Rurality as Concordance: Mental Health Service Delivery for Rural Survivors of Intimate Partner Violence

Abstract

This manuscript examines how a shared sociospatial or “rural” identity may uniquely facilitate mental health care delivery. In particular, we consider the significant but largely unexplored role that domestic violence center staff, whom we term “Reputational Provider-Experts” or RPEs, play in addressing the mental health needs of rural women who have experienced intimate partner violence. Using data collected through semi-structured individual and focus group interviews with RPEs across 12 counties and four tribal reservations in northern Wisconsin (N = 15), we detail the sociospatial commonalities that enable RPEs to provide trusted, sustained mental health support to rural women. Because these advocates are rural community members whose approach implicitly appeals to local norms and values, we argue that they represent rurally concordant providers. In this way, rurality emerges as a meaningful and novel form of patient-provider concordance, one with critical relevance to addressing the rural mental health crisis in the United States.

Keywords

rural studies mental health culture inequality

Introduction

Like many rural regions in the United States, rural northern Wisconsin communities suffer from limited, and in some areas, nonexistent, mental health and health care services (Hastings and Cohn 2013). Amid population declines, state and federal spending cuts, and the growth of high-deductible health plans, rural areas additionally contend with decreasing numbers of mental health providers and physicians as well as a diminished property tax base—that is, the primary means by which many rural counties finance health and mental health care (Vogenberg and Santilli 2018).

The pervasive poverty experienced by rural regions often prevents access to quality care and in some cases prompts cuts to already insufficient services (Hoeft et al. 2018). This same socioeconomic distress is correlated with the prevalence of mental health problems (Evans 2016; Hudson 2005), which promotes a vicious cycle in which rural Americans’ need to access mental health care rises as their ability to access that care declines. Indeed, in response to a recent, open-ended survey about the general needs of their communities, fully one quarter of low-income northern Wisconsin respondents identified access to mental health services as a critical and unmet need (Wolf and Statz 2018).

In addition to the structural and behavior contours of the rural mental health crisis, relatively less attention has been paid to the sociocultural processes that underlie rural barriers to mental health care. While physical access to mental health care cannot be understated, more subtle barriers, among them shared norms and attitudes, may prevent rural individuals from seeking care or from reaping the maximum benefits of their care—even when health services are made available (Hartley 2004; Robinson et al. 2012). To improve both access to and quality of mental health care in rural settings, social scientists and medical professionals must develop a more granular understanding of how rurality relates to mental health care and how this relationship can inform culturally appropriate mental health care provision. After all, and as we argue here, it is precisely relationship—in this case between respected and local mental health care providers and potential patients—that bridges the rural mental health care gap.

Background

Concordance in Patient-provider Relationships

In this manuscript, we frame empirical research on rural mental health provision in the context of intimate partner violence (IPV) through the lenses of concordance and cultural capital. By drawing on the concordance literature’s attention to shared experiences, values, and communication, and likewise underscoring the social class aspects of cultural capital, we integrate these frameworks to demonstrate the critical relevance of sociospatial identity as an axis of concordance in rural patient-provider relationships. This is a meaningful intervention in the literature, and one with particular salience to mental health provision.

Numerous studies have demonstrated that patients’ and providers’ demographic attributes determine patients’ access to and satisfaction with their health care. One vein of literature, namely that on concordance, has examined patients’ and providers’ attributes with relation to one another—that is, whether or not their attributes match—and how these concordant or discordant relationships affect health care provision and outcomes. Here, “concordance” is defined as a shared demographic attribute between the patient and provider, such as gender, race, or language. Conversely, “discordance” is when these demographic attributes between patients and their providers are at odds. Although the relationship between gender concordance and health outcomes remains largely ambiguous (Jerant et al. 2011), researchers have demonstrated that other forms of concordance are strongly and consistently related to better health care experiences and health outcomes.

Among these, racial concordance has been the most widely investigated form of relational concordance in the health care setting. Lisa A. Cooper et al. (2003) find that in racially concordant patient-physician relationships, patients use more services, are more satisfied with those services, and rate their physicians as more participatory than patients in racially discordant relationships. While some studies challenge the effect of patient-provider racial concordance on health outcomes (see Meghani et al. 2009), patients’ subjective ratings of their experiences, health-related outcomes, and willingness to use health services prove consistently related to racial concordance (LaVeist and Nuru-Jeter 2002; Okunrintemi et al. 2018). As specifically pertains to mental health, others demonstrate racially concordant patients’ increased likelihood of continuing their mental health care (Alegría et al. 2013) and patients’ preferences for mental health providers of their own racial identity (Cabral and Smith 2011).

In the health care setting, language concordance is also documented as leading to better health outcomes, better health care provision, and higher satisfaction with providers (Ali and Watson 2018). While some argue that the effects of racial concordance can be explained by language concordance (August et al. 2011)—that is, the ability of the patient and provider to speak the same language proficiently—still others find separate effects for racial and language concordance (Cooper and Powe 2004; Traylor et al. 2010).

The relevance of racial and language concordance to health care outcomes points to a significant reality: the perceived similarity between a patient and provider in terms of culture, beliefs, values, and communication matters. As our and others’ work demonstrates, these shared attributes are worth considering further. For instance, Richard L. Street et al. (2008) examine the relationship between racial concordance and patient outcomes by measuring two dimensions of similarity: personal (defined by beliefs and values) and ethnic (defined by race and community). Measures of personal, but not ethnic, similarity predicted patients’ trust, satisfaction with care and intent to adhere to the providers’ recommendations. These findings suggest that personal similarity (beliefs and values) may be the mechanism through which patient-provider concordance along various demographic characteristics leads to better health care experiences and health outcomes. Other work similarly evidences that general perceptions of similarity along the lines of communication, beliefs, and values are related to patients’ reported amount of trust in their providers—a measure strongly associated with positive health outcomes (Street et al. 2009; Thom, Hall, and Pawlson 2004).

