S5E2: How can we address mental health needs in rural Maine?

Many people nationwide are experiencing a decline in their mental health. Rates of anxiety, depression, and substance abuse are rising, more so in rural areas. Ten out of 16 Maine counties have a shortage of mental health professionals. Only about half of the state population receives the services they need. 

At UMaine, a major effort is underway to recruit more mental health care providers to serve in rural areas. Using federal funding, researchers from the Psychology Department and School of Social Work are working with other experts to increase the number of psychologists, social workers and substance abuse professionals in areas with the greatest need. We speak with those researchers about their plans on this episode of “The Maine Question” 


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Dr. Jeff Hecker:  There’ll continue to be challenges 5 and 10 years from now. People will feel anxiety. Depression will be a reality. It always has been as a recorded history of humankind. In the state of Maine, the people will know they can get help. There’s opportunities there to address these problems.

Dr. Sandy Butler:  I do think that the stigma around mental health will continue to decrease, and that’s important in terms of people getting the help they need and also for there to be funding for the services.

Ron Lisnet:  That’s Jeff Hecker, Professor of Psychology at the University of Maine, and Sandy Butler, a professor of social work talking about the state of mental health in Maine, particularly in the state’s rural areas. I’m Ron Lisnet, and this is “The Maine Question” podcast.

It will likely not be a shock to anyone that anxiety and depression are increasing for a lot of folks these days. Economic upheaval, political unrest, not to mention the pandemic, can be blamed for much of that rise.

Some estimates put the rate of depression at around 30 million in the US. The numbers for anxiety disorders are even higher, affecting some 40 million people or more. These issues are often more common in rural areas. Isolation, lack of opportunity, and the lack of people who can help are some key contributing factors.

Much of Maine is rural in nature. For many, these issues hit pretty close to home. One in four children in Maine suffer from a mental health disorder during their childhood years compared to one in six nationally. Maine’s suicide rate and percentage of adults with mental health issues is also higher than the national average.

10 of Maine’s 16 counties have insufficient mental health coverage, and about half the population in those areas are not getting the help they need. Now, an effort is underway to help address the shortage of mental health professionals in Maine’s rural areas.

The Psychology program at UMaine along with the School of Social Work have received funding, and they are putting together a team that will train folks who can help with these issues. Students in the program will become clinical psychologists, social workers, mental health and substance abuse professionals.

We spoke about these efforts with Jeff Hecker and Emily Haigh from UMaine’s Psychology program and Sandy Butler from the School of Social Work. It’s great to to visit with you on what is certainly an important topic.

Maybe let’s go around the table, so to speak, and have you introduce yourselves and maybe give us a sentence or two why you’re involved in this project. What motivates you to be interested in what you’re studying here? Maybe, Emily, let’s start with you.

Dr. Emily Haigh:  Thanks. My name is Emily Haigh, and I’m an associate professor in the Department of Psychology. Currently, I’m serving as the Director of Clinical Training for our doctoral program in clinical psychology.

In that role, that’s probably the main reason why I’m interested in this topic, looking at ways that we can maximize the training we provide at the doctoral level so that it truly meets the needs of the state.

Ron:  Sandy, how about you?

Dr. Butler:  Hi. I’m Sandy Butler. I’m a professor at the School of Social Work, and I’m the Director and the MSW Coordinator as well. Very similar to Emily, I’m concerned about our students getting the best preparation possible. Almost all of our students stay in the state of Maine. Most of them work in rural areas.

Having them be able to meet the extreme needs of our rural populations is the motivation for me.

Ron:  Last but not least, Jeff, how about you?

Dr. Hecker:  Thanks, Ron. My name is Jeff Hecker. I’m Professor of Psychology. That’s a great question. I’ve been at the University of Maine for 35 years. Over that time, I’ve held a variety of positions, and through those positions, I’ve developed a great love for the state and also somewhat of an appreciation of the challenges that the state faces.

