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Iowa does not have enough psychiatrists, psychologists, therapists or other mental health care providers to handle an increasing need to care for farmers dealing with relentless flooding this year, several mental health experts IowaWatch interviewed warned.

Many health care specialists don’t want to work in small, rural areas for reasons ranging from a lack of local resources to seeing few options for personal growth that comes from cultural events or entertainment, the interviews revealed.

The result is that people who need mental health care immediately have a difficult time getting it, a problem in the parts of rural Iowa hit this year by devastating flooding.

“We turn people away every day because we don’t have available appointment slots. We do a lot of referring to other agencies,” said Susan Ecker, director of Waubonsie Mental Health Center, which has locations in Fremont, Page and Montgomery counties in southwestern Iowa, all hit hard by the flooding.

“There is no competition between service agencies in our community because all of us combined cannot handle the volume of people that are seeking service.”

Fifty of the 59 Iowa counties designated as disaster areas because of flooding this year also have been designated by the U.S. Health Resources and Services Administration as having inadequate mental health care. In all, 86 of Iowa’s 99 counties are designated mental health professional shortage areas because they do not have an adequate number of providers for the number of people living in those counties.

Some of the counties hit hardest by flooding are not targeted by national programs that encourage young healthcare professionals to work in the rural U.S. with incentives like student loan forgiveness, scholarships and grants. Many mental health professionals still feel a strain on mental healthcare resources in heavily-flooded counties even when provided these incentives, interviews revealed.

For many, their caseloads become too large to handle adequately, leaving them with an ethical dilemma of taking on more clients at the expense of others they already are seeing. Meanwhile, patients in these underserved areas rely on therapists who get shuffled to multiple locations during the week. Patients have to wait five to six weeks to be seen if not needing urgent care — one to two weeks if they do, health care professionals said in interviews.

Alecia Dougherty, clinical supervisor at Plains Area Mental Health Center, which covers a wide patch of northwest Iowa, said some patients are on their second or third therapist in one to two years. She said switching therapists, especially after building a therapist-client relationship over the course of years, can be traumatizing.

“Turnover is probably the biggest barrier to getting good services to people in this area,” Dougherty said. “It affects community coalitions, it affects clients.”

Clinicians at Plains Area Mental Health Center move to places like Sioux City or Des Moines after starting in the smaller, rural areas Plains Area serves, Dougherty said. “I have actually two clients on my caseload right now who saw their previous therapist — one of them saw her for nine years, the other one saw her for 13 years — who were honestly traumatized by having to start seeing me. So it was a major setback for their treatment.”

Ecker works in Clarinda but lives on a farm near Elmo, in northwest Missouri just south of the Iowa-Missouri border near where she grew up on a rural Big Lake, Missouri, farm. Both areas sustained serious flooding this year. She said she feels connected to her community. Her husband, Terry Ecker, is a farmer.

“I’ve lived here all my life. This is home to me. It makes me really sad that there’s this disaster in the community, and there’s such a great need, and I don’t know how to employ therapists to meet those needs,” Ecker said.

Photo courtesy of Terry and Susan Ecker

Photo courtesy of Terry and Susan Ecker

Unmet demand for mental health care services in disaster-ridden, rural regions in the state are part of a larger problem in Iowa, mental health care advocates said. “We don’t have psychiatrists, psychologists, nurse practitioners, therapists, clinical social workers,” Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness, said. “It goes all the way down the line. We just don’t have enough.”

Even if enough care providers were available, barriers exist in linking farmers, whether they are in flood zones or not, to mental health care services, the IowaWatch interviews revealed. Financial difficulties, transportation issues, time constraints and limited internet access, but also many therapists’ lack of understanding of agriculture and a stigma attached to mental healthcare in farm communities also make it difficult for farmers to get the help they need when confronting stress and behavioral health issues.

