On most days, therapist Becky Kopp-Dunham counsels farmers and other clients across 10 North Dakota towns from her home office on a crop and cattle farm in Morehead, Minnesota.
With a reliable internet connection and videoconferencing service, Kopp-Dunham can inform and treat patients in rural and remote places.
“I’m a hands-on therapist, so I do a lot of art and games and music and movement, and I thought, ‘How am I going to be able to pull this off? We’re just on a screen. But I’ll try it,’” Kopp-Dunham said. “I’ve been very pleasantly surprised of how I’m able to connect with people.”
She and her colleagues call it “farm-to-farm therapy,” but it’s widely known among medical providers as telehealth delivery of mental health services. It’s just one of the many approaches states are taking to address mental health among rural and agricultural populations, as the need rises against the backdrop of a struggling farm economy.
This year at least seven states, including Colorado, Kentucky, Minnesota, New York, Texas, Oregon and Wisconsin, considered bills to boost local mental health authorities. Several, including Minnesota, New York and Wisconsin, focus on agricultural communities. Some are related to strengthening farm finances, but also intended to support mental health and well-being. It’s unclear to what extent state efforts will fulfill the need.
Rural residents experience mental disorders and drug addiction just as much as their urban counterparts, and their need for mental health services is similar. But rural suicide rates are greater than urban ones, and the gap has grown steadily since 1999.
And yet, rural people have less access to treatment sources. There’s a stark lack of providers in rural counties given the vast territory and small populations. Most areas with a shortage of mental health providers are partially or entirely rural, according to the U.S. Centers for Disease Control and Prevention. And since 2010, 119 rural hospitals have closed.
As self-reliant people, farmers often are suspicious of mental health resources. In small-population places, where people may know their neighbors’ vehicles and routines, rural people can lack anonymity, which experts say is key to accessing and receiving treatment.
“It just isn’t practical for farmers to leave the farm to access services,” said Kopp-Dunham, who’s licensed in North Dakota and Minnesota. “It’s very often hours of a drive one way.”
Many counties in Nebraska, the Dakotas, Kansas and other states depend on agriculture for their economy. Across the country, while residents of booming big cities were most likely to have growing incomes, rural areas and small cities had very mixed outcomes in per capita income between 2016 and 2018, according to a recent Stateline analysis.
Nebraska counties, which have been the victims of floods, the trade wars and a weak ethanol market, suffered the biggest income losses.
U.S. farmers with midsize operations, long battered by low commodity prices, face new uncertainties amid increased competition from large corporate farms and President Donald Trump’s trade war with China.
For more than a year, weather extremes have devastated nearly every region of the country — hurting farmers’ returns on commodities such as soybeans, cotton, pork and dairy products. There is now widespread attention on farmers’ mental health.
“Beyond the financial losses, there’s the potential fear of loss of a lifestyle,” said Walt Hill, CEO of High Plains Mental Health Center in Hays, Kansas. “So, we hear more and more of individuals losing hope and committing suicide.”
Between 2001 and 2015, large metropolitan counties saw 257,000 suicides, compared with 173,000 in smaller metro counties and 115,000 in rural counties.
Over that period, large metros had a suicide rate of 11.9, compared with 17.3 in rural areas, according to the CDC.
In October, the U.S. Department of Agriculture announced the regional recipients of four grants totaling $1.9 million to provide stress assistance programs to people in agriculture.
The grantees will launch the Farm and Ranch Stress Assistance Network, which was authorized in the 2018 farm bill signed by Trump last December. The funding will support more rural mental health research, programming and trained staffing.
The farm bill also increased the annual budget for the Distance Learning and Telemedicine Program, from $75 million to $82 million, through fiscal 2023. The program helps rural communities use telecommunications to address challenges related to isolation and low population density.
In October, U.S. Sens. Chuck Grassley, an Iowa Republican, and Jon Tester, a Montana Democrat, introduced the Seeding Rural Resilience Act. The bill would train government employees to identify distressed farmers and talk to them.
The bill also would provide $3 million to create a public service announcement to raise awareness of rural suicide and stress. And it would direct Agriculture Secretary Sonny Purdue to assemble a task force of agricultural and rural leaders to determine best practices for responding to farm and ranch stress.
Finally, U.S. Sens. Amy Klobuchar and Tina Smith, both Minnesota Democrats, and Rep. Tom Emmer, a Minnesota Republican, in October announced a $235,000 USDA grant to CentraCare Health System to expand telehealth services across central Minnesota.
The money will equip 10 clinics across nine counties with video technology over a two-year project estimated to serve about 2,000 patients.
Despite partisan clashes, the Wisconsin legislature approved $200,000 for a program that provides mental health counseling vouchers and workshops to farm families. In addition, a task force on suicide prevention led by Republican state Rep. Joan Ballweg has advanced eight policy recommendations, including financial aid for farmers taking business management classes.