For me, personally, I’m shifting back into a faculty role, I’m looking for something that I can sink my teeth into and that I cared about. The opportunity to collaborate with the School of Social Work and working with the Clinical Psychology program arose and is targeted exactly at what is important, which is helping Maine to be a great place to live.

Ron:  You all certainly bit off a big chunk in terms of an issue and a project to take on. Maybe let’s start here. The big picture overview of the state of physical and mental health and well‑being in rural Maine these days, where is it? How is it trending up? What direction are we headed in?

Dr. Hecker:  I’ll take a stab at that. I’ve said I love the state of Maine. It’s a wonderful place, and yet it faces a variety of challenges. There are common health problems that are common around the United States, but the rates of those problems are even higher in the state of Maine.

Maine has higher suicide rates, for example, than the national average and higher substance abuse rates than the national average. If you look then within this state, if you look at the rural counties, you see that their problems and the challenges are even worse.

Rural Maine has a higher median age. I’m sure everyone here knows that Maine itself has the highest median age in the country.

The rural areas have the higher age. They have higher rates of common health problems like obesity, opioid abuse, diabetes and the higher rates from common conditions like heart disease and cancer.

What’s particularly challenging, you talk about the status of these problems. They’re exacerbated by the relative shortage of health care providers. If you look in the rural areas of the state and you look per capita, there are fewer physicians, nurse practicioners, physician assistants than in the more metropolitan parts of the state.

Of course, our interests, there are fewer clinical social workers and clinical psychologists per capita in the rural parts of the state. The health and mental health challenges are exacerbated by a relative dearth of providers. Looking forward, there’s not an easy solution for that.

Unfortunately or fortunately, we’re all aging, including the clinical social workers and psychologists. The state has looked and said there’s a need for an influx of people with the right kind of training to help address the kinds of problems the state is facing.

Ron:  What kinds of things are mental health workers, social workers, psychologists doing to address these needs? What does the field look like today versus what we might think of as an older stereotype? Sandy, let’s start with you.

Dr. Butler:  A hallmark of the social work profession has been and continues to be helping marginalized, vulnerable populations and working to change systems to better meet their needs. Throughout the country, clinical social workers provide about 60 percent of the mental health services people receive.

Social workers are crucial in helping meet the gap that Jeff was just talking about here in rural Maine. Another essential aspect of social work is seeing the individual within their environment. What obstacles do they face in meeting their potential?

In addition to individual change, we address large system change. Sometimes that means policy change, working on community initiatives. Things like increasing broadband or transportation, very important in rural areas, or the minimum wage.

Our social work students actually work with advocacy organizations in our statewide professional organization to work on such bills in the state legislature. Some of the current trends in social work include a more focused attention to trauma and providing trauma‑informed care.

Another trend is incorporating technology such as telehealth, which we’ll be doing in this project. A third trend in the field is recognizing and amplifying the importance of social workers in the health field, so integrated behavior health fits here. This is helping individuals cope with the difficult diagnoses or being an advocate for a client in the health care system.

A persistent stereotype of social workers is that they’re the ones that take your children away, who work for Child Protective Services. There are some really hard working and committed social workers in the Department of Health and Human Services working to make the best decision possible for children facing neglect and abuse.

But most CPS workers are not even trained social workers and many people who call themselves social workers do not have social work degrees. I just wanted to clarify that.

Ron:  Emily, from a psychologist point of view, what kinds of things are being done to help this situation?

Dr. Haigh:  Psychology as a field is trying to address this need in a couple different ways. We recognized the need to scale and become more efficient with our services and able just to meet the greater demand. Like Sandy said, telehealth has become a major modality for providing services.

With the pandemic and our clinic on campus, we certainly became proficient in providing those services and really found that they were quite helpful in reaching folks that otherwise might not have come to our clinic on campus. We’ve been able to retain them because some of the barriers of getting to treatment are eliminated with telehealth.