“I guess that agriculture’s a tough job anyways, but this year is probably a hundred times more stressful than a typical year,” said Corey McIntosh, a fifth-generation farmer near Missouri Valley, Iowa, on the western side of the state, which has had some of the worst flooding from the Missouri River. “I’d say a lot of the people around here are probably experiencing, you know, certain levels of depression.”

McIntosh’s farm has flooded twice this year. Although he is not seeking counseling, he said it would be difficult if he were because he would not have time to do it.

He sees more flooding in the future. “It can’t be denied that we’re experiencing more extreme weather events,” he said. “The Corps of Engineers recognizes that climate change is happening but they have yet to start planning for it.”

MENTAL HEALTHCARE DILEMMAS IN SHORTAGE AREAS

Eight of the counties hit by flooding have not received designation by the national Health and Resources Service Administration as mental healthcare provider shortage areas (Cass, Dallas, Fremont, Mills, Montgomery, Page, Polk and Pottawattamie). This designation can have importance for healthcare providers in rural areas because the National Health Service Corps uses the administration’s designations to decide where to help clinics provide financial recruiting incentives to bolster rural healthcare systems.

Though a recruiter at one clinic IowaWatch spoke with said the clinic used the National Health Service Corps program as part of a more robust recruiting strategy that produced helpful results, many others said the program is not the complete answer when attracting mental healthcare providers to rural areas.

Ecker, from the heavily-flooded southwest of the state, practices in counties that previously had been declared a shortage area but lost their designation for reasons she said she does not fully understand. She said National Health Services Corps helped Waubonsie Mental Health Clinic for many years but that has changed. “Every few years, they rewrite the different areas. And our rating scale changed somewhat by a point or two,” she said.

Dougherty said Plains Area Mental Health Center employees continually feel understaffed and are fighting high turnover rates, even with Service Corps funding and employment benefits such as numerous health insurance policy options and pay that is 7% higher than the state average.

Dougherty blames high turnover and a perceived unattractiveness of rural communities, in part, on colleges failing to prepare students for the specific needs in rural areas. She said she has seen employees straight out of school quit the profession within their first few weeks because the work was too challenging.

“A lot of treatment models are set up for urban areas — I would say most of them, to be honest — and then we try to implement them in rural Iowa, because they have such good outcomes,” Dougherty said.

Despite widespread challenges with recruiting mental healthcare professionals to rural America, employees at one clinic IowaWatch spoke to said they have doubled their staff in the past year and are expanding services. The clinic is Crossroads Behavioral Health Center in Creston, Iowa, in a region that also has experienced heavy flooding. Last November, it hired human resources and marketing director Macie Blazek, who has a recruiting background.

Crossroads provides employees some of the same financial incentives as other clinics: service corps backing and what Blazek called a good retirement program. The clinic additionally pays for an independently-licensed therapist to supervise a clinic therapist’s first two years in practice. This process can be a financial drain on therapists if they have to pay it.

Many mental healthcare clinics do not have full-time recruiters. “We’re still hiring several positions, currently,” Blazek said. “And so even though we feel like we’re in a good place right now, it’s something we still kind of have to keep working at.”

POTENTIAL SOLUTIONS

Telehealth or telepsychiatry, with appointments conducted online, is a potential solution to delivering mental health care to farmers in underserved rural regions but many of those regions lack adequate high-speed internet connection.

RESOURCES Iowa Concern 24/7 Phone Support:

1-800-447-1985 CommUnity crisis phone/text:

1-855-325-4296

Local Crisis Line: 319-351-0140 Your Life Iowa resources:

Call: (855) 581-8111

Text: (855) 895-8398 NAMI Iowa (National Alliance on Mental Illness, Iowa chapter):

HELPLINE: 1-800-273-8255 (Editor’s note: This resource box was added 7/30/19 after a reader’s suggestion.)

Beau Pinkham, director of crisis services at CommUnity, an Iowa City-based organization that provides crisis management to Iowa residents, including farmers, said delivering such care is impossible if someone does not have adequate internet connection. Research undertaken by Connected Nation Iowa, a broadband access advocacy group, shows many parts of Iowa have few or no broadband internet providers.

