Handbook of Rural, Remote, and very Remote Mental Health

Preface
Contents
About the Editors
Contributors
1 Rural, Remote, and very Remote Mental Health
	Introduction
	Distinctive Features of Service Delivery in RRvR Areas
	Concluding Comments and Recommendations
	Take-Home Messages
	References
Part I: Context of Rural, Remote, and very Remote Mental Health
	2 Social Determinants of Mental Health in Rural, Remote, and very Remote Contexts
		Introduction
		Distinctive Features
			How Do Social Determinants Influence Mental Health?
			What Are the Social Determinants of Mental Health in RRVR Locations?
			Access to Services
			Employment
			Social Capital
			Social-Political Exclusion
			Importance of Secure Housing
			Is Rurality a Social Determinant?
		Practice Implications
			Country Level
			Community Level
			Individual Level
		Concluding Comments and Recommendations
		Take Home Messages
		Cross-References
		References
	3 Global Mental Health Perspectives on Rural and Remote Mental Health Provision
		Introduction
			The Emergence of Global Mental Health
			Culture and Its Impact on Understandings of Health and Illness
			The Biopsychosocial Model and the Need to Attend to Cultural Factors
			Scaling-Up and Task-Sharing for Mental Health
		Distinctive Features of Effective Rural and Remote Practice in LMIC
			The Context in Uganda
			The Context in Bangladesh
		Practice Implications for Rural and Remote Mental Health Work in LMIC
			Training People to Deliver Interventions in Rural Settings
			Utilizing Existing Community Resources
			Ethical Considerations Associated with International Collaborations
		Case Study from Bangladesh: Shomaj Shongi
		Case Study from Uganda: Group Support Psychotherapy for Depression Treatment in People with HIV/AIDS in Northern Uganda
		Concluding Comments and Recommendations
		Take Home Messages
		Cross-References
		References
	4 Indigenous Mental Health in Remote Communities
		Introduction
		Strategies for Moving Forward
		Practice Implications
		Distinctive Features
		Concluding Comments and Recommendations
		Take-Home Messages
		References
	5 Mental Health Research and Evaluation in Rural, Remote, and very Remote Settings
		Introduction
			Using and Also Creating Evidence Is Fundamental to Effective Mental Health Practice
		Distinctive Features
			The Form and Function of RRvR Research
			The Purpose of RRvR Research
			Principles of RRvR Research
		Practice Implications
			Cultivating a Learning Orientation Supports the Generation and Use of Evidence
			Partnering with Practices and Academics Can Amplify the Learning Opportunities
			Engaging Patients - The Heart and Soul of Practice - In Collecting and Using Evidence
			Demonstrating Impact
		Concluding Comments and Recommendations
		Take-Home Messages
		References
	6 Recovery in Mental Illness Among Rural Communities
		Introduction
		Distinctive Features
		Practice Implications
		Recovery
		Meanings of Recovery
		Elements of Recovery
			Clinical (Reduction in Symptoms)
			Social
				Connectedness
				Hope and Optimism
				Identity
				Meaning in Life
				Empowerment
		Tasks of Recovery
			Developing a Positive Identity
			Framing the Mental Illness
			Self-managing the Mental Illness
			Developing Valued Social Roles
		Personal Recovery in a Rural Environment
			Defining Rural
			Access to Clinical Support
			Dual/Overlapping Relationships
			Rural Community Understanding of Mental Illness
			Stigma
			Limited Employment Opportunities
		Enabling Recovery in Rural Areas
			Social Inclusion
			Community Support and Service Interventions
			Antistigma/Antidiscrimination Interventions
			Co-design
		Conclusion
		Take Home Messages
		Cross-References
		References
	7 Professional Ethics in Rural Practice: Relational Territory
		Introduction
		Overlapping Relationships and Objectivity
			Boundaries
			Overlapping Relationships and Professional Ethics
			Overlapping Relationships in Practice
			Overlapping Relationships and Practice Adaptations
			Reframing Overlapping Relationships