Similarly, to social work with this notion of integrated behavioral health, what we’re trying to do is embed ourselves in a team setting. Perhaps if you imagine a primary care setting where there are different health providers, doctors, PAs, social workers, psychologists.

We’re embedding ourselves there so that we are able to receive warm hand offs say from a physician and really provide an immediate intervention that will have an impact and reduce all the hoops and barriers that may get in the way of getting immediate attention to some mental health issues.

Another way that I think psychology and in particular our training program at the University of Maine is trying to address some of these needs is to look at partnering with the state and trying to leverage their needs by providing well‑trained doctoral students to provide clinical services in exchange for funding for assistantships.

We’ve also been working pretty diligently to expand our training program. We’ve been a relatively small training program with a few number of faculty. We’ve been working with the university with partnerships at the state level.

Pursuing federal grants, working with private donors to try to really increase the number of students that we can get in the program, get in the pipeline, and remain in Maine to meet the needs.

Ron:  If you look on the UMaine news website and you look under this topic, there’s a lot of initiatives and a lot of work going on in this area. It’s hard to keep it all straight. Maybe you can break down the various proposals and projects.

How do they differ? How do they work together? Always in academia we love our acronyms. There’s one here, RIBPHC. Maybe let’s start there. Sandy, that’s you. What does that stand for and just a thumbnail of what some of these projects are about?

Dr. Butler:  We’ve been trying to figure out how to pronounce this acronym and we’re calling it RIBPHC, I think. It’s the Rural Integrative Behavioral Health and Primary Care Project. It’s funded through the Health Resources Agency through the federal Department of Health and Human Services in response to their behavioral health work force education and training program.

It’s focused on training students in behavioral health to meet work force needs. The bulk of the money goes to student’s support. It’s a four year program and each year it will support 20 graduate students in social work and two clinical psychology doctoral students.

This happens in their final year of their academic programs and they’ll be in field placement supervised by experienced practicioners. Focused on integrative behavioral health with the aim to increase the number of sites associated with primary care, as Emily mentioned and with interdisciplinary teams as the project progresses.

Some of our sites currently are at Katy Hospital, Penobscot Community Health Center, Aroostook Mental Health Center, Wabanaki Health and Wellness, the Behavioral Health Center, Job Corps of Bangor, and Mount Desert Island Hospital.

To ground the students in their learning in the field, they’ll participate in a seminar that’s taught by Jeff and a project coordinator that we’re hiring right now. That will meet biweekly and there will also be continuing education series that’s open to the students and practitioners and their supervisors.

Ultimately, students will receive a certificate in rural integrative behavioral health from participating in all parts of the program. They will then on graduation work in medically under‑served areas.

Ron:  Jeff, I know you’re involved in several of these projects. Maybe you could talk about what your end of this looks like.

Dr. Hecker:  As Sandy mentioned, I’ll be playing a role in the RIBPHC project, co‑teaching a class on integrative behavioral health and working with our colleagues in the school’s social work to expand the number of placements for our students.

I’ll also have a role in this continuing education series that Sandy eluded to. Our goal was to get the partners together to form a working group that says, what are the needs for practitioners in the community? We as the research university use our national connections to bring the highest quality continuing ed here.

I’m also engaged in some research that’s in its early stages, but again somewhat opportunistically there’s some really interesting things going on in treating people who are really on the spectrum of mental health disorder at the severe end. People with schizophrenia, schizophrenia spectrum disorders. Those folks have very significant challenges and they pose challenges to their communities and their families.

There have been some interesting research in the last couple of decades showing that if you can get these people connected to multifaceted treatment very early. If you can see the signs early and intervene early, intervene pharmacologically, intervene with their families, provide education, help them with support in school and jobs, they do very well. They do very well in the long run.

I was excited about that research. There’s some very interesting work going on in the Portland area. They have something called the PIER program, the Portland Identification and Early Referral program. That was really a national leader in this.