Concordance and Social Class

Although “social class” has yet to be theoretically labeled as an axis of concordance in patient-provider relationships, the impacts of social class discordance are widely evident. Research on the effects of discordant social class relationships in the health care setting has framed class largely as differences in cultural capital—namely the interaction styles, dispositions, beliefs, and skills that individuals bring into interactions—and has explained the process through which cultural capital reproduces class-based health inequalities. For instance, Annette Lareau (2003) demonstrates that while middle-class children are taught to advocate for their health care needs and view their doctor as a resource and ally, working-class children are largely coached to mistrust their doctors, view doctors as potentially judgmental authority figures, and in some cases restrict the amount of information they share or even lie about health behaviors. As a result, doctors are often able to provide more comprehensive and accurate health information to middle-class families. Janet K. Shim (2010) likewise argues that individuals from higher social class backgrounds, and therefore those with more cultural capital, are better equipped to build rapport with health providers because they share similarly-classed interactional styles and experiences.

Cecilia L. Ridgeway and Susan R. Fisk (2012) further theorize class discordant interactions as “gateway interactions”—cross-class communications that are especially crucial for poor and working-class individuals to navigate for the sake of health and social mobility. Other examples include college interviews, job interviews, and appointments with lawyers, interactions in which “success” largely hinges on an individual’s ability to match the disposition, preferences, and interactional styles of the other party. As they pertain to this particular research, these cultural capital studies demonstrate that social class discordance in interpersonal interactions—including those in health care settings—perpetuates social class (and by extension, health) disparities.

Of course in some settings, we can arguably capitalize on this information, demonstrating the profound potential of health care interactions that involve and reflect shared social norms, spatial experiences, and class identities. In what follows, we integrate and extend existing attention to racial, linguistic, and class concordance to a meaningful recognition of space. Specifically, we highlight rurality as an important axis of concordance/discordance and explain how this conceptualization can help us better understand and address the rural mental health crisis.

The Present Study

In the United States, “rural” is variously classified in terms of population size and geographic isolation, through economy or policy-relevance typologies such as “low education” or “persistent poverty” (ERS 2015), and even as “what is not urban” by the U.S. Census Bureau (Ratcliff et al. 2016). Of particular relevance to this manuscript, a number of scholars have centered on sociospatial aspects of “rurality,” including rural residents’ attachment to local community and kin networks, rural place, and the lifestyle it represents (Boglioli 2009; Struthers and Bokemeier 2000); a high density of acquaintanceship (Freudenburg 1986); and an assumption of shared values, including self-reliance (Barcus and Brunn 2010; Lobao 2006; Sherman 2009).

Rural U.S. communities also tend to have substandard infrastructure and human capital deficits, with once secure agricultural and extractive industries increasingly replaced by manufacturing and service jobs—many of which are low-wage and non-unionized (Merrett and Struthers 2002). Owing to this economic restructuring, a prevailing characteristic of much of rural America is increasing poverty, including working poverty (Anglin 2002; Smith and Tickamyer 2011; Thiede, Lichter, and Slack 2018)—even as rural areas have consistently had higher rates of poverty than metropolitan areas since the 1960s (Farrigan 2014). Of course, this economic trend also reflects broader historical and political factors, among them the cumulative and cross-generational impacts of structural violence experienced by rural Native communities and people of color (Kirmayer, Gone, and Moses 2014).

With full acknowledgment of the complex diversity in and across rural communities in the United States, we propose that the aforementioned sociospatial and economic aspects of rurality may uniquely impact how rural individuals think about and interact with the mental health care system. Drawing on Ann R. Tickamyer and Debra A. Henderson’s (2003) attention to the “deep-seated local affiliations and loyalties” of rural women in the United States (p. 112; see also Walker and Logan 2018), we recognize that a shared, lived experience of place—the “local affiliation” and all it signifies—is likely significant for establishing rapport between rural patients and their rural mental health providers. Moreover, and as we already know, this perceived similarity between the patient and health care provider leads to positive health care experiences and outcomes (Street et al. 2009).

As we demonstrate below, “rurality” proves a multifaceted identity, one that includes, mitigates, and at times exceeds other forms of concordance/discordance between patients and providers. In what follows, we argue for rurality as an important axis of concordance by documenting rurally concordant mental health care relationships and considering how their concordance relates to rural individuals’ orientations toward and experiences of mental health care.

Data and Methods

IPV in Context

This study explores the lived experiences of individuals who provide mental health services to rural female survivors of IPV. This addresses a critical gap in the literature, for while research has examined the role of mental health providers in responding to IPV (Chapman and Monk 2015; Trevillion et al. 2016), its inverse—namely how or if domestic violence advocates address mental health needs—remains largely unexplored.

While used interchangeably with “domestic violence” by our respondents, we primarily utilize the term “IPV” in this manuscript. We understand IPV as relationship abuse that includes physical and sexual abuse, psychological harm, and stalking by a current or former partner (Breiding, Chen, and Black 2014). With full acknowledgment that both women and men are victimized by IPV, we center here on the experiences of rural women. We do so because women are at a greater risk than men of repeated abuse, severe physical and sexual violence, and violence that occurs in the context of controlling behaviors (Karakurt, Smith, and Whiting 2014). Research also suggests that rural women may experience a higher frequency of psychological and physical abuse, alongside a decreased likelihood of help-seeking, compared with their urban counterparts (Krishnan, Hilbert, and VanLeeuwen 2001; Peek-Asa et al. 2011; Shannon et al. 2006). Moreover, rural perpetrators of domestic violence are nearly twice as likely as urban perpetrators to inflict severe physical injuries and are more likely to use a weapon during their assault (Logan, Shannon, and Walker 2005; Pruitt 2008), and rural female victims of domestic violence are more likely to be married to the batterer; to experience sexual assault in domestic violence incidents; and to be victims of childhood abuse than their urban counterparts (Logan et al. 2005; Pruitt 2008; Rennison, DeKeseredy, and Dragiewicz 2012).