In New York, a bipartisan bill would create a rural suicide prevention council to make policy recommendations. The council, whose members would be appointed by legislators and the commissioners of health and agriculture, would examine the causes of rural suicides or suicide attempts and prevalence among farmers and agricultural workers. The bill awaits Democratic Gov. Andrew Cuomo’s signature.
The suicide rate is three times higher in rural areas of New York state than in urban areas, CDC data shows. Statewide, the suicide rate increased 30% from 1999 to 2015.
“We’ve been seeing an increase over the years rather than a reduction, so we need to focus as a state on developing a statewide strategy,” said Sen. Jen Metzger, a Democrat who sponsored the Senate bill. Metzger, who chairs the Senate agriculture committee, represents rural Delaware County, which has the state’s third-highest rate of suicide.
Meanwhile, Minnesota increased its annual appropriation to the state Department of Agriculture from $113,000 to $250,000 to add a second therapist focused on farmers and other statewide mental health counseling to farm families and business operators through the state college system.
In April, the University of Minnesota Extension formed a task force to provide educational programs and resources related to stress and mental health. Emily Wilmes, who leads the group, knows farmers who have committed suicide.
“I received a call I’ll never forget, Sept. 12, 2018, from a dairy farmer, a close friend,” Wilmes said. “He informed me quickly in our conversation that another dairy farmer had died by suicide the day before. The pain in his voice was something I’ll never forget. It turns out that dairy farmer was the father of a college classmate.”
In recognition of the financial concerns that can affect mental health, Minnesota also created a program that awards grants to eligible dairy farmers to encourage participation in the federal Dairy Margin Coverage program, financial protection for dairy producers when the margin between feed costs and milk prices falls below a certain amount, said state Rep. Jeanne Poppe, a Democrat who sponsored the bill. The North Star State lost about 10% of its dairy operations last year.
Besides competing priorities in tight budgets, another challenge for legislators is to know how to address the economic needs of various levels and types of agriculture — and when to act, said Poppe, who represents southeastern Minnesota.
“We struggle with just making sure that we’re being helpful,” Poppe said, “and we’re not setting one [farmer] up against the other.”
The Telehealth Solution
High Plains Mental Health Center serves 20 rural counties across 19,000 square miles in northwest Kansas. For roughly a decade, it’s offered telehealth for psychiatric services and some counseling. Of the 100,000 people in its coverage area, roughly 6,000 use the center’s mental health services.
“There’s just no way we could serve people in this area with the kinds of needs they have without having telemedicine that we deliver out into the farther rural areas,” said Hill, the center’s CEO.
Experts say there’s a limited but growing awareness of telehealth as a viable option for rural residents needing mental health services. Telehealth’s benefits include linking clients to behavioral health practitioners in faraway places and bypassing the stigma of being seen parking a vehicle at a counselor’s office. Although farmers typically work from home, they don’t work 9 to 5, and they don’t take days off.
“The option to discuss their needs with a professional and preserve their privacy at the same time lowers a barrier that people have to accessing mental health services,” said Sean Brotherson, a professor at North Dakota State University in Fargo who specializes in family science.
Telehealth seems like an obvious solution for serving people in hard-to-reach places, especially as advocates stress crisis situations in Farm Country, but regulatory and infrastructure challenges limit its reach.
For example, Medicare restrictions limit receiving telehealth from home based on the eligibility of geographic areas, so providers like High Plains Mental Health Center have expanded into office space where clients can use approved videoconferencing equipment. It’s also contracted workers from other parts of the country to deliver services, Hill said.
The Minnesota Department of Human Services is encouraging more telehealth services as a solution to stress and suicide among farmers. It also will offer technical assistance to ensure the interactive video equipment and connection providers use comply with federal standards.
“As it is a relatively new service,” according to an emailed statement from the department, “there remains some confusion regarding which services are allowable across mental health and substance use disorder services.”
Although studies show that psychiatric services related to diagnosis and treatment delivered by videoconference are comparable to services delivered in person, providers are concerned about damaging the rapport between therapists and clients.
In addition, research on which rural clients benefit most from specific technologies, such as chat and text messaging, is limited. Despite federal investments to improve rural internet access, broadband remains expensive and limited.
Ted Matthews was Minnesota’s sole state therapist serving farmers for more than two decades, until the legislature appropriated money for a second therapist earlier this year.
Matthews travels the state to meet farmers in their homes or at designated locations. He doesn’t use videoconferencing because of a lack of equipment and infrastructure and prefers counseling face-to-face.
“This isn’t going to sound very nice. [Telehealth is] better than nothing,” Matthews said. “And at this point, I would say that’s pretty good, because what a lot of areas are getting is nothing. So, my fear is that it’ll become the norm instead of a stopgap.”