“You Can't Do Anything by Yourself”: Recruiting and Retaining Mental Health Professionals in Rural America

by Allee Mead

It's no secret that rural America has a shortage of mental health professionals. A national recruitment organization, state behavioral health organizations, and a mental health center CEO discuss the challenges in recruiting and retaining mental health professionals and share solutions such as improving workplace culture, partnering with community organizations, and recruiting locally.

Challenges to Recruitment and Retention

Some challenges for recruiting mental health professionals start as early as the education process. Most training programs for mental health professionals are in urban areas, so "even when rural individuals want to be trained and want to work in rural areas, they very often have to go away to get that training, especially at the doctoral level," Catherine Jones-Hazledine, PhD, said. Unfortunately, students might not come back to rural areas if they establish roots in the urban communities.

Jones-Hazledine is a clinical psychologist, owner of Western Nebraska Behavioral Health clinics, and co-director of BHECN Panhandle. BHECN (Behavioral Health Education Center of Nebraska) works to develop behavioral health workforce in the state and has six regional sites.

Along with isolation and fewer resources, Jones-Hazledine said another barrier for rural mental health professionals is the "difficulty for people starting in the workforce to be able to link with a business or an agency that can help support them in their career, which is more common in our urban settings…While people are working to get credentialed or they're working to get their license finalized, if they don't have that agency support, they're not getting paid during that time."

"Oftentimes private practice is the only option in rural areas," Tara Wilson said. Wilson, a professor and BHECN Panhandle co-director, added that new graduates might not want to build a private practice "from the ground up" and might feel more comfortable working for an organization in an urban community.

Additional challenges in recruiting and retaining mental health professionals include lower salaries, fewer resources, higher workload, and burnout.

"Rural healthcare systems, whether it's a safety-net facility or a Critical Access Hospital, might lack some of the necessary resources, such as funding for training or professional development, or administrative support," Mandi Gingras said. "If you have a lack of team support or limited access to other specialists that you can refer patients to, that can increase stress and lead to higher rates of burnout, which can have a negative impact on retention."

Gingras is the Director of Education for 3RNET (National Rural Recruitment and Retention Network) and leads the recent HRSA-funded initiative to collect national and state-level behavioral health resources supporting recruitment and retention. She discussed the challenges related to geographic and professional isolation: "A lot of times in rural areas, behavioral health professionals might feel isolated from other colleagues or maybe even from professional development opportunities or networking resources that are going to be more readily available in urban settings."

Helping Students

Jessica Seel is the 3RNET Board President and South Carolina Network Coordinator as well as the Director of Behavioral Health Initiatives & Workforce Development at the South Carolina Office of Rural Health. She is part of a state project mapping out mental health professions and education requirements so that people interested in these careers better understand what paths they can take.

The project will answer questions like: "What is the array of behavioral health professions in South Carolina? … What's the scope for those different professions? Where can you work? What are the education requirements or continuing education requirements? And what is the pay scale? Where can I enter with the education that I already have? … How do I move up? Where can I go to school? How long will I need to be in school, if at all?" Seel said.

Seel said the team got the idea from a California program during a 3RNET effort to find and share best practices across the country. She added that this visual representation will be easily accessible and useful for high school and college students as well as adults looking to change careers.

Seel shared her own educational experience: "When I went to school to get a degree in social work, I didn't know what kind of degree I needed. I started in psychology and was told that's not right. When I went to take it to the next level with my master's degree, I was discouraged from going into the social work program."

Seel's team is also looking at creating workforce simulations for cases where students may not be able to job shadow due to patient confidentiality concerns.

For healthcare facilities, Gingras from 3RNET recommended connecting with local or regional Area Health Education Centers (AHECs) or HOSA (Future Health Professionals) programs as well as colleges, universities, and other organizations to create more opportunities for students to complete internships or rotations at rural facilities.

These opportunities can be beneficial not only for the students but also for the professionals mentoring them. Wilson recalled a rural clinician in solo private practice who had taken on an intern. Now they work alongside each other. The clinician was able to reduce their workload and the intern was able to complete training in a rural area.

Jones-Hazledine from Nebraska recommended providing funding to students during their training, such as practicums or internships, to encourage them to stay in rural areas. She remembered one student who, thanks to a BHECN graduate training stipend program, was able to leave a paid internship in South Dakota and return to Nebraska to complete training and find a job.

Recruiting New Employees

Healthcare facilities may benefit from examining current hiring practices to see what can be improved. Gingras from 3RNET evaluated the recruitment and retention practices of three drug and alcohol commissions in South Carolina: "How they're currently recruiting and retaining, what their website looks like, what their process is, what their application process is, pay scales," Seel said. This Virtual Recruitment for Retention Readiness Assessment helps participants identify facility and community strengths as well as areas for improvement.

For any healthcare facilities looking to hire, Gingras recommended offering "incentives providing loan forgiveness or loan repayment programs, having strong sign-on bonuses, offering relocation assistance," as well as flexible work schedules and telehealth options. In addition, hiring facilities should tell job candidates about professional development opportunities such as access to continuing education, mentorship programs, and networking.

…once people get their footing and they really start to establish those roots in a community, that's going to foster long-term retention.