The mental health consequences of IPV on women include an increased likelihood of clinical depression, anxiety, post-traumatic stress disorder, substance abuse, low self-esteem, and self-harm (Banyard et al. 2018; Humphreys and Thiara 2003). These consequences are arguably compounded in a rural setting, where women additionally experience physical and social isolation, scarce or distanced health care and advocacy services, the stigma attached to being a victim of domestic violence, and, relatedly, the lack of anonymity that is characteristic of small towns and often deters individuals from reporting rape or intimate abuse (Feyen 2001; Gallup-Black 2004; Statz and Pruitt 2019).

Rural IPV and Mental Health Service Delivery Systems

In the United States, including northern Wisconsin, IPV and mental health service delivery systems share an important characteristic: a structural shift toward the centralization and regionalization of services (Ostermann and Vincent 2019). In the mental health context, economic constraints as well as a shortage of mental health care professionals (de Vogel 2018; Linnane 2017) has accelerated the centralization of mental health services to urban centers. As a result, 87 percent of Mental Health Professional Area Shortages are in rural areas (Bird, Dempsey, and Hartley 2001). This trend has left northern Wisconsin, like many other rural regions, with limited or nonexistent mental health services (Hastings and Cohn 2013). As mental health service delivery becomes both literally and figuratively distant, unfamiliar, and tailored for urban residents (Blank et al. 1995), rural community members are further alienated from critically needed care.

The philosophy and practice of IPV service delivery combats some of the negative repercussions of this shift toward urbanization (Kulkarni, Bell, and Rhodes 2012). As our data demonstrate, IPV centers tend to emphasize holistic, personalized, and community-based care. These values are reflected in their differential staffing compared with the mental health service delivery system. Although some of the IPV centers we researched are considered “regional” in terms of their designated service areas, the centers themselves are staffed by rural community members who live within the given service area. Moreover, IPV system staff often practice in a relatively informal capacity, while those in the mental health delivery system tend to be formally trained and educated. In this way, the IPV service delivery system remains local and more familiar to the rural women who utilize it when compared with the mental health delivery system, despite economic and legislative urges toward centralization in both sectors.

This paper does not offer an in-depth comparison of these two systems. Rather, our aim is to highlight elements within the IPV service delivery system that effectively address the mental health needs of rural IPV survivors—in this case, de-centralized, community-based care (Ala-Nikkola et al. 2018; World Health Organization 2003). Our hope is that these elements might serve as important guideposts for mental health service delivery in rural regions more broadly.

Sample, Data Collection, and Analysis

Using data collected by Michele Statz and Jordan Wolf, we identified local domestic violence center staff and directors across Northern Wisconsin (N = 15) as a critically trusted, if not exclusive, source of mental health care provision. In fact, in a survey of low-income residents in Northern Wisconsin, residents most often reported that domestic violence center staff and directors were sources of mental health care in their communities (Wolf and Statz 2018). Borrowing from the sociological literature on “reputational leaders” (Gunn, Brooks, and Vigar 2015; Shoemaker and Nix 1972), we term these individuals “Reputational Provider-Experts” (shortened to “RPEs” throughout): informal mental health advocates who have high visibility in the community, are active and influential participants in local networks, and are viewed by others as trustworthy and knowledgeable.¹

The majority of these organizations provide shelter, food, and clothing to victims of IPV, and most also offer some counseling, support groups, and advocacy. In the spirit of the breadth of these services—and the expansiveness of staff efforts—we generally refer to these agencies as “centers” rather than “shelters.” To protect participant anonymity and confidentiality in the reporting of results, we here utilize pseudonyms. Likewise, in acknowledgment that many domestic violence centers do not publicly disclose location to protect residents and staff, we deliberately locate respondents and facilities within the more generalized “a northern Wisconsin county” or “a northern Wisconsin tribal community” throughout this manuscript.

Between January and March of 2018, we conducted one-on-one, semi-structured interviews with personnel (N = 8) at eight domestic violence centers that cover 12 counties and four tribal reservations within northern Wisconsin and one focus group interview with domestic violence center staff (N = 7) at a tribal reservation in the region. While our sample is small according to disciplinary standards, the total population of domestic violence center personnel in the study region is also small: there are 16 total domestic violence shelter organizations within rural-designated northern Wisconsin counties (WCASA 2020). Consequently, a sample of 15 is a much larger proportion of the entire target population than is often possible. We contacted all 16 rural domestic violence shelter organizations and eight either declined to participate or did not follow up. Of the eight centers that agreed to participate, all shelter personnel consented to be interviewed. All respondents self-identified as female. The majority of the RPEs have lived in northern Wisconsin for most of their lives (80 percent [12 out of 15]), and 20 percent (3 out of 15) openly self-identify as survivors of IPV. Most have held their current positions for over 10 years. Fourteen of the 15 individuals we interviewed do not have advanced or clinical training in a mental health-related field but spoke openly about being locally known and utilized as ad hoc mental health providers for victims of IPV: “Each county has mental health resources in the way of a crisis line through the county,” noted one RPE. “You might be able to at least call and talk to a social worker. But [the social worker is] going to end up referring them to my office.” RPEs variously described their efforts as including “brief therapy,” prevention work, one-on-one counseling, case management, advocacy, and support groups. Many of the RPEs we interviewed work on behalf of survivors from geographically but also socially isolated communities in northern Wisconsin, including undocumented im/migrants and the Amish.

