In Utah, child mental health advocates find new ways to help rural families heal from abuse
In many counties outside Utah’s Wasatch Front (home of Salt Lake City, Provo and Ogden), the population averages just two people per square mile. For these rural residents, grocery stores, restaurants and reliable cell signals may be limited to the nearest town.
In other areas, small towns may be home to several thousand people and have solid basic services. But in both cases, specialized approaches to health care — let alone mental health care — can be hard to come by.
This is especially true for some of the state’s most vulnerable residents: children who have been abused.
“We should have the ability to connect every child that needs it to quality mental health services. We just don’t have enough capacity right now,” says Tracey Tabet, administrator of the Utah Children’s Justice Center Program.
The statewide agency, which is run out of the Utah Attorney General’s Office, oversees more than two dozen Children’s Justice Center (CJC) sites, about half of which are in rural areas. The centers help kids get free, science-backed therapy and other services so they can recover from abuse. “It can change the trajectory of their life if they get that kind of support,” Tabet says.
But many rural communities don’t have enough mental health providers at all, let alone therapists with experience in child psychology and trauma-informed care. This means families often have to drive several hours to see a specialist — assuming they have reliable transportation and can afford the gas to make the trip.
The questions Tabet’s team grapples with often go something like this: “How do we connect kids with quality mental health services when even the school district can’t lure a clinician to come and be the school counselor in the district?”
Telehealth could help in some areas. But in others, video visits aren’t an option because cell and WiFi signals aren’t strong enough. Or families won’t open up to a therapist who isn’t a familiar presence in their town.
And yet, the CJCs have reason for hope. They’re developing customized solutions for 10 of their rural centers. This work, in partnership with the National Children’s Alliance, is supported by a two-year, $1 million grant from the parent organization of Regence BlueCross BlueShield that will help kids get back to being kids.
Now, Tabet’s staff is empowered to ask center leaders something different: “What do you need to have sustainable mental health services? If you could dream big, what would that look like?”
Their solutions fall into a few broad categories: training new therapists, retaining and supporting existing community mental health providers, technology to support video visits, and partnerships with schools and other agencies.
Rural kids have ‘the right to heal’
The project in Utah is remarkable because rural areas nationwide are often overlooked when it comes to mental health care. Utah has some unique challenges, but its struggle is emblematic of the difficulty rural communities face coast-to-coast.
“There’s a lot of discussion about the right to heal,” says the National Children’s Alliance’s Blake Warenik. “No matter what situation or what part of the country they live in, or how much money they have, children have a right to access these services.”
But along with racial, ethnic and economic issues that can limit access to care, rural areas are diverse, complex places. There’s no one-size-fits-all solution to help kids get the support they need to recover from abuse.
“The challenge, of course, is that ‘rural’ covers a broad range: communities with 1,000 people, and some with 4,000 people or more, and yet both are considered rural,” Tabet says.
For example, the kids served by Utah’s CJCs could be from polygamous families, tribal nations, new immigrant enclaves or extremely rural communities — all of whom have reason to be slow to open up to outsiders.
That’s a problem because it can delay treatment. The longer kids go without help, the more likely they are to have lasting issues, and to pass them on to the next generation.
Think of childhood abuse and neglect like a cut, says Warenik. Therapy is like stitches. “The quicker you get it sewn up and tended to, the more likely you are to have a minimal scar. Compare that to a wound that’s allowed to fester and never stitched up properly — it becomes a big, jagged scar. It’s very much like that in terms of the neurological effects.”
By making trauma-informed therapy accessible to rural kids, the Utah CJCs and NCA hope to disrupt the generational cycle.
Deondra Brown works in community outreach for the CJCs. She also sits on Utah’s Behavioral Health Crisis Response Commission, tasked with improving the way Utah handles mental health crisis calls statewide.
“Our biggest goal is making sure that our rural communities have the same access to critical mental health care as our populous cities,” she says. “We have a strong focus on making sure the kid population is part of that.”
Solution 1: Training more providers to respond to trauma
The CJCs’ clients benefit from two types of evidence-based treatment: child and family traumatic stress intervention and trauma-focused cognitive behavioral therapy.
Utah doesn’t have enough therapists who know how to deliver this kind of treatment, though, especially in the state’s far-flung areas. So some of the grant money will go toward training up to 60 providers, including therapists already in rural communities.
Existing providers are a key piece of the puzzle, says Carrie Jensen, program support specialist for the state CJC Program.
That’s because once rural families start to see a therapist in their home community, they can be reluctant to go elsewhere, either in person or through video visits.
Jensen recalls when one of the centers’ trauma-focused trained therapists was planning maternity leave and tried to transfer her clients to a provider at a children’s hospital. “They were like, ‘No, we'll wait for you to come back.’ Rural communities are used to their little group of people who they know understand them and their idiosyncrasies.”