I’m intrigued by the idea of trying to replicate or I shouldn’t say replicate because we know it won’t work. What works in Portland won’t work in rural Maine. But to take what we can from that project and apply it in rural areas.

We formed partnerships with the Katy Hospital. They’re very interested in this work in trying to develop early intervention programs. Also with my colleague at the University of Maine Machias, Dr. Lois‑Ann Kuntz, who’s been a great partner in this. She’s very well connected in Washington County.

Then we’ve also connected with the folks of Maine Medical Center Research Institute on the research side. What we’re looking at is trying to see the current status of people who are in rural Maine and we’re focusing right now on Washington County. We refer to it as pathways to care that they take. Some arrive through their primary care doctor,.

Some arrive through law enforcement. Some arrive through the school system. Trying to understand those pathways to then design ways to intervene to identify these folks earlier and getting them connected with treatment.

I think it compliments the RIBPHC program in that we’re engaged in some of this research. We’ll be working with some of our same partners who are engaged in the training on examining the challenge from a research perspective.

Ron:  Emily, I know there’s some funding and some gifts that came in to help with this effort. Maybe you could speak to that and a thumbnail of how that’s helping the cause.

Dr. Haigh:  Sure, yeah. For the past several years we’ve been really fortunate to be working with the Albert B Glickman Foundation. This foundation has a really long‑standing commitment to addressing mental health issues in Maine.

More recently, they’ve been interested in increasing high quality access to mental health care in Maine. Last year about this time, with the support of the Glickman Foundation and the university, the clinical program launched the Glickman Fellowship in clinical psychology.

The fellowship is designed to specifically meet this increased demand for psychologists. What we did with this fellowship is we’ve tried to figure out, how can we get more psychologists in Maine? We looked at the literature and it really said that the number one way to do so is to recruit students with a rural background from the area that you want them to remain in.

The Glickman Foundation was designed to do just that. Last year we welcomed Lindsay Lagerstrom. She’s a Presque Isle native. She is enrolled in our doctoral training program and she’s trained to become a clinical neuropsychologist. Upon graduation, her intent is to return to the county and to practice and to fill a gap. I believe, currently, there are maybe, possibly zero neuropsychologist in that area.

More recently, we have worked with the Glickman Family Foundation on another project, and they made a very generous donation to our program. The aim of that donation is to provide us with the resources to increase our training capacity to meet these workforce shortages.

With this support and with the University’s commitment to sustain this gift, we will be recruiting two new tenure‑track faculty members, two additional doctoral students, and a professional staff position to help coordinate experiential training experiences across the state at both the graduate and the undergraduate level. This fall, we will begin our search.

We’re going to be looking for a tenure‑track faculty member with expertise in dissemination and implementation science. What that means is that that faculty member will have expertise working with communities throughout the state to try to implement and maintain mental healthcare delivery programs.

For the second tenure‑track hire, we’re looking to recruit a faculty member with experience in substance use and/or trauma. We’re so excited. We think these hires will have a transformational impact on our graduate and undergraduate training as well as on the local communities.

Ron:  If you look around today, there’s certainly no shortage of things to make people anxious and tax their mental health, no matter where they live. That’s the state of the world we live in right now. How do the issues and problems for rural residents differ from other demographics?

You mentioned access to services and care. That’s certainly a big factor. Isolation and a number of other factors, I’m sure, work into this. How does their situation different from the state of mental health overall or from other demographics?

Dr. Hecker:  You’ve hit on some of the key things, Ron. The first is the relative isolation. These communities ‑‑ I’m sure you’ve seen the the news recently ‑‑ are shrinking. Look at the 2020 census versus 2010. The rural parts of the state are shrinking in size and particularly shrinking in young people. The consequences of that play out.

I’ve been interested in youth sports and noticed that there may be no football at the high school level in Washington County because there aren’t enough young people to form teams.