Participants were recruited through word of mouth via networks established in the course of the broader research project. An ongoing collaborative partnership with a legal aid organization in the region introduced us to the directors of three centers. These individuals in turn introduced us and our study to personnel at other shelter facilities across the region, all of whom agreed to participate in telephonic, one-on-one, interviews. One individual additionally invited us to conduct a focus group interview with center staff at a tribal reservation. All informants provided written consent, and the institutional review board at the University of Minnesota approved the study protocol.

Jordan Wolf conducted all telephonic interviews, and Michele Statz conducted the focus group interview. Individual and focus group interviews were semi-structured using the same interview guide. The flexible nature of these methods allowed respondents to determine which topics they found most important. RPEs were asked about their roles in their communities, the unique health needs of their rural residents, and the barriers and facilitators to mental health care that locals experience in their communities (see interview guide in Appendix). This manuscript accordingly highlights the primary issues and themes that emerged in the course of these interviews about providing mental health care for IPV in rural contexts.

Data analysis was led by Michele Statz and Jordan Wolf. Each interview was audio-recorded and transcribed verbatim by a research assistant, then uploaded to NVivo software for data management. Data were analyzed via a grounded theory approach that integrated theoretically informed questions and ongoing, collaborative interpretation to identify key themes (Glaser and Strauss 1967). We integrated this approach with abductive theory, a more contemporary inferential process aimed at producing new hypotheses and theories by holding surprising research evidence against the backdrop of diverse literatures (Timmermans and Tavory 2012).

Michele Statz and Jordan Wolf independently engaged in line-by-line coding, attaching descriptive codes relevant to central research questions throughout (Thornberg and Charmaz 2014). We then did a second round of coding to collaboratively identify and discuss emergent themes. During this process, Michele Statz reviewed these themes and any unexpected data with relevant research participants for clarification, validation, and additional perspective (Baxter and Jack 2008). Since themes were consistent across the two types of interviews, we analyzed the data in tandem but were cognizant of the different methodologies and how they may affect the data we collected throughout the coding and analysis process. Accordingly, check-in conversations were frequently held to make sure we similarly defined themes and evidence supporting them, and likewise to explore our own positionality and potential biases in regard to the data. In collaboration with Katie R. Billings, analysis then proceeded to an interpretive phrase in which text, codes, and themes were organized in an explanatory framework that foregrounded female participants’ points of view.

Results

Two prominent themes emerged in our analysis of interview data. The first encompasses the structural, spatial, and social barriers to mental health provision in northern Wisconsin. The second identifies what is working in spite of, and at times because of, these barriers, namely a concerted appeal to local norms and values by RPEs. Consequently, in the first half of our results section, we discuss how rurality uniquely affects female IPV survivors’ experiences of mental health care in northern Wisconsin. These results demonstrate the importance of rurality in determining both access to and orientations toward mental health care. In the second half, we show how domestic violence center staff are key, albeit ad hoc, providers of mental health services to women experiencing IPV—as well as under- or unrecognized authorities in mitigating the social and emotional impacts of domestic violence. We draw on these advocates’ perspectives as experts in understanding disparities in mental health care and as guides in identifying spatially and culturally relevant interventions (see also McNichols, Witt, and Gatewood 2016).

We argue that because these advocates are rural community members who appeal to rural norms and values, they represent rurally concordant providers who are uniquely situated to provide mental health care to rural community members. This is evidenced in RPEs’ awareness of and sensitivity to clients’ experiences; their holistic approach to mental health needs and service provision; their visible presence and partnerships in the community; and their commitment to work beyond the bounds of job titles or descriptions. To that end, we conclude the paper with a discussion of the role these informal “Reputational Provider-Experts” and how their position as rurally concordant mental health care providers might help identify meaningful interventions on a larger scale.

Structural Barriers

RPEs noted numerous structural barriers that prevent or hinder women’s ability to access mental health resources. One RPE explained,

[Victims of IPV] have to jump through a bunch of hoops. There are always hoops . . . If you are fleeing for your life, and you are leaving a rural community where you were isolated to begin with, imagine how hard it is . . . You have to get back on your feet financially, then try to find low-income housing that doesn’t exist.

Relying heavily on state and federal grants, as well as in many cases tribal governments, RPEs steadily underscored the strains they felt were unique to Wisconsin. “We are right on the border of Michigan,” said one RPE.

The resources that are available to DV clients and families are very short in Wisconsin. I’ve had clients I’ve had to transfer over to Michigan because there are just more resources available. There’s more financial assistance, there’s more housing opportunities . . . Wisconsin is lacking.

An advocate in northwestern Wisconsin similarly described clients’ general preference for services “across the bridge” in Minnesota.

Mental health resources are similarly lacking—both a dearth of resources and overburdened mental health professionals prevent rural community members from receiving mental health care. One RPE explained,

We would love to be able to refer our clients to professional therapists or counselors . . . [But] there is always surprise to people who aren’t from around here originally [when they] find out how hard it is to try and get in to see a therapist.

Overall, RPEs noted the structural limitations of living in rural Wisconsin that prevented many women from seeking and/or receiving needed services, and even led some to seek services out of state.

Spatial Barriers

Our interviewees’ noted spatial limitations by discussing distance from resources and transportation as foremost concerns for victims of IPV in northern Wisconsin. RPEs shared that most of the individuals they work with travel anywhere from 5 to 40 miles to access jobs, childcare, shopping, and health and social services. This travel time is often compounded by inclement weather, particularly during the long winter months. Moreover, many of these clients are low-income. Because of the limited employment, childcare, affordable housing, and educational opportunities characteristic of rural space, the RPEs noted that victims of IPV are often financially dependent on an abusive partner. “The lesser of two evils, I’ve heard them say, is to stay in the violent or abusive situation,” stated one RPE. “At least they have a roof over their head and they’re with their children.” Further impacts of rural poverty, like limited or unreliable transportation, mean that “those outside supports . . . are so far away,” noted another RPE.