		Community Pressure and Integrity
			Integrity
			Community Pressure in Context
			Practice Adaptations for Community Pressure
			Reframing Community Pressure
		Generalist Practice and Competency
			Generalist Practice in Context
			Practice Adaptations for Generalist Practice
			Reframing Generalist Practice
		Interdisciplinary Collaboration and Confidentiality
			Interdisciplinary Collaboration in Practice
			Practice Adaptations for Collaboration
			Reframing Collaboration
		Professional Development and Support
			Professional Development in Context
			Practice Adaptations for Professional Development
		Critical Incidents and Ethical Development
		Contextualizing Ethics
		Take Home Messages
			Professional Ethics in Rural Practice
		References
Part II: Professional Practice in Rural, Remote, and very Remote Mental Health
	8 Models of Service Delivery and Funding of Mental Health Services
		Introduction
			Distinctive Features
				The Complexity of Mental Health Funding
					Total Funding
				Funding Sources
				Australian Government Funding
					Total Funding Growth
					Funding Distribution
					State and Territory Expenditure and Funding
					Businesses and Organizations
					Donations and Philanthropic Support
					Service Users
				Funding Recipients
					State and Territory Government Services
					Non-government, Community-Controlled, Not-for-Profit Organizations
					Private Health Providers
					Primary Health Networks
					Private Hospitals
					Individual Mental Health Consumers
					Teaching and Research Institutions
		Practice Implications
			Structure and Flow of Funding
				A Complex Picture
			Accountability for Mental Health in Australia
		Rural and Remote Mental Health
			Prevalence and Burden of Disease
			Rural Mental Health Expenditure
			Rural Mental Health Workforce
			Rural Mental Health Access
			Youth Mental Health Access
			Other Characteristics of Rural and Mental Health
		Concluding Comments and Recommendations
			A Better Approach to Funding Rural and Remote Mental Health
		Take-Home Messages
		Cross-References
		References
	9 Integrated Primary Mental Health Care in Rural and Remote Contexts: The Australian Experience
		Introduction
			The Big Picture
			What Is Meant by ``Integrated´´ Primary Mental Health Care?
			Why Is It Beneficial to Integrate Mental Health Care into Primary Care?
		Case Study
			Unique Population Characteristics of Australia
			Rural Areas and Equity
			Risk Factors and Needs of Rural People
			Social Exclusion
			Indigeneity
			Incidence of Mental (and Other) Health Issues in Rural Communities
			Equity of Access to Primary Health-Care Services
			Primary Mental Health Care in Rural Australia: Distinctive Features
			Mental Health Specialities in Rural Australia
				Mapping of Primary Mental Health Service Providers
				Information in Relation to Each of the Four Mental Health Specialities
					General Practice
						Overseas-Trained Doctors (OTDs)
						Group vs. Solo Practice
				Mental Health Issues in Rural Communities
					Psychiatry
					Psychology
					Mental Health Nursing
			Practice Implications
				Models of Integrated Rural Primary Mental Health Service Delivery in Australia
		Concluding Comments and Recommendations
		Take Home Messages
		References
	10 Visiting Workforce
		Introduction
		Visiting Rural and Remote Mental Health Services
			Distinctive Features
				Models of Visiting Services
				Advantages and Disadvantages of Visiting Service Models for the Community
			Practice Implications
				Competencies for Visiting Rural and Remote Mental Health Practice
				Support Needs for Effective Visiting Rural and Remote Mental Health Practice
				Considerations for Organizations Providing Visiting Services
				Community Perspectives of Visiting Services: Considerations for Practitioners and Organizations
				Training and Supervision of Visiting Rural and Remote Mental Health Services
				Visiting Service Models: A Rural Workforce Recruitment and Retention Opportunity?
