rates are higher in rural areas of the state than they are in the urban centers. And we are now seeing that the income-to-debt ratio has reached an all-time high among farmers in this country. That is creating significant mental-health stressors on our farming communities.
MP: How do economic problems impact a person’s mental health?
KP: Tariffs, rising debt and declining incomes are a significant source of stress. Plus, many farmers or their family members hold off-farm jobs to cover their costs, and to provide health insurance. COVID has created job losses that are hard on these families. They’re losing insurance coverage, and the loss of income from those jobs can feel significant. I’ve had farmers say to me in session that the stress of survival in these times is “like carrying a boulder on my back.” They tell me that the threat of financial collapse seeps into all aspects of their lives.
MP: Was it hard for you to build a client base in Litchfield?
KP: We have many farmers and people working in the farming community here. It was only after two or three years working in Litchfield that I got my first farmer as a client. I’ve worked in rural health for the past 13 years. In a small town, it takes people a long time to trust you and feel comfortable seeking your services.
MP: How did you get that first farmer to come in and see you?
KP: It wasn’t directly. A local physician, an ER doc, called me and said she’d recently seen a farmer in the hospital. He’d come in with all the signs and symptoms of a heart attack, but after she ran all the panels, they all came back negative. Sensing that some of what was going on was stress and anxiety, she referred the farmer to me for individual psychotherapy. He refused to come. It wasn’t until his spouse put her foot down that he agreed to make an appointment.
MP: Do you see a lot of this kind or resistance from your patients?
KP: This is a pretty typical story. Farmers are generally hesitant to enlist mental health services. Often I will see a farmer when a medical issue that brings them in. Farmers in general tend to be people who want to handle their problems on their own. Some of that’s what makes them successful as farmers: They are independent and used to having big, broad shoulders to carry all the burdens.
MP: Why do you think that suicide and depression are on the rise in rural communities?
KP: We’ve got this cascade of events occurring right now. The income-to-debt-ratio problem, major issues with tariffs, with commodity pricing, extreme weather issues. Add COVID-19 to the mix and it’s the perfect storm.
MP: Is it just farmers who are experiencing this rise in mental illness? Or do these larger issues also impact their family members?
KP: It’s not uncommon for a farm family to share the same plot of land and build all of the family houses there. They may have grandparents, parents and kids all in relatively close proximity. During this time of COVID-19, with day cares and schools closing and elder cares closing, life is turned upside down. In the farming community, the support role of the spouse has always been really important. Now that person needs to stay at home and homeschool the kids and keep an eye on the grandparents. People aren’t getting breaks like they used to. Many spouses had off-farm jobs that helped pay the bills and provided them with a break from the stresses of family life. With household responsibilities piling up and without an opportunity to partake in restorative activities like working off-farm, spending time with friends or going out for coffee, it is a recipe for mental health concerns.
MP: What strategies do you use to encourage local folks to make — or keep — an appointment with you, to take better care of their mental health?
KP: I try to explain to patients that taking care of our mental health is very important. I say that scientists now understand that when we get more anxious and stressed it has an impact on our immune systems. We can get sick because cortisol, the body’s stress hormone, is attacking our organs. I explain that taking care of our mental health is one way to avoid getting sick.
MP: I grew up in a small town. Back then nobody talked about their mental health. I’ve lived in the city for decades and many people here now seem pretty comfortable talking about mental illness. Are attitudes changing in rural communities?
KP: There is still a perceived and real stigma in rural communities about seeking mental health care. If you’ve ever been to a waiting room in a rural clinic, many times it’s like a social hour. It seems like everybody’s there. When you are wanting a zone of privacy around your mental health, this kind of thing makes people hesitant to go in.
One silver lining is telehealth. Since COVID hit, and I’ve been able to provide remote mental health services. Because of that, I’ve seen more famers and farm families than ever. More clients are willing to meet with me via telehealth because it offers more privacy. They don’t need to come into the clinic and risk seeing all their neighbors in the waiting room.
MP: Clearly the privacy that telehealth provides is a major plus. Do you see other benefits to remote therapy?
KP: Things are just so much more spread out in the country. I’ve had clients who’ve had to drive an hour each way to see me. At harvest time, that kind of time commitment is just not possible. Telehealth opens up new options. I can be working with patients wherever they are. They can have an appointment on their smartphones. My therapy appointments last 45 minutes to one hour. Telehealth makes that time commitment more obtainable for busy people. And we can schedule appointments at flexible times. I can work around their schedules.
MP: That flexibility is probably important, because people are juggling so much right now.
KP: Since I began offering telehealth, I’ve had almost a zero percentage of no shows. That’s completely the opposite of how it is for in-person appointments. If someone isn’t there at the scheduled time, I can almost always reach them: Most people carry their cellphones with them wherever they go. Maybe they’ve been distracted and forgotten their appointment. When I reach them on the phone, they’ll say, “I completely forgot the time. Let me pull over.” They can meet with me wherever they’re at.
MP: Is telehealth particularly helpful in Greater Minnesota, where mental health providers are few and far between?