With a bigger pool of qualified providers, the CJCs will be able to get kids into treatment sooner by referring them to nearby therapists. This will cut down on waitlists and eliminate the need to drive hours for services. And working with local providers increases the chances that trauma-informed therapy can be adapted to be culturally relevant for a given community, Warenik says.
It could also benefit whole families, says Heather Williams-Young, director of the CJC that serves Juab and Millard counties, in the western part of the state.
The list of providers who treat trauma in her area is “very, very small,” Williams-Young says. “Sometimes when a child discloses abuse, their parents may also disclose their own abuse and trauma histories for the first time.”
But right now, parents have to leave the county to find their own treatment. They often don’t make it a priority because it’s inconvenient. With more therapists available, Williams-Young says, “there are options not only for children, but also for their parents to begin to heal.”
Solution 2: Supporting therapists so they stay in rural communities
Counseling people in crisis is a hard job, especially when you’re the only person doing it in your community. “They’re dealing with some really tough cases,” Tabet says. Two of her biggest concerns are that rural therapists will burn out, or they will leave.
“If they don’t leave to another community, sometimes they leave the field entirely. They decide to do something that’s a lot easier, frankly. We want to make sure we’re attending to those concerns.”
That’s why the grant includes a plan for providers to get peer support and supervision. It will connect rural therapists with others doing similar work, to help them process the issues that come up in their practices and to ease their sense of isolation.
Solution 3: Using technology to bring ‘big city care’ to rural areas
As a result of the COVID-19 pandemic, telehealth services are more common than ever, including for mental health counseling. And some of the rural CJCs are betting big on video visits to connect qualified therapists with kids in need.
They’re partnering with urban trauma-trained therapists for counseling, purchasing iPads for kids to use for counseling sessions, and providing IT support to make sure children can get connected online for their appointments.
Not only do video visits “help us have ‘big city care’ in our little town,” they also make it easier for kids to get weekly counseling, says Tonya Murray, director of the CJC that serves two northeastern Utah counties near the Uintah and Ouray Indian Reservation and the Wyoming-Colorado border.
Once a week is the recommended frequency for trauma-informed therapy. But many rural kids have counseling less often because it’s hard to get an appointment or for their families to commit to a three-hour trip to see a therapist every week.
In some cases, seeing someone on a tablet screen has an added benefit for tight-knit communities that are cautious about sharing their family business, says Stephanie Furnival, who oversees the CJCs that serve four counties in southern Utah, including a recent expansion into Garfield County thanks to NCA funding.
Furnival says that only one or two therapists are available in the counties her center serves. In a small town, the therapist might be related to the family seeking services or have lost trust in the community for some reason. “Through tele-mental health we can address those concerns and provide mental health services to families where it was not an option previously.”
Solution 4: Meeting demand through community partnerships
CJCs will use some of the grant funding to hire therapists who work on-site. But others see potential to reach kids more effectively by collaborating with school districts, county mental health agencies and other community mental health partners.
It’s a question of meeting people where they are, says Kristy Pike, director of the Washington County CJC. For the last few years, her center has worked with local schools to allow kids who have been abused to get therapy on campus during the school day.
“This has resulted in a number of kids overcoming the barrier of transportation to frequent therapy appointments,” Pike says. “It also takes a burden off of families who are already in crisis.”
Unfortunately, the CJC hasn’t yet been able to make school-based therapy a reality for every school. Washington County borders Nevada to the west and Arizona to the south. In the past, it’s been hard to justify paying a therapist to drive 80 to 90 miles roundtrip for a single session with a child in a town on the far edge of the county.
“Because this grant specifically targets rural access, it will allow us to get therapists out to those areas. Those schools are anxious for the help,” Pike says.
Her counterparts in other counties are using grant funds to train therapists at their local mental health authority or hospital system, so that they can refer kids to nearby therapists for trauma-informed care.
“It’s not going to be a cookie cutter type of fix for every community,” Jensen, the CJC Program’s program support specialist, says. “That’s where the grant is going to be a lifesaver. We’re able to mold and shape it to the individual community.”
Crisis averted
It’s not an overstatement to say that filling the pipeline with qualified providers in Utah can be a matter of life or death.
As Pike recalls, a few months ago a parent brought their child to her center because of suspected abuse. During the session, the child shared traumatic details about their abuse, but did not seem distressed by these revelations.
Later, however, “we discovered that this child had a plan to go home that night and end their life.” As Pike’s team dug deeper, they learned that the child’s parent also was planning suicide.
Using a trauma-informed approach, the CJC providers were able to build a suicide safety plan with the family and help them get additional support.
“What a blessing it was for our team to be present in that crossroads of crisis and to have the tools that we needed to change the trajectory for that family,” Pike says. “Without grants and training and partners, we would have been helpless, and that is just not an acceptable option.”
Jillian Cohan Martin is a journalist and content strategist based in Portland, Oregon.