Ploughing a lonely furrow

Asking for help for a mental health problem can be a daunting
prospect for any individual. But for those living in small rural
communities it can be overwhelming.

People who live in towns and cities may complain about the
anonymity of living in urban areas, but when it comes to accessing
services for a problem you’d rather keep private, not being noticed
is an advantage.

Ignorance and prejudice can be even more ingrained in rural areas,
where the population tends to be older. And the close-knit village
lifestyle might feel suffocating when help is sought for mental

“You are very observable in a small community. If a community
psychiatric nurse visits on a weekly basis everyone will know. You
can’t be as anonymous in the country as in a town and that can be a
real deterrent,” says Keith Elder, rural development manager for
mental health charity Mind. He adds that it is hardly surprising
that people in rural areas hold outdated views of mental health
services given their limited exposure to new kinds of

Farmers are particularly vulnerable. Suicide rates are high in some
areas and poor mental health is increasingly a problem in the
aftermath of foot and mouth and BSE. But farmers remain proud and

“That independence is a strength in some respects, but it can work
the other way,” says Elder. “If people are proud and self-reliant,
it can mean they won’t go anywhere near a formal mental health

But even if they wanted help, being able to get it can be quite
another matter. A recent Social Services Inspectorate report in
Cumbria found that the range of mental health services depended on

As most services are provided in towns and cities where there is a
higher population density, accessing services is difficult for
people in rural areas, a problem often exacerbated by poor
transport links.

Although widespread provision should be the ideal, the lack of
resources makes this an impossible dream. Malcolm Sinclair,
director of mental health for Wiltshire and Swindon at Avon and
Wiltshire mental health partnership NHS Trust, says tough decisions
have to be made. “Do we keep services in outlying towns and
villages that serve a small number of people – not very cost
effective – or do we keep services that serve more of the
population in towns?” he asks.

Although he admits it would be impossible to provide “everything
everywhere”, Sinclair insists that the answer is “certainly not
just to move things into a small number of towns”. Instead he
suggests central bases of services with smaller outreach posts for
those unable to access them.

“Another answer is to work in partnership with other organisations
and share buildings and premises,” he says. “Equally it’s about
supporting users and carers to be able to travel around. Health and
social services should work more closely with local authority
transport services.”

The distance to services may be a challenge for service users and
their carers, but it is equally problematic for staff. They often
spend significant parts of their working day travelling to clients
in remote areas. Mary Hanna, area director for East Cambridgeshire
and Fenland at Cambridgeshire and Peterborough Mental Health
Partnership NHS Trust, spends up to four hours a day in her car
covering her 60-mile patch.

She worries about a “hidden population” not accessing services. “We
have to suspect that there is unmet need that we would pick up more
easily in an urban area,” she says.

Also, attracting staff to rural areas can be even more of a
challenge than it is in urban areas. Hanna says that in her area it
is hard to recruit for all posts, but highlights particular issues
in attracting consultant psychiatrists. “They don’t have access to
the support networks that they would have in hospitals in urban
areas, so are more isolated,” she says. But she adds that once
staff arrive they tend to stay and settle.

The limited availability of statutory services in rural areas means
that the voluntary sector has an important role to play,
particularly with regard to outreach work. However, as with
statutory services, it is easier to argue for funding for voluntary
projects in urban areas where there are more potential

Stigma, availability and accessibility of services all contribute
to the difficulties of people with mental health problems living in
rural areas. People in urban areas may be subject to six-month
waiting lists before they receive treatment, but once they reach
the top of that list services should be accessible within a
manageable distance.

Mental health services throughout the UK still have some way to go,
but those for rural communities have an even longer journey ahead.
Not unlike the rural service users themselves.

Rest assured 

“They think of psychiatric institutions as being big bins where
men in white coats come and take you away. They don’t want to wash
their linen in public. Some people’s spouses don’t even know we are
dealing with them,” says Chris Coates, team leader at the Rural
Emotional Support Team (Rest), which provides help to farmers with
mental health problems.  Rest was set up after research revealed
that agricultural workers were not accessing mental health
services. Reasons included stigma, a culture of self-reliance and
concern that confidentiality would be breached. Opening times of
services were also a deterrent, as farm duties always took

“Health does not come high on their list of priorities. They
think that if I’m feeling rough today I’ve still got 100 cows to
milk, and by the time they’ve finished the surgery is closed,” says

Rest, which is managed by South Staffordshire Council for
Voluntary Service, has tried to overcome these barriers and offers
a confidential assertive outreach service to farmers in their own
environment. The clients tend to be isolated and reluctant to
engage with services, and many have attempted or thought about
committing suicide.  

The problems range from stress and depression to bipolar
disorder and paranoid psychosis. The interventions include therapy,
links to financial advice and anger management. The outreach
workers also offer practical help and will “chuck a bit of straw or
give some feed”. 

Being accepted by the client is the first challenge for the
outreach workers who must pay careful attention to the way they
dress and speak.  “We never turn up with badges, briefcases or a
shirt and tie because we will be judged and if you go in with clean
hands then that is picked up immediately,” says Coates. “If we go
in there with a lot of jargon they’ll say ‘thanks a lot and bugger

– Rest can be contacted on 01785 255305.

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