Obviously, that isn’t a national crisis, but it’s a little picture of what happens. There’s an opportunity for youth to get together and form a sense of team and form friendships and be collegial, and that’s gone. That isolation is a significant factor.

Then the ones you that you referred to, when people are experiencing problems, can they get help? Can they interact with people who can identify that, yes, they need help and get them connected.

We’re talking in one of our projects in collaboration with the University of Maine Machias, we’ve gone out and interviewed people in the health care industry, but also schools, social services, and law enforcement. Just to have conversations with them about what are their experiences when they run into a youth who they suspect is having difficulties.

The number one thing we heard is that it’s not that they can’t see these kids, it’s that they don’t know where to turn. The resources that they turn to, working hard, trying very hard, but often have very long waiting lists and can’t provide immediate care.

The newer ways that people connect through online, etc., in rural areas even those are challenges. It’s one of the things we’re looking at in the RIBPHC program is, how do we reach rural areas? Assuming that everyone has WiFi and connect is probably not a fair assumption. How else can we connect with folks to provide good care?

Ron:  Sandy, I know in social work there is work being done on opioid use and abuse and aging. Some people might wonder, how does that work with workforce development? Is workforce development part of what’s going on here?

Dr. Butler:  Yes, exactly, Ron. Thank you. Both of those projects are funded by HRSA the way RIBPHC is. They both are focused on workforce development. They’re areas, as you say, we have great needs in Maine and across the country to increase workforce and health.

The first one I’ll talk about is we call it POWR. Of course, we have an acronym. It’s Professional Opioid Workforce Response. It’s structured very similarly to the RIBPHC program. It’s just three years and we’re in our final year now.

Each year, 10 MSW students have participated as trainees. It also has a bi‑weekly seminar. Dr. Elizabeth Armstrong, an assistant professor in our program, is the director of this, and she teaches that seminar. She’s arranged colloquium. Last year, we had a couple of great colloquium.

One was a partnership with Wabanaki Public Health and the Penobscot Nation and MCMap Health that looked at Indigenous wellness and healing and substance use disorder treatment. Then the second was focused on trauma‑informed services for those experiencing substance misuse concerns.

The training sites for POWR had some overlap with the training sites that we’re using in RIBHPC and also some others, they have a training site at Pleasant Point Health Center and the Indian Health Service Center Services at Penobscot Nation and a few others.

Then the other project, also funded by HRSA, is the geriatric workforce enhancement program. This comes out of the University of New England. The Center on Aging, and the School of Social Work, and a few other units on campus are participating. It is to increase geriatric healthcare workers.

The other units on campus are social work and psychology, nursing and nutrition, all graduate programs. They have periodic interdisciplinary field visits together, which is a great learning opportunity. There are also lunch & learn events with speakers.

This year, the social work students are working with the volunteer program for older adults, RSVP, to create a telehealth simulation. It’s very exciting, and they’re usually three to five social work students in it each year. It’s in its third of five years now.

Ron:  For both psychology and social work, how set up are you now to meet the needs and take on these problems, and how much of a difference will these new efforts make to fill those gaps? Maybe Emily, to start with you.

Dr. Haigh:  It’s a really exciting time. We’re seeing a real renewed energy and commitment to mental health. A real sense of genuine collaboration, not only across the system, as Jeff mentioned, with UMaine Machias, but within our own university working with all these different disciplines with social work and nutrition.

We’ve certainly have relationships with the state. We’ve been working with the Office of Behavioral Health, the State Forensic Service. Then, similar to social work, we have placements at various hospitals and community mental health centers. What we’re starting to see is some momentum of us all working together on this common cause.

It’s building. We’re leveraging that, and we’re getting more opportunities, as evidenced by the recent donations that we’ve received by the Whitman Family Foundation. We’re in a great position to take advantage of some of these new opportunities with the HRSA grant and the donations.