KP: In Litchfield we are an underserved shortage area for mental health care. This is where I think telehealth can be especially helpful. If people don’t show for their in-person appointments, it is difficult to fill. We don’t have many of those kinds of issues with telehealth. People who are actually registered for appointments are getting seen. And we can see more patients in a day. People don’t feel like they have to take a half day off work just to travel to an appointment. They can say, “I’ll see you over my lunch hour,” and we can make that happen.
There are so many benefits that have come from telehealth. It’s unfortunate it took a pandemic for us to finally get comfortable with using these tools to make our lives better.
MP: After hearing your enthusiasm, it almost seems silly to ask you this, but do you see any disadvantages to telehealth?
KP: You do miss some of the micro-expressions that you’d observe in person. Some clients say they find telehealth impersonal or uncomfortable. But the benefits exponentially outweigh those types of issues.
MP: Do you hope to continue offering telehealth as an option for patients into the future?
KP: Yes. The majority of my patients want to be seen by telehealth. I would still encourage having the first evaluation appointment face-to-face if that is an option, but into the future, I want people to be able to offer the option of a telehealth visit. Having this option has been so helpful in my practice: I’m hoping that we will be able to get that messaging out to the insurance companies, to get them to see the data that shows just how beneficial this option has been for our patients in the rural communities.
MP: What drew you to rural mental health? Has it always been a passion of yours?
KP: Actually, this is my third career. Right out of college, I moved to San Francisco and worked in the wine industry. Then I taught middle school for five years. During that time I realized that I enjoyed the interaction with students, getting to know their personalities and helping them with barriers they were encountering. When I had my own children and wanted to stay home with them, I started taking classes at night. Eventually I got my master’s and doctorate in clinical psychology. When my partner finished medical school, we moved to Minnesota so he could do his residency at North Memorial.
MP: Do you like living and working in the country?
KP: I do. I like small towns. I grew up in rural eastern Washington state, in a town of 5,000. I now live in a town of 800. My father was the director of mental health services for the county we lived in, so I always had therapy in my blood. This job was a natural fit for me: I’m curious about people and feel amazed and fortunate to be able to help people who are actually making changes in their lives, who are working to make their lives better.
MP: Do you offer therapy services outside of Litchfield?
KP: On Fridays, I have a private practice in Wayzata. For some time, I had received calls from physicians who were heading up their medical practices. They were seeking mental health care but didn’t want to be seen within their own clinics. So I set up this private practice. It’s nice to get that diversity in my work, to have a private practice but also have a base in a hospital and clinic.
MP: Do you see similarities between your Wayzata physician clients and the Litchfield farmers?
KP: There are actually many similarities between the farmers and the doctors. Both work hard. They are hard-charging, high-achieving, independently minded leaders who are used to being able to chart a course and get the results they’ve been looking for.
MP: It must feel especially hard for these kinds of people to live in a world that that feels like it’s out of hand.
KP: That’s a big part of what we are dealing with now. Many of the farmers I work with are taking external world events and internalizing them as personal failings. Some of the physicians are doing that, too. Though they have done nothing to influence what is happening in the world, they somehow feel like they carry the responsibility for it on their shoulders.
That’s where I feel I can be the most helpful, challenging those expectations about what is under their control. This is different from what happened to folks in past generations. This is a cascade of things happening all at once.
MP: What therapeutic approaches seem to work best for your patients?
KP: I have found that cognitive behavioral therapy, or CBT, has been very effective in my work with farmers. In CBT, you challenge a patient’s assumptions, the past schemas, and provide them with other options for response. It turns out that people do the best they can with the options they believe they have been given. When you open up more options for response, that’s were change occurs. I’ve seen CBT being extremely helpful in many cases these days.
MP: In your role at the APA, you’ve been an outspoken advocate for more openness and transparency around mental illness and seeking mental health care. Why do you think that it’s important to be open about our mental health?
KP: We need to get more comfortable talking in groups and with individuals about the state of our mental health, just like we would if we had an issue with our physical health. Being able to say, “I’m feeling stressed out today. Here’s why,” is so important.
People have an easier time talking about their diagnosis of diabetes than their diagnosis of anxiety. Just last week one of my clients said while we were in the middle of our telehealth session, “If I push my laptop down that’s because someone came in.” I’ve been working with this person for a year and they still didn’t feel comfortable telling people that they’re seeing someone. So many people are still not comfortable talking about their mental health.
MP: So you’re saying that if people were more open about their mental health, more people would feel comfortable getting the help they need?
KP: We have a saying we use in psychology: “Never worry alone.” If we can get people to see a psychologist or talk to a family member or loved one about their mental health, that’s the first step. When people try to go it alone and it builds up and there is nobody challenging their negative thoughts, the brain can misfire and we can start believing those thoughts. That’s why it’s really important to have someone who can help you understand that some things are outside of your control.
MP: Not worrying alone means talking to others. That can be a therapist — or friend or family member.
KP: If everyone could just open up more it would help with destigmatizing mental illness. We’re fine with talking about a broken leg but not about our mental health: When it gets to the point that we treat the brain just like any other organ, that will be a real breakthrough. We still haven’t moved the dial that far in the rural communities. That’s why I’m working hard to get out the message that caring for our mental health is just as important as caring for our physical health.