		Concluding Comments and Recommendations
		Take-Home Messages
		Case Studies
		References
	11 Telemental Health in Rural and Remote Contexts
		Introduction
		Barriers to Mental Health Service Provision
			Access and Acceptability
			Retaining a Workforce
		Distinctive Features: Telehealth in Rural and Remote Communities
		Practice Implications of Telepsychology: Opportunities and Impediments
			Benefits for Clients
				Practical Benefits
				Access to Quality Therapeutic Options
				Client Empowerment
			Barriers to Uptake
				Funding
				Technical Glitches
				Lack of Training
				Increased Work Burden
				Professional Concerns
		Optimizing Telepsychology: Therapeutic Adjustments in the Provision of Service
			The Case of ``Michael´´
		Setting Up a Videoconferencing Service and Managing Risk
		Concluding Comments and Recommendations
			Practice Implications: Five Key Points for Effective Practice
		References
	12 Improving Access to Psychological Services in Remote Australia with a Patient-Led Clinic
		Improving Access to Psychological Services in Remote Australia with a Patient-Led Clinic
			Distinctive Features
			Practice Implications
			Treatment Efficiency
			Strategies to Improve Access and Efficiency
			A Disconnect Between Treatment Design and Treatment Delivery
			The Dose-Response and Good Enough Level Models of Treatment Delivery
			Linking to Recovery-Oriented Approaches
			Summary and Justification for Changing the Standard Approach
			Applying the Innovation
			Establishing the Clinic
			Operating the Clinic
			Patient-Led Appointment Scheduling
			The Method of Levels
			Evaluating the Innovation
			Access
			Efficiency
			Effectiveness
		Concluding Comments and Recommendations
			Policy and Practice Implications
			Final Remarks
			Take Home Messages
			Case Study
		References
	13 Multidisciplinary Teams in Rural and Remote Mental Health
		Introduction
		Defining Multidisciplinary Teams
		Multidisciplinary Team Challenges
			MDT Workforce
			MDT Leadership
			Role and Professional Ambiguity
			Clinician Autonomy and Collective Decision-Making
			Conflict Resolution
		Multidisciplinary Team Strengths and Advantages
		Establishing Multidisciplinary Teams
		Concluding Comments and Recommendations
		Take Home Points
		Cross-References
		References
	14 Improving the Physical Health of Rural People Living with Mental Illness
		Introduction: Background and Context
			Comorbidity
				Avoidable Physical Illnesses Cause More Premature Deaths than Suicide
		Specific Risks and Challenges
			Contributing Factors and Implications for Care
			Smoking
			Medication Effects
			Exercise
			Diet
			Social Inclusion
		National and International Policy Context
		Practice Implications
			Working Effectively as Part of the Available Health System and Supports
				Adopting a Human Rights-Based Response
					A Right to Equal Access to Quality Care
					A Right to Participate in Care Planning
						Respect, Enhancing Autonomy, and a Partnership Approach to Recovery: Two Examples
				Ensuring Physical Health Screening, and Medical Interventions
					Screening
						Physical Health Conditions Cause Ten Times More Early Deaths than Suicide
					Support and Advocacy: For Physical Health Screening
					Advocating for Quality Physical Health Care: ``Don´t Just Screen: Intervene!´´
				Addressing Key Lifestyle Factors
					Smoking Cessation
					Poor Nutrition
					Inactivity
					Substance Use
					Medication
					Daily Structure and Social Participation
				Using an Integrated Approach to Care
					Horizontal Integration
					Vertical Integration and Stepped Care
					Other Dimensions of Integrated Care
		Concluding Comments and Recommendations
		Key Points for Effective Practice
			Checklist: Ten Evidence-Based Actions to Improve the Physical Health of People Living with Mental Illness (in Order of Priorit...
		Case Studies
		Cross-References
		References
Part III: Role of Different Professions in Rural, Remote, and very Remote Mental Health Practice
	15 Rural and Remote Psychiatry
		Introduction
		Rural and Remote Psychiatry
		Practice Applications
		Conclusions
		Take-Home Messages
		Case Studies
			The Development of Open Dialogue
			Our Psychosis Project
			Northern Saskatchewan Reserves
			Phenomenology of Rural and Remote Psychiatric Practice - Getting to Experience
		References
	16 General Practitioners
		Introduction
		Where, Who, and Why? Distinctive Features of Mental Health Care in Rural and Remote General Practice
			Where?
			Who?
			Why?