I set up a solid training program both at the undergraduate and graduate level that will not only create this new pipeline, but expand mental health awareness more broadly.

I’m thinking of the undergraduate. One of the new initiatives we’re excited that we’ll be able to do is with these new tenure‑track hires is we’re looking forward to creating new experiential learning experiences, both research experiences and hands‑on applied to more field experiences.

We are also supplementing this with a new professional pathways in psychology course which is aimed at freshmen where we want to introduce them to the different pathways there are to be able to impact mental health and the various career trajectories, whether it be psychology or any other related discipline.

Through these courses, these research experience, these experiential applied experiences, that students will be able to develop a real clear sense of a way forward and a clear pathway for success in a way to get them excited about pursuing careers in mental health. Ultimately, create a healthier Maine for all of us.

Ron:  Finally, maybe we can hear from all three of you. Just look out. Take your crystal ball out. Look out 5 or 10 years. Certainly, with pick your issue, or we’re in the middle of a pandemic, we got political unrest, there’s plastic in the ocean, pick your issue. There’s no shortage of the need for what you folks are working on.

As you look out 5 or 10 years from now in rural Maine or just in the state overall, what do you hope to see? What difference will be made? Do you think as a result of all the work you guys are doing? Whoever wants to take a crack first.

Dr. Hecker:  I’ll take a crack first. That’s a great question. My tendency is always to be uber‑optimistic and say that we will cure the state of mental illness and thrive on. The reality is, and you talked about the challenges and stressors that we’re facing now, we’ll continue to face them, or new ones, or variations.

My vision is that people in the state of Maine, it’ll be easier for them to recognize their experience, and they will be able to get help. That’s going to take a multifaceted approach. Some of it is, the role we’re trying to play by providing more providers, but like any other big problem, it’s going to take partnerships with the state.

How do we fund these operations? How are they organized? How do we create more opportunities for people, both to work in these areas and to get services in these areas? My image is that, yes, there will continue to be challenges 5 and 10 years from now.

People will feel anxiety and depression. The depression will be a reality as it always has been in recorded history of humankind. In the state of Maine, the people will know they can get help. There’s opportunities there to address these problems.

Ron:  Sandy, How about you? What do you hope to see? What do you think we’ll see?

Dr. Butler:  I want to build a little bit on something Jeff said. I do think that the stigma around mental health will continue to decrease, and that’s really important in terms of people getting the help they need and also for there to be funding for the services. I also have great hope for the younger generation in terms of their views on marginalized groups.

Their openness around gender issues, sexuality issues. Their anger about racism. All of those things will help us to provide more equitable care. I hope, anyway. Also, we continue to have great interest in people applying for social work programs. I know that there are people out there that are very empathetic and very much want to help. I think that will continue.

Ron:  Emily, we will give you the final word.

Dr. Haigh:  I guess I’ll bring it back maybe to my vision on more of the training level or what I see is our system response to mental health. I’d like to envision that in 5 to 10 years. Some of these emerging collaborations and efforts become stronger, and they coalesce and become consolidated.

Perhaps so that we become a major clearinghouse for the state and serve as a center for clinical excellence and a center for health and well‑being.

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Dr. Haigh:  I’d be really excited. There’s a lot of overlapping interests and energy. If we could leverage that, it would yield dividends moving forward.

Ron:  So much great work going on. We thank you all for sharing your thoughts with us.

Dr. Hecker:  Thank you, Ron.

Dr. Haigh:  Thank you, Ron.

Dr. Butler:  Thanks, Ron.

Ron:  Thanks for joining us. We look forward to any questions or comments you may have about the show. Hit us up at mainequestion@maine.edu. We can be found in a lot of places, and the list of outlets for our podcast is growing.

Apple and Google Podcasts, Spotify, Stitcher, and SoundCloud, and now we’re on UMaine’s Facebook and YouTube pages. This is Ron Lisnet. We’ll catch you on one of those channels next time on, The Maine Question.