It’s tough to get farmers to seek help by breaking through the feelings of helplessness and the stigma that surround severe depression. But it’s even tougher to realize that those who take that brave step may find there’s nobody nearby to listen.

“When they get to the point when they say, ‘I need help. I don’t want to commit suicide,’ who do they go to? The answer is often, ‘nobody,’ because they’re not there,” says Paul Force-Emery Mackie, a professor at Minnesota State University, Mankato and former president of the National Association for Rural Mental Health.

As of October 2018, the U.S. Department of Health and Human Services, has identified 2,692 rural “professional shortage areas”—a figure that climbed by 20 such areas over the month before. Bringing those rural shortages up to levels that would fully meet local needs would require 1,865 mental health providers—psychiatrists, psychologists, counselors, social workers, and psychiatric nurse practitioners.

That will require a steady buildup of trained professionals. To address the immediate need, farmer and psychologist Mike Rosmann of Harlan, Iowa, has been advocating for $10 million per year in farm bill funding for the Farmers First Act, which would establish a network of state and regional farm crisis telephone services to provide counseling and referral to rural people in need of help. The program—under the name Farm and Ranch Stress Assistance Network—was approved in the 2008 farm bill, but never funded.

The Farmers First program is modeled after Sowing the Seeds of Hope, which Rosmann administered for a decade. Sowing the Seeds of Hope established phone banks in Minnesota, Iowa, Wisconsin, South Dakota, North Dakota, Nebraska, and Kansas to provide confidential assistance on financial, disaster, legal, and behavioral health emergencies. Over their 12-year funding cycle, those hotlines received more than 250,000 calls and provided vouchers for behavioral health services to more than 15,000 farm families. Though Sowing the Seeds of Hope had built trust within the farm community, Rosmann says, government support ultimately dried up. He is hoping that including Farmers First in the new farm bill will establish more stable funding.

Culturally appropriate. One of the notable things about Sowing the Seeds of Hope was the requirement that helpline responders had a background in agriculture as well as mental health training—vital to be able to deliver what Rosmann calls “culturally appropriate assistance.” They understand the unique pressures farmers face—the economics, the weather, the way their identities are tied to the land. They feel the pain.

Rural people also tend to stay in the small communities they serve. Mackie points out that the vast majority of successful, long-term rural behavioral health providers come from rural backgrounds. They are comfortable living in the country or a small town, so they’re not eager to scramble back to the city when another opportunity arises.

The problem is that many rural students don’t end up getting pursuing the educational degrees that prepare them for a career in behavioral health, says Mackie, so the flow of trained experts who are most likely to succeed in rural areas is just a trickle. Instead, many rural clinics are staffed by qualified and dedicated professionals who receive student loan forgiveness from the National Health Service Corps in return for at least two years of service in an underserved area, but many of those professionals move back to the city when their hitch is up.

Reaching into rural schools. Mackie has a different vision—a program that reaches into rural schools to attract students into behavioral health, trains them, and lets them bring their skills back to the communities they come from. Ideally, says Mackie, many of those students would find training opportunities in rural areas so they could be more easily attracted to the programs and could afford to attend. However, Mackie says his plan could also work if rural students could be drawn to state universities and other institutions farther afield.

“We could look at developing pipelines out of rural America to the educational facilities with the understanding that these are people who are more likely to go back or want to go back,” he explains. “We don’t have to entice them or trick them, and we don’t have to pour a lot of money in like the revolving door of the National Health Service Corps.”

Another boost to rural mental health care would be creating a force of peer support specialists, says Mackie, a job that has no specific educational requirements. He notes that the field is growing and is even licensed in some states, which boosts standards and respect within the behavioral health community. Creating on-the-job training programs or online training (which Mackie acknowledges is still a poor option in some areas because of poor internet infrastructure in many rural communities) could bring this opportunity to more people in the country.

Mackie points out that there’s another benefit to establishing behavioral health as a viable career path for rural students—it can help take the stigma out of the profession as well as the need to tap into its services.

“It kind of normalizes the narrative,” he says.

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