			Recovery-Oriented Care
			Central Role in Primary Health-Care System
			Whole Person Generalist Care
			Improved Physical Health Outcomes
			The Doctor as Healer
		What and How? Practice Implications for Rural and Remote General Practitioners
			Health Promotion and Illness Prevention
			Identification and Early Intervention
			Assessment, Diagnosis, and Formulation
			Treatment Planning and Shared Decision-Making
			Biological
			Psychological
			Social
			Where to Begin?
			Intervention
			Prescribing
			Referral
			Collaboration
			Self-Care, Supervision, and Sustainable Practice
		Concluding Comments and Recommendations
		Take-Home Messages
		References
	17 Rural and Remote Mental Health Practice: Nursing Roles
		Introduction
		Distinctive Features: Limited Services, Stigma, and Increased Acuity
			Limited Access to Mental Health Services
			Increased Acuity
		Practice Implications: Flexibility, Collaboration, and Therapeutic Relationships
			Collaboration and Working in Isolation
			Multifaceted Role and Therapeutic Relationships
			The Intercultural Context
		Concluding Comments and Recommendations
		Take-Home Messages
		References
	18 Challenges and Rewards: The Role of Psychologists in Rural and Remote Areas
		Optimal Care with Suboptimal Resources
		Adapting to Personal Challenges and Professional Struggles
		Relevant Professional Struggles
			Competition
			Government
			The Prescriptive Authority Debate
			Registration and Mobility
			Advocacy
		The Sociohistorical Context
		Responding to the Rural Context
			Adaptations to Professional Practice Norms
				Rural Specific Practice Guidelines
		Reaping the Intrinsic Rewards
		Conclusion
			Concluding Thoughts
		References
	19 Social Work, Mental Health, and Rural Practice: A Perspective from New Zealand
		Introduction
		Competence to Practice Social Work with Māori
		Rural Aotearoa New Zealand
		Te Whare Tapa Whā
		The Discipline of Social Work
		Anti-oppressive Practice and Rural Social Work
		Case Study
		Take-Home Messages for Effective Practice
		References
	20 Peer Work in Rural and Remote Communities and Mental Health Services
		Introduction
		Distinctive Features
		Defining Peer Work
		Local Connection and Dedication: Peer Work in Rural and Remote Communities
		Local Peer Workers Bridge Gaps Between Transient Workers and the Community
		Research from Across the Globe
		Peer Workers Are Crucial to Multifaceted Services
		Practice Implications
		Preparing the Workforce Culture to Accept and Value Peer Work
		Historically Slow Uptake of Peer Work
		``Everyone Knows Everyone Here´´
		Different Perspectives
		Concluding Comments and Recommendations
		Take Home Messages
		References
	21 Critique of Psychiatry in Rural and Remote Communities
		Introduction
			Context for the Criticism of Psychiatry
			Political Considerations
			Overemphasis of Psychiatric Medications
			Psychiatry´s Lack of Cross-Cultural Awareness
			Research on Psychiatry in Rural and Remote Locations
		Practice Implications
		Conclusions
		Take-Home Messages
		References
	22 Maintaining Control: The Importance of Self-Care to Effective and Enduring RRvR Mental Health Service Provision
		Introduction
		Distinctive Features of Self-Care in RRvR Areas
		Practice Implications
		Case Study
		Concluding Comments and Recommendations
		Take Home Messages
		References
Part IV: Important Areas of Practice in Rural, Remote, and very Remote Mental Health
	23 Suicide and Self-Harm: It´s Everyone´s Business
		Introduction
		Distinctive Features
		External Factors: Challenges for Rural and Remote Service Provision
		Internal Factors: Common Factors of the Rural and Remote Lifestyle
		Practical Implications
		Community Directed
		Community Backing
			Capacity Building
			Community Leadership/Elders
			Community Development/Strategic Plans
		Practitioner Directed
			Education
		Cultural Appropriateness
			Service Collaboration
			Communication
		Concluding Comments and Recommendations
		Take-Home Messages
		Case Studies
		References
	24 Substance Abuse in Rural and Remote Areas
		Scope of Substance Abuse
		Substance Use in the United States
		Substance Use in Australia
		Substance Use in New Zealand
		Substance Use in Europe
		Unique Problems and Factors in Rural and Remote Areas
		Health Disparities in Substance Use and Treatment Between Racial and Ethnic Groups
		Prevention and Treatment of Substance Use and Abuse
		Remote Therapies for Rural and Remote Populations
		Intervention Considerations Between Racial and Ethnic Minorities
		Summary and Conclusions
		References
	25 Quality Use of Psychotropic Medicines in Rural and Remote Setting
		Introduction
			Ethical Considerations
			Frameworks and Policies
			Clinical Reasoning in Medicines Management
		Distinctive Features
