Unsettled country: rural Oklahoma's struggle with addiction, mental illness
September 2, 2016
From its vast, open ranges in the northwest to its lush, rolling hills in the southeast corner, rural Oklahoma still evokes an idyllic image.
The archetype of quiet, small towns with a strong sense of community – where friendliness is abundant and “big city” stresses are few – often marks the popular imagery used to represent the state and its values.
But for many of those who live in Oklahoma’s rural areas, the reality does not match the trouble-free imagery.
Outside of Oklahoma City and Tulsa and their suburbs, a disproportionate number of residents betray key signs of untreated mental-health problems and substance abuse, an Oklahoma Watch analysis of state data found.
Some of those signs register tragedy.
Among the 10 Oklahoma counties with the highest suicide rates over the last decade, for example, all but three have populations living mostly in rural areas. And the non-rural areas in those three counties consist of smaller towns – what most people consider rural, or non-urban.
The picture is similar for the 10 counties with the highest fatal drug-overdose rates and the 10 counties with the highest rates of people reporting frequent mental distress. Those counties don’t contain gritty inner-city neighborhoods or endless suburbs; rather almost all have vast, sparsely populated areas punctuated by small or mid-size communities. The largest city in the 10 counties with the highest mental distress rates is Muskogee, whose population is just shy of 40,000.
Not all rural areas are beset with high mental distress and drug and alcohol abuse. Moreover, urban parts of Oklahoma and Tulsa counties have nearly the highest crime rates, which can signal a social disarray that worsens psychological stress and depression.
But swaths of rural Oklahoma do face troubling levels of mental illness and drug abuse. And in most cases these two afflictions are accompanied by a third: high levels of poverty.
The data shows that all three are inextricably linked – the poorest counties generally have the highest rates of drug abuse and mental illness. And in nearly all of the poorest counties, most people live in areas designated by the Census Bureau as rural.
“Every bit of it comes back to economics,” said Robinson Tolbert, a licensed clinical social worker who has worked in rural mental health care and social services for more than 20 years. She was instrumental in starting the Stigler Health and Wellness Center’s mental health program. “The money does not get very far beyond Oklahoma and Tulsa counties. That’s where the money is, and that’s where the money stays.”
Mental-health providers come to rural areas to practice and often leave within a short time, creating instability in the system and sowing mistrust among residents, she said.
“The instability is so profound, that it’s almost impossible to provide mental health services in rural Oklahoma,” Tolbert said.
Most rural areas also harbor significant barriers to mental-health treatment, including a shortage of key mental-health professionals and a lack of transportation. Thus, people in rural areas are more likely to go untreated for depression, bipolar disorder, drug abuse and alcoholism, mental-health officials say.
Treatment resources in rural areas are often spread out, and it’s difficult to find workers to fill provider positions, said Jeff Dismukes, spokesman for the Oklahoma Department of Mental Health and Substance Abuse Services.
“Demand for decades has outpaced the resources we have available,” Dismukes said. “It’s very difficult to deliver services in these areas.”
Rural areas often lack robust public transit systems, making it difficult for people without a vehicle to access widely scattered treatment resources.
“It takes a long time to get anywhere from Eufaula,” said Joy Sloan, chief executive officer of Green Country Behavioral Health, which operates in Muskogee and McIntosh counties. “And if you don’t have transportation or good transportation, you could be sitting somewhere for a long time waiting for help.”
The hiring challenges for providers are evident at the Monarch halfway house in Muskogee County – a center that serves women from around the state with substance abuse problems.
“It’s very difficult, once we have an opening, to find counselors who want to come to these areas. You may have a position that stays open for six months,” said Lakisha Reed, clinical supervisor at Monarch. “That just drags down the rest of the staff, because now they’re carrying two caseloads. It doesn’t matter if you offer a bonus, it’s hard to get people to move here or commute.”
