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The medical and scientific models of dyslexia

A 52 percent rate of alcohol use in the past 30 days has been found among rural 12th graders 3. Compared with metropolitan areas, rural areas have a large proportion of alcohol-related motor vehicle accidents and resultant injuries and fatalities 3 , Among certain subpopulations, such as rural women and rural Native Americans, problems related to alcohol use are particularly acute, as reflected in high levels of spousal violence, deaths due to medical complications of alcoholism, and fetal alcohol syndrome 1 , 3 , In addition, although abuse of illicit substances such as marijuana, stimulants, cocaine, PCP, and heroin among rural residents is lower than among metropolitan residents, urban and rural trends are converging, and residents of remote rural areas are increasingly implicated in the trafficking and production of these drugs 1 , 3.

Besides substance use disorders, rural residents are at risk for significant mental illness 1 , 2 , 3 , 11 , 12 , 13 , 14 , 15 , Symptoms related to mood and anxiety disorders, trauma, and cognitive, developmental, and psychotic disorders appear to be at least as common among rural residents as metropolitan dwellers 1 , 2. Moreover, rural residents may experience more or more severe symptoms during certain seasons of the year, as at harvest time, or if they live in areas affected by natural disasters or severe economic conditions, such as during the farm crisis and the destabilization of rural communities over the past decades 1 , 3 , Rural suicide rates have surpassed urban suicide rates over the past 20 years 1.

For example, there are 1. S, and in some regions, suicide rates in this group are three times the national average for adults and higher than the rate for elderly metropolitan residents 3. Rural residents who are women, who are poor, elderly, or of minority racial or ethnic status, or who have heightened psychosocial problems such as unemployment are especially likely to manifest psychiatric symptoms 1 , 2 , 3 , 5 , 13 , 14 , 15 , Finally, rural residents have higher rates of chronic illness, life-threatening medical conditions, and limitations on physical activities, placing them at increased risk for medical-psychiatric comorbidities Compared with metropolitan residents, rural dwellers experience greater environmental hazards, have increased overall age-adjusted mortality, and are more likely to subjectively assess their health status as fair or poor For these reasons, mental health issues in the areas of substance dependence and psychiatric disorders, psychosocial stresses, and personal well-being are among the most prominent health concerns faced in rural regions 1 , 2 , 3 , 11 , 12 , 13 , 14 , 15 , Two states, Alaska and New Mexico, illustrate a number of difficulties in mental health care needs and access experienced in rural and frontier communities.

Alaska is the largest state , square miles and the second least populous state in the United States, with 1. However, it has the third highest suicide rate in the nation, with 20 suicides per , residents. Similarly, New Mexico, which is the fifth largest state , square miles and has a population of 1.


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Both Alaska and New Mexico have high rates of alcoholism and of deaths associated with medical complications of alcohol misuse, homicide, firearm-related fatalities, fetal alcohol syndrome, accidental injuries, and motor vehicle accidents 17 , 18 , 19 , Mental health needs are very acute among Alaska Natives and American Indians, one-third of whom are believed to need mental health services for primary psychiatric disorders 3 , American Indian and Alaska Native adolescent boys and young men commit suicide at a rate two to three times the national average for the general population, and the death rate due to alcohol abuse among American Indian and Alaska Native women is ten times greater than that of Anglo women in the U.

Despite the great need for mental health care, Alaska and New Mexico have significantly limited services. Obstacles to rural mental health services include shortages of qualified mental health professionals; severely limited access to inpatient care and to emergency services for psychiatric and substance abuse problems; insufficient case management and community-based supports for special populations with mental disorders such as elderly persons, children, and chronically and severely ill persons; and inadequately integrated and poorly funded systems of general and mental health care 1 , 2 , 3.

Defining dyslexia: a modern dilemma

Specifically, 12 percent of Alaska residents and 18 percent of New Mexicans lack access to primary care, placing these states 33rd and 45th, respectively, among the 50 states in providing access to general health care In Alaska was ranked 50th and New Mexico 47th with respect to community hospitals, which are key institutions in providing mental health care. In Alaska the rate is. The national rate is 1. Only two psychiatric hospitals exist in Alaska, and only 12 serve the state of New Mexico. Hence, the majority of counties in these states have no psychiatric or alcohol treatment beds In terms of clinicians, both states have far fewer physicians per resident than the national average—1.