			Decreased Access
			Cultural Diversity
			Communication Challenges
			Physiological Variations
				Translation of Medicinal Trial Data to Clinical Practice
		Practice Implications
		Case Study
		Conclusion
		Take-Home Messages
		References
	26 Providing School-Based Mental Health Services in Rural and Remote Settings
		Introduction
		Youth Mental Health in Rural and Remote Communities
		School-Based Mental Health Services and Barriers to Utilization
		Modalities of School-Based Mental Health Services
			School-Based Health Centres
			School Mental Health
			School-Based Telehealth and Telepsychology
		Effectiveness of School-Based Services
		Establishing School-Based Mental Health Services
			Interdisciplinary Collaboration
			University-Community Partnerships
		Implications for Prevention and Intervention
			Positive Behavioral Interventions and Supports and Multitiered Systems of Support
			Evidence-Based Practice
			Engaging Families
			Challenges of Working in Schools
		Concluding Comments and Recommendations
		Take Home Messages: Keys for Effective Practice
		Case Studies
			Assessment, Support, and Counseling (ASC) Center
			Youth Experiencing Success in Schools (Y.E.S.S.) Program
			Conjoint Behavioral Consultation (CBC) Model
		References
	27 Social and Emotional Well-Being: ``Aboriginal Health in Aboriginal Hands´´
		Introduction
			Social and Emotional Well-Being: Distinctive Features
		A Strength-Based Approach for Aboriginal and Torres Strait Islander Social and Emotional Well-Being Service Providers
			Practice Implications of Using a Strength-Based SEWB Approach
		Risk and Protective Factors for Healthy Social and Emotional Well-Being
		Strengths-Based SEWB Approach for Working with Rural and Remote Communities
		Listen Respectfully to the Person
		Build Genuine Relationships
		Use Effective Communication
		Critically Reflect on Australia´s Historical, Political, and Social Contexts
		Apply a Human Rights-Based Approach
		Evaluate the Process and Outcome
		Concluding Comments and Recommendations
		Take-Home Messages
		Cross-References
		References
	28 Working with Rural Families: Issues and Responses When a Family Member Has a Mental Illness
		Introduction
		Protective Factors and Stressors for Families Living in Rural and Remote Environments
		Access to Support and Treatment
		Stigma
		Burden of Care
		Particularly at-Risk Family Groups
			Intimate Partner Violence
			Aboriginal and Torres Strait Islander Families
			Culturally and Linguistically Different (CALD) Families
			Families Where a Parent Has a Mental Illness
			Lesbian, Gay, Bisexual, Trans/Gender Diverse, and Intersex (LGBTI) Individuals and Their Families
		Practice Implications
		Systems Change
		Concluding Comments and Recommendations
		Take-Home Messages
		Cross-References
		References
	29 Supporting Communities
		Introduction
		Social Support
		Gender Differences and Social Support
		Social Support and Rural Communities
		Community Groups as Social Support
		Building Community
		Support Groups as Formal Social Support
		Social Media and Mobile Phones for Social Support
		Financial Counselors
		Implications for Rural Mental Health Providers
		Take-Home Messages
		Concluding Comments and Recommendations
		Cross-References
		References
	30 Environmental Impacts on Mental Health
		Introduction
		Distinctive Features
			Environmental Problems and Health
			Climate Change
			Related Environmental Threats
			Health Impacts of Climate Change and Related Environmental Threats
			Mental Health Impacts
			Impact on Rural and Remote Populations
			Gradual or Indirect Causes of Climate Change on Mental Health and Psychosocial Well-Being
			Impacts on Rural and Remote Populations
			Climate Change Impacts on Health Systems
			Vicarious Causes
			Protective Factors
		Practice Implications
			Implications for Rural and Remote Practitioners
			Building Resilience
		Concluding Comments and Recommendations
		Take Home Messages
		Cross-References
		References
	31 Addressing Climate Change
		Introduction
		Distinctive Features
			Responding to Climate Change
			Mitigation
				Reducing Your Environmental Footprint Within the Rural and Remote Mental Health Practitioners´ Workplace
				Advocating for Strong Climate Policies with Governments, Decision-Makers, Opinion Leaders
			Adaptation
				Preparing for and Responding to Extreme Events Within the Sector
				Preparing for and Responding to Extreme Events Within the Workplace
				Preparing for and Responding to Extreme Events Within the Community
				Communicating About Climate Change and Health
				Household Disaster Preparedness
				Preparing for and Responding to Extreme Events Within the Individual: Psychological Adaptation: Coming to Terms with Climate C...