Attracting the most highly trained mental health professionals is challenging. Fewer than 20 percent of all psychiatrists in Oklahoma live outside large metropolitan areas, and only a single child psychiatrist lives outside a metro area, according to data from the Oklahoma State Department of Health. That means rural residents often turn to medical doctors, of which there is shortage, or telemedicine for mental-health treatment.
A lack of people with insurance poses another barrier to mental-health care in rural areas.
“It’s a huge issue – in rural Oklahoma, but all across Oklahoma as well,” Dismukes said.
Dr. Debbie Moran, executive director of the Carl Albert Community Mental Health Center in McAlester, said a large majority of clients at her center rely on Medicaid or state-funded indigent services. Only a small fraction use private insurance or pay out of pocket. During the oil and gas slump, even more people are relying on government-subsidized programs, she said.
“When the oilfield takes a cut, we get hit hard in southeast Oklahoma,” Moran said.
In some counties in eastern Oklahoma, more than 40 percent of the population is enrolled in Medicaid, state data shows.
Many mental health workers said declining reimbursement rates for mental health and substance abuse services have an outsized impact on providers’ ability to offer services in rural areas.
In Okmulgee, the CREOKS clinic gets some funding from the Department of Mental Health to pay for treatment of the uninsured, “but those are a limited amount of funds we typically exhaust every year,” said Kim Hamilton, the clinic’s site director. “We’re basically giving pro bono. Ethically, we’re not going to stop giving services to clients who desperately need it. So we just carry on until the next fiscal year.”
Residents in rural communities also face a higher degree of social stigma about mental illness and substance abuse.
The tight-knit nature of rural Oklahoma – often regarded as an asset – can also prove a disincentive to seeking mental-health treatment.
“I would say the biggest barrier to treatment in the rural areas is stigma,” said Traci Cook, who grew up in Tonkawa, a town of about 3,300. “As you know, when you grow up in a small town, everyone knows your name, knows everything about you.”
Many mental health workers say they have seen stigma associated with mental illness and addiction affect how and whether individuals seek help.
“I have experienced it,” said Don Loman, a licensed counselor in Hugo. “I had a man who drove a company truck. He said, ‘Everybody knows my truck,’ so he would park next door or down the street and then come over.”
Grand Lake Mental Health Center CEO Charles Danley said he was once providing mental health services to a local teacher and her daughter, but when they went to leave the office, she met one of her students.
“I’ll be damned. She’s coming out my door and he’s coming in. You could have hit her with a brick. He said, ‘Oh Mrs. So-and-so, I didn’t know you were coming here,’” Danley said. “I’m thinking, ‘Oh crap, it’ll be all over the school before the sun sets.’”
In the coming months, Oklahoma Watch will examine in depth the issues of substance abuse and mental health in rural parts of the state, and how individuals and providers are trying to overcome barriers to treatment.
What Is Rural?
Government agencies use a variety of methods to classify areas as urban or rural. A 2008 article in the U.S. Department of Agriculture’s Amber Waves identified three different concepts for how government agencies determine if a place is “rural:”
• Land use: Used by the Census Bureau, it identifies urban areas based on how densely settled the area is – the picture of settlement you get from an airplane. Among the agency’s measures are percentage of a county’s area that is rural, and percentage of a county’s population living in a rural area. The measures can belie public understanding of what is rural or a “small town.” For example, Kay County, which includes Ponca City, is defined as 98 percent rural in area but with 24 percent of residents living in rural areas. With just under 25,000 residents, Ponca City is relatively small.
• Administrative: Used by many USDA rural development programs, this concept defines urban along municipal or other jurisdictional boundaries.
• Economic: Used in most rural research applications, it recognizes the influence of cities on labor, trade, and media markets that extend well beyond densely settled cores to include broader “commuting areas.”
Oklahoma Watch is a nonprofit, nonpartisan media organization that produces in-depth and investigative content on public-policy issues facing the state. For more Oklahoma Watch content, go to oklahomawatch.org.