Pinkham said CommUnity’s hotline has received more texts and messages through its online messenger option than phone calls in recent years. People are more comfortable being emotionally vulnerable when a conversation is not face-to-face or voice-to-voice, but mediated through text on the internet, a psychological phenomenon known as the “online disinhibition effect,” Pinkham said.

Mental health concerns associated with the flooding are still developing. More than a dozen mental health experts IowaWatch spoke with said the full demand from farmers who need mental health resources in the flooding’s aftermath has yet to emerge.

Statewide hotlines like one at CommUnity and the Iowa Concern Hotline, which Iowa State University Extension Services began as a response to the 1980s farm crisis but which now serves all Iowans, did not see a major uptick in calls immediately following the beginning of the floods, representatives of each said in interviews.

Drawing on experience from aiding Hurricane Katrina survivors who relocated to Iowa, Tammy Jacobs, who helps coordinate the Iowa Concern Hotline, said it usually takes some time after a disaster – 60 to 90 days, for example – for people to start reaching out for mental health assistance. Things slow down and people have time to think, she said. “And that’s usually when we start getting more of an increase in the calls,” she said.

Pat Sheldon, whose family has been farming near the small town of Percival in the southwestern corner of Iowa for four generations, has been working continuously to maintain the 2,500 acres of farmland owned by him, his father, his brothers and his son. Sheldon also is the president of the Benton/Washington levee district, which has become a demanding position after multiple levees breached in the flood.

“I’ve been really busy. So you just keep going. Adrenaline kicks in and away you go,” he said.

Sheldon said he has not needed to seek mental healthcare, and has dealt with the emotional impact of the floods by spending time with friends and focusing on moving forward. But he said he thinks many farmers having difficulty dealing with flooding probably need professional help.

Tina Popson/special to IowaWatch

HEFTY WORKLOAD

Farmers impacted by the floods are dealing with a hefty workload to make their land functional again while also worrying about the financial realities of bringing in little to no income from a crop this year. Many stored grain from 2018 in bins over the winter in hopes of better economic conditions in the future but lost it when floodwater busted open the bins. McIntosh, the farmer from near Missouri Valley, said some of his neighbors had livestock die from stress-induced strokes while being evacuated.

McIntosh said the Missouri River has flooded his farm several times in the past decade. He described the flood of 2019 as especially devastating, even though flooding in 2011 was larger in magnitude, because farmers had less time to prepare for it. He and his neighbors were forced to evacuate livestock and equipment in just three days this year, whereas they had three weeks in 2011.

McIntosh said dealing with the flood and the personal stress it is putting on farmers is like “trying to put out fires, one after another.” Farmers have no time to think about how the pressure to cope with the flood affects them mentally, he said. “And every day it’s another challenge, you know, an unexpected challenge.”

Paul Daniel, a psychotherapist in Marshalltown, Iowa, in 2019 flood-disaster zone Marshall County, recalled the July 2018 tornado in his town and how it still affects residents’ mental health needs. He said trauma from natural disasters can affect people out over the course of years, not just weeks or even months.

He also said just knowing you live in a region prone to flooding can trigger anxiety and depression. “I’m sure it just kind of brings back a lot of memories, and triggers, and especially when it’s raining, often here, three, four days in a row,” Daniel said. “They’re like, ‘is my house gonna flood?’ I mean, you live with that fear all the time.”

Mike Rosmann, a farmer, therapist, and something of a spokesperson for farmer behavioral healthcare, from Harlan, Iowa, said that, even without flood conditions, behavioral healthcare often is financially inaccessible for farmers who are tentative about their insurance fees being impacted by an official diagnosis of mental illness.

“Farmers will sometimes pay out of their pocket, or maybe they even have high deductibles,” he said. “But they don’t want an official claim form to become processed.”