In addition to offering financial incentives, it's important to connect new hires to the larger community. "Make sure that you have a great onboarding plan to really get [new hires] ingrained and get them rooted into the community right off the bat," Gingras said, "because we know that once people get their footing and they really start to establish those roots in a community, that's going to foster long-term retention."

Gingras also recommended connecting new hires to community organizations. "Make sure that they feel that they are included, they have a voice, and they feel that sense of belonging within the community and within your organization," she said.

"It's hard to duplicate that meaningful work and the impact that you can have in a rural tight-knit community," Gingras said. "So make sure in all of your marketing that you're really highlighting the unique opportunities of working in a rural area. Highlight also the lower cost of living and having access to outdoor recreational activities."

Put together a marketing and recruitment team. Find your champions who are really thriving in the organization to include with onboarding, mentoring, and networking efforts.

To implement these types of changes, Gingras said, "Put together a marketing and recruitment team. Find your champions who are really thriving in the organization to include with onboarding, mentoring, and networking efforts." She also recommended asking community members to help with recruitment.

Recruiting Locally

Gingras from 3RNET also recommended recruiting locally: "Focus on the people who are from your local communities…These are the people who are going to be familiar with the culture and the particular needs of your area. If behavioral health professionals have friends and family who are already in a rural community, they're going to be more invested and they're going to be more committed to staying in your rural community for the long term."

Sanilac Community Mental Health (Sanilac CMH) is a public mental health agency in rural Sanilac County, Michigan. Sanilac CMH takes hiring locally a step further by investing in its current employees' education. The mental health center offers tuition and student loan reimbursement for staff to work toward a bachelor's or master's degree. Sanilac CMH offsets some of the education costs if staff commit to continue working there for a set amount of time.

CEO Wil Morris remembered a front-desk employee 15 years ago who wanted a career in social work and was encouraged to go back to school. "Now she's probably one of my top two therapists in the agency," he said. "When you make those small investments in people, the payout is so phenomenal in the end."

To retain employees and build a positive workplace culture, "we also provide a lot of staff enrichment opportunities and staff appreciation activities," Morris said. Many recent hires came to the agency because of recommendations from current employees. "We may pay a little less [than competitors], but it's worth it to them because of the culture," he added.

"While money is important to folks entering in this profession," Seel from South Carolina said, it is also important to understand "what policies and culture should be in place in an organization, not only to recruit folks but to retain them."

Networking and Partnering

One strategy BHECN Panhandle uses to retain professionals and address isolation is monthly social gatherings, which rotate among different rural communities in the Nebraska Panhandle and allow professionals as well as Master's-level students to network. BHECN Panhandle also provides mentorship dinners between mental health professionals and students at the high school, college, graduate, or post-graduate level.

I've noticed a shift in the community of more collegiality, more working together, more supporting each other.

Due to the monthly social gatherings, Wilson said, "I've noticed a shift in the community of more collegiality, more working together, more supporting each other." Professionals can talk to one another about issues such as audits.

BHECN Panhandle uses email and social media to inform professionals about funding opportunities, legislation, and other updates. It also offered the Rural Provider webinar series, which were recorded and are available online.

In addition, BHECN Panhandle offers one-day workshops and an annual conference, which bring in experts from outside the region. This approach reduces travel time for participants, and these workshops and conferences feature topics chosen by participants.

When we think about obstacles to retention, there's isolation and there's when clinicians feel ineffective and unsupported.

"When we think about obstacles to retention, there's isolation and there's when clinicians feel ineffective and unsupported," Jones-Hazledine said. To address the latter, she recommended "providing good-quality guidance and education and training in things that rural providers specifically have to deal with."

In addition to connecting mental health professionals with one another, it's important for mental health facilities to connect with other community resources. Sanilac CMH in Michigan works with other healthcare facilities, the county health department, law enforcement, schools, and other community partners. "You can't do anything by yourself. You have to have friends," Morris said. He remembered weekly county emergency management meetings during the COVID-19 pandemic. These meetings allowed Morris to meet community leaders and build a relationship with them.

These relationships are already paying off. For example, a local hospital system's nurse practitioner had received training in behavioral healthcare, but the system's primary care clinic did not "have a week's worth of work for her," Morris said, "so we rent her from the hospital." The nurse practitioner works two days a week at each facility, giving her a full caseload.

A psychiatrist at Sanilac CMH provides supervision, guidance, and consultation to the nurse practitioner. The nurse practitioner can refer primary care clinic patients to Sanilac CMH. "They still continue with her as their prescriber, but then they get the therapy and the other services that we provide," Morris said.

Morris said Sanilac CMH is also considering renting space in another hospital and sharing staff for behavioral health urgent care.

In addition to sharing staff, mental health professionals can ease some of their workload by working with peer support specialists, especially in team-based care, Seel said. Peer support specialists' lived experience with mental health and substance use helps build trust with patients, and their work can lessen the workload for other professionals.

Despite the challenges facing the rural behavioral health workforce, Wilson from Nebraska says it's worth it. "In rural areas, it's so easy to talk about the challenges that we face, but it's such rewarding work," she said. "There's no lack of work. My day is incredibly exciting and it varies. I'm never doing the same thing."