Rural students experience rocky adjustments from hometown mental health stigma

It’s just not talked about, they said. Not in Caledonia, Minnesota, and not 54 miles away in Red Wing, Minnesota. It’s hard to talk about mental health, mental illness, counseling, therapy, anxiety, depression, grief and eating disorders, especially when no resources are at hand.

Neuroscience major Austin Werner said people in Caledonia, population 2,750, didn’t talk to each other about mental health. There also wasn’t a professional to talk to in town.

“I didn’t hear a lot about mental health until I got to college where you can access help,” Werner said. “And at home, it was just like, ‘are you feeling okay?’ Like, that’s all you got.”

But now that Werner has access to help on campus, and reasons to use it, he’s not going to.

Cheyanne Thurston, a junior studying strategic communication from Red Wing, said it was as if depression and anxiety didn’t exist. People didn’t acknowledge it, much less her eating disorder.

She knew she needed help, but the therapists in Red Wing couldn’t do anything for her, so she had to drive an hour to the Twin Cities to find treatment. Thurston said she had seen the stigma others faced when they sought help, and then she too experienced the staring and hushed tones.

“It’s taboo completely,” Thurston said.

Despite the differences in their life experiences, Thurston and Werner have both witnessed the stigma surrounding mental health and the void of mental health resources characteristic of Greater Minnesota.

Studies and experts agree that those in rural areas are less likely to seek help for mental health issues than their urban counterparts. The stigma, attitudes and beliefs surrounding mental illness and seeking treatment play a large role in that help-seeking disparity, as does the lack of mental health resources in rural areas.

Social supports can help rural students through some of the problems they face at home. But when students face a new imposing environment at the University of Minnesota – Twin Cities, the distance from their communities can trigger feelings of isolation that challenge their mental health. While the university offers counseling, therapy and other support, rural students are less likely than urban students to use those services.

Lynn Edwards, a primary school psychologist and postdoctoral researcher at the university, notes that being rural itself—with the stigmatized attitudes, insufficient resources and additional stress-inducing social determinants—can itself be a risk factor for mental health problems.

“I think there are more individuals who will reach out for services in urban areas, but you still have quite a bit of that stigma involved, regardless of who you might be serving,” Edwards said. “But for rural individuals, it’s a big part of it.”

Edwards herself grew up Cannon Falls, which she said was entrenched in stigma toward even just finding services for mental health problems.

“My family, for example, because of the religious beliefs that they held, they didn’t think that it was something you should pursue, because it was outside of what God wanted,” Edwards said. “They would say things like ‘Oh you know, psychology is the devil.’”

Facing the stigma

Thurston went to therapy at age 14 for an eating disorder. She had heard what people said about the other girls who went away for treatment. There would be whispers and pointed fingers.

“I was just to the point where I really didn’t have a choice,” Thurston said. “It didn’t really bother me that I was looked at that way, because I was just trying to live.”

When she came back from treatment, she ended up losing friends. They just didn’t understand, and they didn’t want to. But because of her experiences, her remaining friends would go to her for help.

“I remember one of my friends—I literally had to go talk to her dad and ask if she could go to therapy,” Thurston said. “She was that scared.”

That’s how intensely stigmatized mental health can be in rural settings, she said.

“I’m glad that I was available for them to help. But I hate that it got to that point for some of them. That it was so stigmatized that it took that for them to seek help,” she said.

Even within Thurston’s family, the stigma was present. At the beginning, her dad swept her problems under the rug, but she said his understanding of her needs and their relationship has significantly improved throughout her treatment. Yet her middle brother won’t say a word about her eating disorder, she said.

“That’s just how we grew up,” Thurston said. “You don’t talk about that stuff.”

And that’s how it was in Werner’s hometown too.

“I think my community took it seriously,” he said, “but it was just never talked about. It was kept within the family. I would say I’m really different, I’m open, I talk about it.”

Werner is in the St. Paul campus’ Alpha Gamma Rho fraternity, where one of the members died last fall. He and his friends have been struggling to cope with the death, but that as far as he knows, no one has gone to therapy.

Recently, one of Werner’s family members started seeing a therapist, but his family never talks about that either.

“We don’t want him to get embarrassed that he’s going, or like, embarrassed that he’s seeking help, because we think it’s a good thing. So, unless he brings it up, then we just kind of let him do his thing,” he said.

Lack of resources and experience

Exacerbating the problem is the scarcity of mental health resources in rural areas, including much of Greater Minnesota. The most support some people can find is a pastor or guidance counselor. Other towns might have therapists, but the chances of a good fit are slim.

In Red Wing, there are mental health counselors, but the choices are limited. The problem, Thurston said, is that therapists likely know patients or their relatives, which can make treatment uncomfortable or prevent someone from seeking help altogether.

When Thurston first sought treatment in Red Wing, she said she picked her therapist because she was a woman and she didn’t know her.

But, Red Wing didn’t have an eating disorders specialist. Other forms of therapy offered there didn’t help, she said. She didn’t find her fit until she drove an hour to the Twin Cities for the Emily Program.

Many towns do not have any counselors at all. Werner said that in Caledonia the only sources for help were the church and a school guidance counselor. He opted to talk to his football coach.

Even now that he lives in the Twin Cities and has professional counseling options, he said he’s reluctant to access those resources. Instead, he talks to his friends.

Edwards, the school psychologist who grew up in Cannon Falls, said seeking treatment from non-professionals can backfire.