I think that probably the biggest challenge is transportation and trying to figure out how we can get these women [places]. They have to take more than one step. You can’t just get in your car and go to the doctor.

An additional dimension of spatial barriers is communication. “We have a lot of the issues big cities have, but we don’t have the resources for our people like they have. Transportation. Housing. Basic things,” noted one respondent during the focus group interview.

“Communication,” added her colleague. “Cell phones, telephone, computers, internet.”

During a later interview, another RPE similarly commented, “[T]he people who live in rural areas cannot afford internet. Cell phones don’t even work in some of these heavily wooded areas, or there isn’t a tower nearby. They have a hard time reaching out for help.”

Social Barriers

Along with structural and spatial barriers, RPEs noted that stigma was a primary reason that potential clients are reluctant or choose not to get help. “We are taking two things that society really stigmatizes, right?” said one RPE. She continued,

Domestic violence, what did you do to deserve that? Why didn’t you leave that relationship? . . . And also, “the new shame”: people don’t talk about their mental health issues. This is not something people feel comfortable sharing with other people: “I’m having anxiety when I’m by myself.” “I can’t sleep.” Or, “These symptoms came about as the domestic violence issue occurred.” It makes people feel really isolated.

Another RPE echoed this sentiment by stating,

Sad to say, but still within rural communities and way back when, it’s just something you deal with at home, and you make it through. A lot of people are still not wanting to expose what happens behind closed doors.

RPEs stressed that social factors—primarily stigma—prevent rural women from seeking needed resources.

RPEs’ Personalized Care Strategies

Despite the previous barriers to care, RPEs note that much is working in terms of providing mental health care to rural community members. As we demonstrate here, RPEs’ position as trusted local community members allows them a unique ability to provide mental health support to women escaping IPV. Below, we consider the elements of their unique position—their informality, familiarity, trust, and appeals to local norms—that they cite as important facilitators to mental health care in rural northern Wisconsin. Throughout, we evidence these factors as critical dimensions of concordance. Overwhelmingly, RPEs stressed trust—and with it, choice and comfort—as critical to mental health service delivery in rural Wisconsin. These needs were often couched within a broader ethic of informality and self-sufficiency. RPEs commonly mentioned self-sufficiency as a powerful local norm impacting an individual’s ability or willingness to seek out help. By comparing the center to other resources, one RPE explained, “There are always hoops victims have to jump through to get these resources. When they come to agencies like ours, this is the only place where we aren’t going to tell them what to do.” The organizational reputation she highlighted matters, as do individual RPE reputations as open-minded, culturally sensitive, and deferential to clients’ decisions. As another RPE reiterated, “We really try to give [clients] a lot of choices.” RPEs appealed to local norms of self-sufficiency to promote trust and confidence in their services.

Other RPEs underscored how access to mental health care is not only shaped by a dearth of providers, as noted previously, but also by a mistrust of elite or unfamiliar mental health providers more generally. In many ways, this hints at the concordance work at the interstices of language and class. “We do have community mental health [here],” stated an RPE, “but [our clients] will shut down on you.” Similarly, another RPE added,

[Clients] are really connected to [the center] and don’t often seek out mental health services. It is just easier to get those services from one site instead of having to re-explain what happened to them, what situation led to the mental health issues . . . I get that. Having to tell another person your story, they could tell their story 5, 6, 7 times in a row. That’s retraumatizing them. Places like [the center] are having to work outside of their scope because that person is only comfortable working in their setting with their staff.

As RPEs explained, the comfort and necessitated informality of IPV centers uniquely appeal to rural victims of domestic violence with mental health needs. So too does the extensive local knowledge and connectedness these RPEs offer.

RPEs and the Community

Throughout our research, RPEs underscored that meaningfully addressing IPV hinges on developing longstanding, trusted relationships with clients and with area stakeholders. Both sets of relationships arguably rely and capitalize on RPEs’ reputations, and in the region we studied, the latter additionally reflects RPEs’ expertise around IPV and clients’ mental health needs. “We were a big part of retraining officers, dispatch, the ER,” noted one RPE.

Because we heard from the people we serve: “I got retraumatized going to the ER, or having to fill out the report with an officer . . .” We helped describe [to community partners] what services people need for both mental health and for situations where they are victims of crime. We created this whole new system of care.

RPEs discussed their efforts to forge connections with area churches, nursing homes, hospitals, public health offices, school staff, student groups, local attorneys and judges, and even employees at a local Walmart. Through these connections, RPEs persistently publicize center resources, provide off-site support groups, and offer ongoing, largely informal public education about the complex spatial, socioeconomic, and health realities of IPV. “We’ve worked with [the employment agency],” stated one RPE.

I had a client who struggled with some mental health. And she was missing a lot of days at work. They weren’t understanding it. I had to advocate for her to help them understand where she is coming from. They have a better understanding, and they actually let her take some time off without jeopardizing her job. [It] was great.

A key component of this community education is publicity around RPEs and the local DV center itself. Although the location of DV centers is often not disclosed to protect victims of IPV (Driskell 2009), RPEs were overwhelmingly deliberate in making their work visible. “We are on the tribal listservs. We are on the tribal e-news. We are within the community, all the public facilities,” stated one RPE. Another commented,

Every month we have an awareness campaign . . . We work [ourselves] into every possible gathering, ceremony, community event that is held here . . . [Y]ou never know where you are going to be when a victim is going to come forward. We are always there. We show up everywhere.