Alaska has relatively few practicing psychiatrists 17 , and less than 10 percent of New Mexico's counties have sufficient numbers of psychiatrists 18 , Alaska and New Mexico thus resemble other less populous states with tremendous mental health care needs, limited access and resources, and significant vulnerable populations.

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Rural caregivers face serious clinical ethical dilemmas every day. Because of isolation and poor resources, rural clinicians commonly provide care without optimal supports, services, and safeguards for their patients 1 , 3 , 4 , 6 , 23 , 24 , 25 , 26 , Rural clinicians find it necessary at times to ration care, to provide care outside of their usual areas of expertise and competence, to deal with patients' "noncompliance" related to access problems, to respond to complaints about colleagues' impairments, and to make complex clinical decisions about reproductive, end-of-life, and quality-of-life issues without the benefit of specialists 8 , 9 , Care for rural patients with mental illnesses poses further problems, such as addressing patients' potential for self-harm and violence, dealing with the heightened social stigma associated with mental disorders, protecting vulnerable patients from potential abuse or exploitation, and grappling with care planning for individuals with impaired decision-making capacity 1 , 3 , 4 , 5 , 6.

These ethically rigorous issues are often more acute in rural or isolated health care settings primarily because usual practices to ensure ethical conduct are narrowed by the scarcity of health care resources 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 23 , 24 , 25 , 26 , In this paper, we describe and illustrate six ethically important attributes of isolated settings that intensify the dilemmas encountered in rural mental health care. A mental health clinician in a remote rural area in Alaska, accessible only by boat or plane, had to buy her winter fuel supply from a man who was her psychotherapy patient.


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Typically, the winter fuel purchase in this community is a major negotiating event, and the final trade price is highly dependent on the nature of the relationship between the buyer and seller. For the clinician, no other options existed for buying winter fuel in this community.

The clinician struggled with how to obtain a "fair market price" with her patient, in light of the dual nature of their relationship. New to a small town, a psychiatrist began dating a woman he met socially. Later, her sister was brought to the emergency room, intoxicated and disheveled, and disclosed that she had been raped. The community had no other psychiatrists, and the mental health nurse who worked with sexual assault victims was supervised by the new psychiatrist. The woman was hesitant to talk about her experience because she felt ashamed in front of her sister's "boyfriend.

Parental mental health and child welfare – the practitioners’ perspective

As these vignettes illustrate, rural health providers routinely interact with patients in nonmedical or overlapping roles. A study of clinicians in Kansas, for example, revealed that 46 percent of family physicians and general-practice physicians in towns of fewer than 5, inhabitants had a significant number of patients who were family members or friends either of the physician or of the physician's staff 7.

The great majority of these small-town physicians had interacted in nonmedical roles with patients, compared with only 13 percent of physicians practicing in cities with populations over 20, The smaller and more remote a community is, the more dependent each community member is on others to meet needs for food, water, shelter, health, education, and companionship The likelihood of overlapping roles is greatest in isolated native villages where most of the inhabitants have some kin connection as well.

In these naturally "enmeshed" communities, there are few options for relationships other than overlapping ones. Overlapping relationships are ethically problematic and potentially exploitive of patients because of their impact on treatment boundaries. Treatment boundaries, especially important in the care of mental illness, define the professional relationship as fundamentally respectful and protective of the patient and as dedicated to the patient's well-being and best interests 29 , 30 , 31 , 32 , 33 , 34 , 35 , However, overlapping relationships place clinicians at risk for ethical problems, as reflected in the observation that half of the ethics complaints reviewed by the American Psychiatric Association in related to harms perceived in association with overlapping relationships 28 , 29 , 31 , Rural clinicians routinely experience the ethical bind of caring for each individual patient while also balancing the competing needs of other patients and the community and keeping separate their personal motivations.

People with Intellectual Disabilities and their Elderly Carers

Rural clinicians thus naturally function in a context of overlapping relationships, potentially conflicting roles, and altered therapeutic boundaries, which may be riddled with ethical problems A year-old man drove miles to an Albuquerque emergency room with a. He stated that he had spent the night in a field near his home, repeatedly holding the gun to his head and then "losing nerve" and shooting into the sky.

The man said that two weeks earlier he himself had found a suicide victim, and since that time he could not rid himself of the idea of killing himself. He reported nightmares, intrusive thoughts, irritability, avoidance, and anxiety. He had not sought care because he didn't want to be identified going to the rural "mental clinic" and had little money to go elsewhere.

If you go in, they think you are crazy. I didn't want them to know I was weak. I didn't want to lose my job.


