COMMENTARY
Technology in Rural Behavioral Health Care Practice: Policy
Concerns and Solution Suggestions
Paul Force-Emery Mackie
Minnesota State University, Mankato
There is a history of expectations attached to the use of technology to better facilitate
ural behavioral health care service delivery. Clinicians, scholars, and government
officials alike have touted the benefits of technology to provide better, more accessible
ehavioral health care, and often consider it a way to
idge the “geographic divide.”
The use of technology is viewed as a response to problems associated with improving
consumer contact. Although the use of technology has effectively addressed many
service delivery concerns, it continues to fall short of being the overarching remedy to
what ails rural behavioral health care needs. Often, challenges associated with the full
implementation and utilization of technology into rural behavioral health care is in
conflict with state and federal policies and laws. Identifying and responding to these
a
iers is important to move opportunities for growth forward, but requires more than
hope and limited support. There is a need for committed political will matched with
focus and desire along with the allocation of adequate resources. Suggestions for policy
changes and responses are offered to encourage continued dialogue on this topic.
Keywords: behavioral health, policy, rural, technology
Providing and receiving behavioral health
services in rural areas have long been identified
as challenges for consumers and practitioners
alike. For example, Stone XXXXXXXXXXshared how a
grant request for money to support purchasing a
desktop computer for a rural social service
agency was viewed as “unusual” in 1986. The
author stated that, at that time, not many social
service agencies had such equipment and many
staff had never seen or used a computer. Stone
noted that not long after his observations sur-
ounding his request for that initial computer,
Macarov XXXXXXXXXXpredicted the growth of technol-
ogy in rural behavioral health and social service
delivery would essentially replace commonly ac-
cepted treatment and information processing mo-
dalities. In 2003, Fa
ell and McKinnon discussed
the importance of the then fast-emerging Internet
as a tool to
idge the geographic divide. Spe-
cifically, they said, “as an alternative to tradi-
tional face-to-face contact for those in rural . . .
areas, the Internet potentially can
idge the
disparities in health care access for rural mental
health services” (p. 20). Indeed. Today, a grant
equest to support the purchase of a compute
would not only be considered normal, it is ex-
pected. Additionally, the use of the Internet is
now commonplace and often is no longer de-
pendent on access to a desktop computer as
phones and tablets are now powerful enough to
conduct the same operations. However, this
does not imply that rural stakeholders, be they
consumers or practitioners, are able to enjoy all
of the benefits the use of technology has to
offer.
Editor’s Note. Dr. Paul Force-Emery Mackie is the Pres-
ident-Elect of the National Association for Rural Mental
Health (NARMH). His two-year Presidential term begins
July 30, 2015. The Journal of Rural Mental Health is a
publication of NARMH and is sent to all members of the
organization. Given these facts, Dr. Mackie was invited to
submit an article identifying one or more significant issues
that he planned on addressing during his Presidency. The
article was not reviewed in the typical manner because it is
an expression of Dr. Mackie’s reflections and views of the
issues discussed herein.
Co
espondence concerning this article should be ad-
dressed to Paul Force-Emery Mackie, Department of So-
cial Work, 358 Trafton Hall North, Mankato, MN 56001.
E-mail: XXXXXXXXXX
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Journal of Rural Mental Health © 2015 American Psychological Association
2015, Vol. 39, No. 1, 5– XXXXXXXXXX942X/15/$12.00 http:
dx.doi.org/10.1037
mh0000027
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mailto: XXXXXXXXXX
http:
dx.doi.org/10.1037
mh0000027
In our modern technological world, there are
considerable benefits associated with the use of
technology in health and behavioral health care
service delivery, such as facilitating communi-
cations between consumers and providers, pro-
viders and providers, and even consumers and
consumers. We have learned that reducing dis-
parities between rural and u
an communities
are now real possibilities in the areas of sub-
stance abuse and mental health services (Bena-
vides-Vaello, Strode, & Sheeran, XXXXXXXXXXWe
also now understand that social media applica-
tions have increased the acceptability and ac-
cessibility of telemental health services in geo-
graphically remote locations (Reed, Messler,
Coombs, & Quevillon, 2014).