RPEs expressed their commitment to educational efforts in the community to reduce stigma and increase the likelihood that individuals seek their resources. One RPE explained this commitment:

We are out in the community a lot. We are talking to people who may never, ever, ever need our services . . . It’s a lot of time for us to do. It takes us away from serving the people we serve. But for this to change, you have to shift the paradigm and make [us] a part of people’s everyday lives.

Holistic Approach to Service Provision

As our data evidence, this local knowledge contributes to a critical understanding of clients’ complex socioeconomic needs, which in turn translates to a holistic and pragmatic approach to individuals’ mental health with deep practice and policy relevance. “We really need to find ways to address [other] issues before we can . . . help clients through their domestic or sexual assault issues,” stated one RPE. “People need housing and food and shelter before they can function properly. These are the other layers that need to be addressed to help them live a healthy and violent-free life.”

In rural or remote northern Wisconsin, there is a sociospatial dimension to addressing these “other layers,” one evidenced by the high frequency with which RPEs referred to DV centers as “hubs.” Whether to address a client’s lack of transportation or distrust of area medical professionals, RPEs steadily underscored the need for in situ service provision. “She didn’t have to go on the bus to a bunch of different places,” said one RPE of a client. “She was able to stay here and have a staff work with her through it.”

We help them through the criminal justice system or legal system . . . We help with divorces, child custody placement, restraining orders . . . We help them with accounting. Connecting them with economic support. Jobs . . . Mental health, connecting them with AODA [Alcohol and Other Drug Abuse] resources. We have a children’s program coordinator who works with children, works on healthy parenting. Safety. Family dynamics. So, when we work with clients, it’s a very holistic view. It’s all aspects of their life we are looking at, not just the initial abuse.

Other RPEs additionally noted clients’ need for food share, BadgerCare Plus (state health care coverage for low-income Wisconsin residents), and subsidized housing programs. In one tribal community, naming ceremonies, sweat lodge ceremonies, talking circles, and transportation to attend a local powwow were also offered. “[We provide] anything that is focused on the culture, and [clients] choose from it to help heal.” RPEs acknowledged that to improve clients’ mental health, they needed to address all the needs clients’ have when they come to the center. “Sometimes mental illness can be brought on by years of experiencing domestic abuse,” commented another RPE. “We look at [all] angles of it. And we help in all aspects to see each client, what resources, and what supportive services help them.”

Discussion

Suffering from limited—and in some areas, nonexistent—formal health services, northern Wisconsin largely reflects rural regions across the United States. Accordingly, we sought out local and informal mental health providers to illuminate the unique needs of women who have experienced IPV and how these needs are met despite the numerous barriers to mental health care characteristic of rural space. Our work documents the complex and interrelated structural, spatial, and social barriers to accessing mental health care in the context of IPV—as well as RPEs’ success in mitigating these barriers and providing survivors of IPV with needed mental health resources. We argue that these RPEs represent rurally concordant mental health care providers, which explains their public presence and remarkable longevity as trusted advocates in their communities. As our data demonstrate, these individuals appeal to local norms and values and emphasize their position as community members, which conveys similarity with the women for whom they are providing care. As already established in the literature, this is key to successful concordance. Most simply, RPEs’ informality, familiarity, and ability to appeal to local norms are consistent with the needs and values of many rural women. We argue that it is precisely these factors, and therefore their rural-concordance, that enables RPEs to successfully provide mental health care to female survivors of IPV.

Structural, Spatial, and Social Barriers to Accessing Mental Health Care

In this section, we situate our specific findings about structural, spatial, and social barriers to mental health care in the existing literature. As in many rural regions in the United States, communities in northern Wisconsin suffer from fewer medical services—including mental health services (Hastings and Cohn 2013; Statz and Termuhlen 2020). The reasons for this are often financial: Insurers reimburse behavioral health services at a lower rate than other medical specialties, and for patients covered by Medicaid, the rate is typically even less. In Wisconsin, where approximately 20 percent of residents have some form of Medicaid coverage, including the state’s BadgerCare Plus program for low-income residents, government funds reimburse mental health providers for about half their costs for seeing Medicaid patients (Linnane 2017). As a result, some psychiatrists set a limit on how many Medicaid-enrolled patients they will accept, and regional health systems are reluctant to expand the behavioral health services they offer. As in other rural regions contending with this relative lack of resources and support, it is increasingly difficult to recruit mental health providers to northern Wisconsin counties. An additional challenge is that many mental health providers are trained at research universities in urban areas and cannot necessarily anticipate the unique challenges of rural practice (de Vogel 2018). Moreover, when outside providers relocate to rural spaces, research suggests that their identities as outsiders hinders their effectiveness and has a negative impact on the providers’ mental health (Chipp et al. 2011).

From a spatial perspective, RPEs noted that the women they work with experience significant and even prohibitive travel burdens in accessing mental health care and other resources. This owes to rural and remote locations, poor roads and infrastructure, and absent public transportation (DeKeseredy et al. 2016; Statz and Evers 2020). These results are consistent with what other scholars have documented, namely that rural women not only experience higher rates of IPV and a greater severity of physical abuse, but they also tend to live farther from available resources (Peek-Asa et al. 2011; Tittman et al. 2016). Moreover, any supports that are available often span a very large service area and are arguably less responsive and comprehensive (DeKeseredy and Schwartz 2009). Accordingly, rural women experiencing IPV are almost twice as likely to be turned away from services as their urban counterparts due to a lack of capacity (Peek-Asa et al. 2011). This highlights the critical consequences of another structural shift, namely the centralization or regionalization of formal mental health care provision. While ostensibly implemented to improve outcomes and reduce costs via increased volume, variety of cases, experience and efficiency (Ostermann and Vincent 2019), centralizing mental health services in urban areas results in a perception among rural community members of mental health care as “distant, unfamiliar, and unacceptable” (Blank et al. 1995). Our data underscore this, while also suggesting that RPEs might actually increase efficiency and improve mental health outcomes.