“Yes, please reach out for help, but at the same time, please do not reach out to someone who isn’t trained,” she said.

In her case, her parents’ decision to take her to a conservative pastor didn’t resolve the struggles she was having with her sexual identity.

“For me being queer and not knowing how to deal with that—that was a huge issue that was something they tried to pray out of me,” she said.

Now as a licensed school psychologist, she said she realizes how devastating this experience was for her. While some pastors can be helpful, she said pastors who are unlicensed and untrained in counseling can do more damage than good.

Yet, she acknowledged, many people in rural areas don’t have very many choices for mental health support systems.

“Even if you do want to reach out for support, then what are your options?” Edwards said. “In rural areas what do the health insurance options look like? Help probably isn’t covered, so you’re ending up trying to figure out and find a therapist who’s lower cost, which could mean you’re not finding a therapist who’s the best fit.”

Benefits of support, consequences of isolation

When rural students come to a large campus such as the University of Minnesota – Twin Cities, the transition itself can exacerbate mental health challenges as they confront isolation on campus, said Allison Bitz, a therapist in Lincoln, Nebraska, who has done research on rural students’ experiences.

“It’s the first time in their life they’re not surrounded by people who love them,” Bitz said.

As a former rural student herself, Bitz said it can be jarring to be surrounded by strangers after knowing everyone in one’s hometown. She said she wishes she could teach rural students how to make friends, as a way of preventing isolation.

Isolation is connected with an “increased risk of depression, anxiety and substance abuse, as well as worsening cognitive health,” according to a study by the University of Minnesota Rural Health Research Center. Isolation can also make it more difficult to be motivated to find help, according to the study.

Both Thurston and Werner say they felt isolated and uncomfortable when they first came to campus. Thurston said she had a difficult time making friends at first. Campus was big. She wasn’t living in the dorms. She wasn’t an athlete, and she didn’t join a sorority.

“I didn’t know how to meet people,” she said. “So that’s challenging, especially just the anxiety in general.”

Werner was uncertain how to connect with others amid city life after coming from a rural community.

“You kind of still just sit in the shadows and are just observing again,” Werner said. “And then you kind of miss that time to jump on and join a group of friends.”

Both ended up finding their communities in organizations on campus.

Social support has been found to be important for rural students’ well being.

In a survey conducted this semester, AccessU: Beyond the Cities found that isolation was the main reason rural students wanted to transfer out of the university, and making friends was their main reason for staying.

“Rural areas have bigger social networks. They have more friends and more family in their social networks,” said Carrie Henning-Smith, the deputy director of the University of Minnesota’s Rural Health Research Center. “And we know anecdotally that rural communities tend to have really strong and welcoming connected networks—so that could be a positive social determinant of health for rural students.”

But Henning-Smith said rural communities also face social realities that can adversely affect mental health before those students come to the university.

“We know that rural communities have fewer economic resources, they tend to have higher poverty rates, lower income, fewer available jobs,” she said.

Such realities can make adjusting to an urban community even more difficult, she said.

“For many students, being far from home, I think, can impact health and well-being, and trying [to find] your own community in a community that looks and feels really different from one that you’re used to,” Henning-Smith said.

Getting help

The stigma about mental health care learned early on, combined with the demands of a new urban environment, keeps rural students from accessing help even when they have those resources at hand, said Sarah Gollust, a professor in the university’s School of Public Health.

And research has shown that having stigmatizing beliefs—either about the experience of mental illness or about treatment—is a big predictor of not seeking care.

“If you’re coming to this campus for the first time – and yes, we have mental health services available at Boynton – but if you’ve never known anyone to use them, it’s going to be harder, I think, to take that step toward accessing needed mental health care,” Gollust said. “Attitudes and beliefs are such an important contributor to whether someone seeks care or not.”

Vesna Hampel-Kozar, the director of the university’s Student Counseling Services, agreed rural students may be more ambivalent than urban students about seeking services—in part because they don’t feel comfortable in that counseling environment.

“That’s a place where students might feel invalidated, or their problems are minimized or maybe they’re worried that someone won’t understand or won’t get their life experience,” Hampel-Kozar said.

Werner now has access to counseling at the university. He also knows he has a lot to deal with between the death of his fraternity brother and a heart attack that left his father blind when Werner was in eighth grade. But he said he doesn’t think therapy is for him.

Instead, he said, he has based his career plans on helping his father: He plans to go into neuroscience research to study the optic nerve, which was damaged by the heart attack.

“I’ve just been trying to balance everything, and I just try to help other people rather than helping myself,” he said. “It’s kind of how I deal with things.”

If things worsened, Werner said, he might go see a therapist.

“Somebody would probably have to tell me, ‘You should go see help,’ and I’d probably get angry, but then I might actually realize I need it,” he said.

Thurston, meanwhile, said she’s glad about her decision to persevere to get mental health help despite the stigma. In high school, she said, she didn’t care that people ostracized her for getting treatment; she just wanted to get better. But others do care what people think, she said.

Just as in Red Wing, her experiences getting therapy at Boynton were not great, she said. Wait times were long. Billing was confusing. Just getting started with appointments was difficult. But although research shows that negative experiences in counseling reduces the likelihood that a person will seek out therapy in the future, Thurston has persisted. She has continued to find help with private therapy.

“I fought for help because I wanted to get better,” she said. “But I know a lot of people who just are seeking general help or general therapy or don’t even really know what’s going on, like they’re not going to fight for help.”