Although much good can, does, and will con-
tinue to come from the aforementioned ad-
vances, claiming that technology is a cornuco-
pia where only good digital fruit spills forward
also is an overstatement. Challenges associated
with the use of technology continue to be very
eal, and are in an a
ay of fields such as licens-
ing limitations, workforce preparedness, con-
sumer literacy and acceptability, insurance, fee-
for-service reimbursement, privacy concerns,
and a variety of related regulatory consider-
ations (Kramer, Kinn, & Mishkind, XXXXXXXXXXTo
address these and other issues, state and federal
policies must be implemented, enhanced, o
strengthened to meet the modern needs. This
can be a challenge given that, too often, the
technological developments occur faster than
legislation. Regardless of the speed of occur-
ence associated with these processes, two
things are quite certain: (a) Opportunities to
expand access to behavioral health care services
will grow as technological advances occur, and
(b) systems that regulate these acts need to be
elevant, supportive, and timely. Therefore, fo-
cused, willful policy work must be accom-
plished if mental health professionals are to
ealize the full potential of what technology can
do to enhance services.
The inclusion of technology into behavioral
health care practice can provide positive out-
comes for rural consumers, a point well sup-
ported in the literature (Benavides-Vaello,
Strode, & Sheeran, 2013; Reed et al., XXXXXXXXXXIn
theory, technology can be used to address many
problems associated with delivering a variety of
health and behavioral health services in rural
places and be the
idge across
oad land-
scapes by meeting consumers “where they are”
ather than “where we are.” In practice, how-
ever, just because technology can be used to
improve the lives of rural residents through new
and innovative ways doesn’t necessarily mean it
will be used this way. There are still many
a
iers to achieving the goal of connecting
ural areas with high quality behavioral health
care: workforce shortages, fiber optics and in-
frastructure availability, consumer and practi-
tioner technology literacy, and licensing juris-
dictions. Perhaps the most stark ba
ier of all is
the lack of effective state and federal policies
developed to encourage and enhance inclusion,
espond to health care rights, and finding ways
to fully integrate all citizens into our delivery
system.
Brief Historical Policy Review
Although it is difficult to identify a specific
date when rural behavioral health services
emerged as State and Federal concerns, one can
identify key historical moments where address-
ing these important concerns emerged and were
addressed through legislation. The Mo
ill Act
of XXXXXXXXXXStat. 503, U.S.C. 301) and the
Mo
ill Act of XXXXXXXXXXStat. 417, U.S.C. 322)
were focused on the development of institutions
of higher education, built on land that was
granted to states for that purpose. These facili-
ties were mandated to provide agricultural and
mechanical educational opportunities, and they
were home to departments and programs di-
ected to provide education aimed at advancing
ural home, family, and community life. Specif-
ically, the Mo
ill Acts and land grant institu-
tions that grew from these laws included edu-
cation in home economics, which was designed
to prepare students to address health and wel-
fare needs in rural regions. This type of educa-
tion evolved into educational responses to a
variety of rural social service needs. Over time,
the further development and growth of the Fed-
eral Extension Service through the Smith-Leve
Act of XXXXXXXXXXStat. 7, U.S.C. 341) advanced
land-grant university connections with rural so-
cial health and welfare responses. Today, what
was the Federal Extension Service is now the
Cooperative Extension System, which is
charged with a wide variety of rural-based
health, welfare, nutrition, and social responsi-
ilities aimed at enhancing the lives of rural
6 MACKIE
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esidents (United States Cooperative Extension
System, 2014).
No discussion about rural behavioral health
policy can be complete and fully inclusive with-
out a discussion about the impact of the Mental
Health Centers Act of 1963 (PL 88–164). This
law was created to provide behavioral health
services to residents of underserved areas,
which included rural locations. Although there
is fair and considerable criticism associated
with this law (Mermelstein & Sundet, 1988), it
was clearly a genuine attempt on the part of the
federal government to increase support and
funding to unde
epresented populations as well
as recognize the need to address behavioral
health needs across the country, especially
among some of the most impoverished and iso-
lated communities in the United States. Later,
other influential policy works such as President
Carter’s Commission on Mental Health in 1978
(Grob, 2005) and President G.W. Bush’s New
Freedom Commission on Mental Health (2003)
further focused political resources and energy
toward more comprehensive responses to be-
havioral health needs. The Mental Health Sys-
tems Act of 1980 (PL 96–398) came as a result
of the Carter Commission, but according to
Grob (2005), “the commission’s work led to the
formulation of the influential National Plan fo
the Chronically Mentally Ill . . . [however,] a
system of care and treatment for persons with
serious mental illnesses was never created” (p.
425). The New Freedom Commission on Men-
tal Health report received criticisms as well
(Satel & Zdanowicz, 2003), though this report
specifically included rural language and in-