Because some of the IPV programs we researched are “regional” and not local, in that they cover a relatively wide service area, our data importantly confront proponents of centralization but also add important nuance to scholarly and policy support for de-centralized, community-based mental health service delivery (Ala-Nikkola et al. 2018; World Health Organization 2003). Most simply, our data steadily point to the importance of individuals within systems who provide concordant, locally accepted services.

The rural spatial context also introduces communication challenges, including limited cell phone service and broadband access. Thus, with a dearth of mental health providers, precarious funding, and limited mobility and technology, northern Wisconsin powerfully evidences the complex infrastructural and digital divide that “rural” mental health provision often encompasses. As we demonstrate here, interventions in rural and remote areas must consider that even basic modes of communication remain out of reach for many low-income and vulnerable residents—and often for mental health providers, as well.

Finally, social barriers to mental health access with particular salience to rural individuals include the stigmatization of IPV and mental health (Colon-Gonzales et al. 2013). Our study is no exception to this trend. RPEs often discussed the double stigmatization of IPV and mental health. Previous scholars have noted that stigma and its attendant shame cause many individuals to remain silent about domestic violence (Owen and Carrington 2015; Roush and Kurth 2016). In a rural context that may exhibit a high degree of social acquaintanceship and distinct privacy norms, this lack of confidentiality can further inhibit victims from seeking formal services—and community members from intervening when abuse is suspected (DeKeseredy and Schwartz 2009; Miller, Clark, and Herman 2007).

RPEs’ Rurally Concordant Care Strategies

Our findings demonstrate that RPEs uniquely mitigate the above barriers and provide critically concordant mental health assistance to rural women experiencing IPV. One key dimension of this work is RPEs’ sensitivity to self-sufficiency as a powerful local norm impacting a rural individual’s ability or willingness to seek out help. In a sense reflecting what others have documented of rural and/or “frontier” cultures in the United States, namely a high moral value accorded individualism and self-reliance (Judd et al. 2006; Sherman 2009), our research shows that rural women’s desire for self-sufficiency may actually bolster treatment effectiveness provided by RPEs in northern Wisconsin (see also Nelson 2005; Zhang et al. 2008) rather than inhibit treatment-seeking behavior (Colon-Gonzalez et al. 2013).

Significantly, if not unexpectedly, the connection we observed between self-reliance and help-seeking largely owes to the barriers described in the above section. In other words, the informality demanded by a resource-poor rural context may uniquely appeal to individuals who prioritize self-sufficiency. This reality largely underscores both the necessity and the success of RPEs in their work on behalf of IPV survivors. Contending with precarious funding, absent mental health and health care professionals, and many of the same communication and transportation challenges their clients face (see Health Resources & Services Administration 2015), RPEs’ broad and ultimately successful response to victims of IPV powerfully appeals to local norms.

While all but one of the individuals we interviewed lack advanced clinical training in a mental health field, every RPE articulated a clear, practiced, and relatively consistent set of factors to address the mental health needs of survivors of IPV in rural and remote communities. First, RPEs identified informality as a unifying norm that appeals to rural individuals who prioritize flexibility and self-sufficiency. While this informality is arguably demanded in DV centers that lack robust funding and clinically trained professionals, RPEs’ appeal to local norms also meaningfully communicates similarity with patients, the backbone of concordance. RPEs also highlighted their own local reputations as trustworthy—and for some, as survivors of IPV—as highly valued by rural victims of IPV. In this context, RPEs’ ability to connect with locals as locals themselves proves critical to connecting with and providing rural women with mental health care.

A corollary finding is that in these rural and remote contexts, regard for a trained mental health professional as an “elite” or “outsider” may inhibit an individual’s desire to seek out mental health services. Indeed, previous research on concordance suggests that “mismatches” between the patient and provider on relevant characteristics compromises the quality of care, likelihood to seek treatment, and satisfaction with treatment (Alegría et al. 2013; Cooper et al. 2003; Okunrintemi et al. 2018).

Expanding this emphasis on “local,” RPEs argued that meaningful mental health support must be holistic and thereby address the complex needs individuals present including housing, food, shelter, and culturally significant opportunities for healing. Significantly, RPEs actually endeavored to meet these needs, typically through well-established networks and a deep commitment to community education. A number of RPEs detailed mental health supports for Native IPV survivors that incorporated traditional practices and values, and all described advocacy and publicity efforts as extending across and beyond reservation boundaries.

An issue of special consideration in this research involves formal training. As described here, many RPEs observed a distrust for “elite” mental health professionals, particularly those with no connection to the community, among the women they served. This concern is evidenced elsewhere in the literature, particularly as regards the worry that if a woman seeks formal mental health services, this, rather than her partner’s violence, will be the subject of professional attention—especially in the context of child custody proceedings (Stanley and Penhale 1999). Research also suggests that women who have experienced IPV fear being pathologized by a medical model of mental health that simplifies complex relational experiences into a diagnosis, and that views counseling as a sufficient response (Humphreys and Thiara 2003; Laing 2001). The idea of a formal mental health professional as “an outsider” supports our argument that RPEs are successful providers because they are spatially concordant with the population they serve. Put simply, RPEs’ identities as local and informal community members allow them to better serve local rural women.

