Treatment in Central Appalachia

Sydney Black, M.S., M.A.

Spalding University 

In the heart of the United States’ oldest mountain range sits a place near and dear to my heart. The Appalachian Mountains stretch from the Canadian provinces of Newfoundland and Labrador to Central Alabama (Britannica, 2019).  Central Appalachia was my home of 17 years.  Central Appalachia is one of the most economically distressed areas in the United States; in 1965, 265 counties across the Appalachian region were considered to be “high-poverty” counties (i.e. noted poverty rates that are more than 1.5 times the U.S. average at that time) (Appalachian Regional Commission, 2017, par 2).  That number has since decreased across the mountains, but the remaining 98 “high-poverty” counties remain in Central Appalachia.  As beautiful as this rural land is to the naked eye, its beauty is not what is portrayed to the general public.  According to the Appalachian Regional Commission (ARC; 2017), those living in rural counties experience more physically and mentally unhealthy days than those in metro areas throughout this region.  Additionally, the poisoning mortality rate is 37% higher, the suicide rate is 17% higher, and the prevalence of depression is greater than the national average.  

As future and early-career psychologists, the impact that living in deep poverty can have on mental health is a topic that is and/or should have been discussed throughout our course loads. With statistics this staggering, a thought might be “well, why doesn’t someone just go there and set up shop?”  As an early-career practitioner, is a “high-poverty” county where you want to begin your career, especially after years of accumulated student loan debt?  Some would say yes, but according to the ARC (2015) the amount of mental health providers per 100,000 individuals in Appalachia is 35% lower than the national average.  On top of this, the more rural communities across this region report even less access to a mental health providers (approximately 50% below the national average). Rural Appalachia is probably not an area high on the “places I’d like to work” list for after post-doc.  Luckily, programs such as National Health Service Corps or Public Service Loan Repayment are two options that are available to practitioners that volunteer to work in rural areas, such as Central Appalachia, and may be a beneficial service for students to consider (see for information).  This benefit might outweigh the presumed costs to being a practitioner in Central Appalachia.   

As these statistics suggest, access to psychologists is few and far between in this region.  Access to providers come with its own challenges that are associated with rural environments: lack of access to public transportation, minimal access to a personal vehicle because of the financial burden it may cause to someone in an economically distressed area, navigating challenging geographical terrain, and managing difficult terrain throughout seasonal weather patterns (Selby-Nelson, et al., 2018).  In many cases, this leads to individuals seeking mental health services from their primary care provider, while many do not seek help at all.  Lack of access to care has been found to emphasize isolation and worsen symptoms (Snell-Rood, et al., 2017).   To combat these challenges, researchers have discussed the implementation of telehealth or integration of mental health practitioners into integrated primary care sites to reduce this burden (Arsanow, et al., 2015; Rios, Kazemi, & Peterson, 2018; Selby-Nelson, et al., 2018). 

Becoming a mental health practitioner in a rural environment includes its own challenges.  Snell-Rood and colleagues (2017) interviewed a small sample of women from rural homes in southeastern Kentucky about seeking treatment. The research team found several themes that were prevalent in their interviews, including doubts about seeking treatment, the stigma that is associated with seeking treatment, and attempts to cope without receiving treatment.  Rural communities are stereotypically small, with a strong emphasis on leaning on your family or being self-reliant (Selby-Nelson, et al., 2018).  The dirty laundry does not leave the family.  The fear of being seen at the psychologist’s office can outweigh the gumption for seeking services.  Snell-Rood, et al., (2017) quoted a participant as saying “[you] go and you sit there for an hour and you tell a perfect stranger or even a person you know fairly well your problems and I don’t know, I’m not throwing off on it; I just think it’s a joke” (p. 7).  Instead, others may opt to seek other options for recovery, including reflection and prayer (Snell-Rood, et al., 2017).  This may mean, if working with clients in this community, utilizing a theory where you may integrate these concepts into your sessions.  If opting to work in these communities, I encourage you to engage in outreach in the community to normalize seeking your services.  In addition, I encourage considering privacy and confidentiality more than you may already—in a small community it is not guaranteed that a waiting room or a parking lot is a safe space.  If feasible, consider creating a separate waiting room and exit lobby to reduce the likelihood of client interactions.   

Currently, APA is utilizing the Deep Poverty Initiative to discuss the role of psychology in “informing the societal and structural decision-making processes affecting people living in deep poverty” (APA Deep Poverty Initiative). There you can sign a pledge for the five-week challenge to learn more about deep poverty.  While I hope this post was able to shine light about treatment in rural Appalachia, this initiative is a great source to garner a greater understanding of this particular population.  I hope APA continues to get students involved in this initiative and creates interests for others to work in areas like Central Appalachia.  Receiving psychological treatment is a dire need for these communities; however, the need might exceed what one might initially believe.  


American Psychological Association. (n.d.) Deep poverty initiative. Retrieved from

Appalachian Regional Commission. (2017). Health disparities in appalachia [pdf]. Retrieved from

Appalachian Regional Commission. (2017). Health disparities in appalachia: Behavioral health domain [pdf]. Retrieved from

Appalachian Regional Commission. (2015). Health disparities in appalachia: Health care system [pdf]. Retrieved from

Encyclopedia Brittanica. (2019). Appalachian Mountains. Retrieved from 

Rios, D., Kazemi, E., & Peterson, S. M. (2018). Best practices and considerations for effective service provision via remote technology. Behavior Analysis: Research and Practice, 18(3), 277-287. 

Selby-Nelson, E. M., Bradley, J. M., Schiefer, R. A., & Hoover-Thompson, A. (2018). Primary care integration in rural areas: A community-focused approach. Families, Systems, & Health (American Psychological Association). 

Snell-Rood, C., Hauenstein, E., Leukefeld, C., Feltner, F., Marcum, A., & Schoenberg, N. (2017). Mental health treatment seeking patterns and preferences of Appalachian women with depression. American Journal of Orthopsychiatry, 87(3), 233-241. 

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