			Coping with Loss and Damage
				Necessary Elements of a Best-Practice Psychosocial Recovery Model
		Concluding Comments and Recommendations
		Take-Home Messages
		References
	32 Depression and Anxiety
		Introduction
		Description and Distinctive Features of Rural and Remote Communities
			Unique Characteristics: Rural and Remote
			Assessment and Diagnosis
		Practice Implications
			Treatment Modalities and Considerations
			Culturally Adapted Interventions
			Expanded Workforce and Community Supports
		Concluding Comments and Recommendations
		Take-Home Messages
		Cross-References
		References
	33 Low Prevalence Psychiatric Disorders in Rural and Remote Settings
		Introduction
			Biopsychosocial Interventions in Schizophrenia
			Ideal Models of Care
		Distinctive features of Schizophrenia in Rural and Remote settings
			Are People with Schizophrenia in Rural and Remote Communities Different?
			Rural People with Schizophrenia Are Often More Disadvantaged
			Health-Seeking Behavior in Rural Communities May Be Different
			Care in Rural Communities May Be More Reliant on Informal Networks
			Aboriginal and Torres Strait Islander PwS
			Rural and Remote Locations Have Fewer Mental Health Professionals
			Effective Service Models in Rural and Remote Areas May Be Different to Urban Models
		Practice Implications for Practitioners Working in Rural and Remote Settings
			Working Creatively with Limited Resources and Distance
			Managing Risk and Uncertainty at Distance
			Working in Smaller Communities
			Working Well as a Lone or Small Team Practitioner
			Psychosis Skill Development
			What Should a Curriculum for Rural Practitioners Working with Psychosis Be?
			Psychosis and Phenomenology
			Psychopharmacology in Schizophrenia
			Psychological Skills
			Rural and Remote Whole System Working
		Concluding Comments and Recommendations
		Take-Home Messages
		Cross-References
		References
	34 Promotion and Prevention of Mental Health Problems in Rural and Remote Context
		Introduction
			Distinctive Features
				Target Populations
				Definitions
					Prevention
					Promotion
					Responsibility
					Risk Factors
					Stigma
			Presentation of Mental Health Problems in Rural and Remote Communities
				Gaps in the Continuity of Care
		Practice Implications
			Practical Approaches to Prevention Programs for Rural and Remote Communities
				Achieving Systemic Change
				Targeted Communications
				Education and Training
			Implementation of Programs
				Collaboration and Partnerships
				Reaching the Target Audience in a Community
				Program Sustainability
				Evaluation and the Importance of an Evidence Base
			Modifying or Adapting Programs
				Investing in and Scaling Evidence-Based Programs
				The Importance of Workplace Programs
				The Role of the Healthcare and Support Workforce
		Concluding Comments and Recommendations
		Take-Home Messages
		Recommendations
		References
35 Future of Rural, Remote, and very Remote Mental Health
	Introduction
	Distinctive Features
	Concluding Comments and Recommendations
	Take-Home Messages
	References
Index