This is part of why Rosmann, along with many other mental healthcare providers IowaWatch spoke with, is a strong advocate for the full funding of the Farm and Ranch Stress Assistance Network, which was established through the 2018 Farm Bill. It called for “farm telephone helplines and websites, community education, support groups, outreach services and activities, and home delivery of assistance, in a case in which a farm resident is homebound.”

The Farm Bill authorized $10 million annually to fully fund this Assistance Network, but Congress only allocated $2 million to it for federal fiscal 2019. This prompted several farm advocacy groups to send a letter asking the House and Senate Subcommittees on Agriculture to fully fund the Assistance Network.

Also impacting farmers’ access to care is that many mental health care providers, even in rural areas, do not have a strong enough understanding of agriculture to make farmers feel that they are being listened to and understood during appointments. Even if a farmer is able to make an appointment, Rosmann said farmers’ relationships with therapists often fall apart due to this cultural disconnect.

Rosmann said he often hears from farmers that, even though a counselor is caring and tries to understand, “she just doesn’t or he just doesn’t understand what I’m going through emotionally, and I can’t make him or her understand how distressed I am.”

Rosmann said that lack of knowledge about agriculture can cause a massive disconnect in how therapists talk to farmers. “The counselor says, ‘You know, I can show you how to manage your anxiety, but you have to apply it.’ And the farmer says, ‘I don’t know how to apply it, I have to feed my cattle every day, I have to I live where the source of my anxiety emerges. It’s harder and harder for me to get up and go out in the morning when all I see is it’s cloudy and rainy again.’”

“We need many, many counselors in Iowa who have a grasp of agriculture,” Rosmann said.

Brandi Janssen, director of Iowa’s Center for Agricultural Safety and Health, said she has encountered therapists in the state who had fundamental questions about how agriculture works. She met with a group of mental health providers that serve Grinnell and Newton, Iowa, who wanted more information about important factors in farmers’ lives, like tariffs and how crop insurance works.

Karen Hyatt, of the Iowa Department of Human Services oversees Project Recovery Iowa, an effort funded by the Federal Emergency Management Agency, has met with people affected by floods, often in parking lots and campgrounds. She has referred them to professional counseling if necessary.

Hyatt said she saw many people displaced by flooding this year who had to pay housing expenses like mortgages and utilities for property they were evacuated from but also for places to which they resettled. Some found themselves unable to pay even for the gas to drive to an appointment, she said. Hyatt said one of the community mental health providers she has worked with obtained a foundation grant to cover the copays for people that are coming into the agency.

Iowa Secretary of Agriculture Mike Naig described the well being of farmers who have been impacted by flooding as “very much a top of mind issue for us.” He said the National Institute for Food and Agriculture recently made available funds for organizations that provide mental health support to farmers.

Naig said he is working with Iowa State Extension Services to “see if we can collaborate on a grant there to get some additional dollars and some additional capacity there.” He said bolstering extension services is his primary means of supporting farmer mental healthcare in the state but he wants to know more about what resources the state lacks.

“I’m always wanting to understand more about those things. And then we’ll help in any way that we can,” he said.

This story also was republished under IowaWatch’s mission of sharing stories with media partners by The Gazette (Cedar Rapids, IA); Iowa City Press-Citizen; The Courier (Waterloo-Cedar Falls, IA); The Oskaloosa Herald; The Valley News (Shenandoah, IA); Little Village Magazine; Business Record (Des Moines); Iowa Public Radio; Public News Service; Reddit.com; the Asheville Tribune (Asheville, NC); KGLO (Mason City, IA) and KJAN.com (Atlantic, IA); and a radio version of this story was aired by 35 U.S. radio stations, including KJAN AM and FM (Atlantic, IA), KSOM-FM (Audubon, IA), KAUS-FM (Austin, MN), KCHE AM and FM (Cherokee, IA), KLSS-FM (Mason City, IA), KRIB-AM (Mason City, IA) and WNAX AM and FM (Yankton, SD) in the Midwest.