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I didn't want the whole town to know I was nuts. A therapist in a remote town conducted psychotherapy with a man who took great caution to keep his visits confidential. Therapy sessions involved many discussions about problems in his marriage and his desire to become a better husband. Unbeknownst to the man, his wife entered counseling under an assumed name with the same therapist.

She was seeking ways to improve her independence and leave her husband. Once the therapist realized who she was, he struggled to maintain an impartial, balanced stance in his work with each. No other counselors were available in the region.

Ethics & American Psychological Association

Rural communities have been likened to "fishbowls. Thus the chances of confidentiality breaches with significant consequences for personal, family, and professional relationships are intensified, as illustrated in vignettes 3 and 4. Protection of the rural patient's privacy is quite difficult, despite its importance to sound clinical care practices 28 , 31 , 33 , 34 , This situation has several ramifications. First, fear of confidentiality breaches may prevent patients from seeking or complying with necessary mental health care due to the consequences of stigma and social ostracism 1 , 3 , 6 , 8 , 33 , Second, decisions to disclose confidential patient information, as required by law, for instance, are especially worrisome when the practitioner can directly see how damaging it may be to an individual to reveal the information.

In such cases, the duty to act beneficently and nonmaleficently 30 stands in disquieting contrast with the need to be law abiding and the desire to fulfill one's perceived obligations to the community—for example, to protect area residents from potential harm, violence, sexually transmitted infections, or sexual or domestic abuse 6 , 7 , 8 , 9. A third ramification of confidentiality dilemmas is evident when rural mental health clinicians perform maneuvers to protect patients' privacy that interfere with optimal documentation and health care 6 , 7 , 8 , 9. Unethical confidentiality "techniques" have been reported in a survey of physicians 7.

They included omitting certain details from insurance forms 37 percent , failing to report illness to local public health officials 21 percent , and purposefully misrepresenting details in the medical record 6 percent or insurance forms 5 percent. For these reasons, confidentiality dilemmas appear to be important factors influencing rural health care practices as well as care-seeking behaviors.

During a recent conference, a frontier psychiatrist described the importance of respecting the customs of Alaskan Natives in providing mental health care. He stated that, although it is perceived to be "against the ethics principles of the American Psychiatric Association," to enter a home of an Alaskan Native and not accept a gift "would amount to complete effrontery. There is no money there…. You cannot avoid participating in the ways of the community if you are to survive and if you are to be accepted.

In most cases, it is also more therapeutic to make arrangements that your patients can fulfill. Experiences of suffering, definitions of illness, and care-seeking behaviors are influenced by cultural values and beliefs 1 , 3 , 5 , 6 , 12 , 13 , 14 , 15 , 16 , 22 , 37 , Particularly among mental health practitioners who are new to rural areas, cultural ethical "errors" may occur through underinterpretation or overinterpretation of the cultural meanings of certain symptoms, signs, complaints, or behaviors 6 , 37 , 39 , 40 , Such errors may greatly interfere with mental health care of patients and their families and members of their small community in the future.

Sensitivity and acumen about the cultural dimensions of mental health care are critical so that patients' concerns are accurately identified and treatment planning is attuned to patients' concerns and circumstances. This type of sensitivity may be especially necessary in issues related to mental health. However, professional ethics guidelines in medicine and psychiatry seldom shed adequate light on the role of cultural beliefs and practices in sound clinical ethical decision making in rural or other resource-poor settings 1 , 3 , 5 , 6 , 12 , 13 , 14 , 15 , 16 , 22 , 37 , In talking about his practice, a psychiatrist commented to colleagues, "I oversee 12 nurse practitioners and three nursing trainees in my area.

I have to trust their judgment, even though I'm sometimes worried about all of the prescriptions that are being written, prescriptions that I will ultimately be held responsible for, legally and in the eyes of the community leaders, if anything goes wrong. The nurses carry the burden of the direct care, sometimes with very, very sick patients. And they don't necessarily have mental health expertise.

But I carry the burden of other things, too. A bachelor's-level counselor for the Indian Health Service described his caseload and supervision in this way. I cover hundreds of people, really, and I don't know how many hundreds of miles.

I have a nurse I can call and I have a family doctor I can call when there are big psychiatric problems, but they are busy, and they sometimes don't know about new medicines, especially for my patients with schizophrenia or mental retardation and seizures. So the patients and families do what they can. They do without care and medicines a lot of the time unless we drive more than miles to the university or the VA. A rural nurse in New Mexico observed, "I had a tough case the other day.