Owing to their personal experience and social location, we argue that RPEs evidence rurally concordant mental health provision. That written, at no point did any RPE—nor do we—deny the critical importance of ongoing and advanced training in clinical mental health counseling or clinical social work. Indeed, as Emily R. Dworkin et al. (2017) discuss, this training should be understood as critical to strengthening the local service infrastructure. When viewed as such, we believe RPEs could, and indeed, must, be better supported by Wisconsin’s degree-granting institutions via remote or hybrid program offerings. Already trusted and well-positioned to offer survivors of IPV the diverse, holistic support they need, this training will enhance RPEs’ skillset and may likewise lend legitimacy in the context of interprofessional collaboration. In this way, resources should be funneled to those who are already concordant with rural community members and therefore most likely to be successful in providing mental health care.

Relatedly, another important consideration this research raises is the deep dexterity and multidimensional expertise of RPEs. RPEs’ active knowledge of the complex needs and barriers that low-income rural individuals navigate has relevance to a host of professional stakeholders. Indeed, the suggestions RPEs offer in contending with—and also capitalizing on—the spatial, economic, and societal realities unique to rural and remote northern regions are likely of value to social service and health care organizations, educators, and local and state policy makers. Moreover, RPEs effectively train, collaborate with, and mobilize a range of diverse community members. This represents an additional dimension of expertise, one with particular salience to efforts aimed at enhancing mental health interventions in rural areas via interprofessional and intersectoral collaboration (see, e.g., Heath et al. 2014).

There are several limitations to study results. For one, our data were obtained from a limited sample of participants, the majority of whom self-identify as Native American or Caucasian and female, and all of whom voluntarily enrolled to participate. These RPEs work on behalf of an ability-, ethnically-, and gender-diverse clientele, but their perspectives remain their own. We must additionally acknowledge that focus group participants in particular may not have shared their full range of views owing to privacy concerns. Although we did not find different themes across the two methodologies, namely individual and focus group interviews, the varying methods may have affected the data we collected. Another limitation is that our data were collected from individuals spanning 14 counties and four federally recognized tribes in rural and remote northern Wisconsin. IPV center staff elsewhere in this region—and in neighboring but arguably better resourced states, like Minnesota—may have substantially different opinions, experiences, and clientele than those we interviewed.

This leads us to a related limitation of this study, namely that we interviewed RPEs but not the IPV survivors on whose behalf they worked. To support our claims about concordance and perceived similarity between providers and patients, we would need to interview women receiving services about their beliefs and experiences with RPEs and/or formal mental health care providers. An important direction for future research is to document the perspectives of these individuals, to more systematically assess the impacts of diverse identities on in/formal mental health care experiences (Hack, Larrison, and Gone 2014), and to necessarily contextualize rural IPV experiences and mental health help-seeking with intersectional factors such as addiction, age, children and/or pregnancy, incarceration, and so on (Bailey and Daugherty 2007; Bennett and O’Brien 2007; Edwards 2015; Teaster, Roberto, and Dugar 2006).

In addition to regional and relational variance, we were unable to determine whether RPEs provide better mental health care than formal providers owing to the study’s limited sampling method and qualitative design. A study that considered these factors in tandem, namely the viewpoints and work of formal mental health providers and RPEs on behalf of rural survivors of IPV, could compellingly illuminate ways in which RPEs can or should function as key intermediaries between IPV survivors and mental health care. This would of course presume that so many of the aforementioned structural, spatial, and social barriers, among them unemployment, precarious state insurance policies, unreliable transportation, and stigma and shame, have been addressed. Consequently, this methodological challenge underscores the broader argument this research makes, namely that the holistic and context-comprehensive work of RPEs is necessitated in and by a rural and remote context.

By establishing rurality as concordance, this study offers a meaningful theoretical intervention with immediate applied relevance. Rather than comparatively evaluate prevailing IPV and mental health service delivery structures or offer explicit recommendations to one or both contexts, this manuscript identifies an element of mental health care delivery in the IPV context, namely RPEs, with value for scholars and policy makers seeking to address the rural mental health crisis more generally. At once attending to and mitigating rural barriers to mental health care, RPEs provide services in an informal, sustained, and community-specific manner—an approach that synergistically lessens barriers and decreases stigma for rural IPV victims. As rural and remote regions continue to contend with well-documented shortages of mental health professionals along with the additional sociospatial barriers presented by rural poverty, RPEs compellingly introduce relevant and replicable ways to address the mental health consequences of IPV across diverse rural regions.

Footnotes

Appendix

Declaration of Conflicting Interests

The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Science Foundation’s Law and Sciences Program (award #1729117).

Notes

Author Biographies

Michele Statz is an assistant professor at the University of Minnesota Medical School, Duluth and affiliated faculty with the University of Minnesota Law School. Michele is trained as an anthropologist of law, and her research examines how socio-spatial dimensions of rurality influence access to justice, rights mobilization, and the efforts of tribal and state court judges in northern Minnesota and Wisconsin. Michele’s research has appeared in Law & Society Review, Harvard Law & Policy Review, and American Journal of Public Health and is generously funded by the National Science Foundation’s Law and Science Program.

Katie R. Billings is a graduate student in the Sociology Department at the University of Massachusetts, Amherst and a graduate fellow for the UMass Center for Justice, Law, & Societies. Billings’ research examines the creation and reproduction of inequality in the mental health and legal fields. Her dissertation, which is funded by the National Science Foundation, is a qualitative study of suicide in the U.S. and includes indepth interviews with suicide survivors. Billings’ research is published in Social Science & Medicine, Law & Society Review, and Sociological Perspectives. katierbillings.com.

Jordan Wolf is a fourth-year medical student at the University of Minnesota Medical School, Duluth intending to pursue a career in anesthesiology. Her research expertise includes identifying neurobiological and behavioral mechanisms that mediate the stress response and chronic pain. As part of an interdisciplinary approach, she is interested in how rurality mediates these effects.

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