There are 1.6 million people living in rural Missouri, and many have a hard time accessing health care. In the 2011 Robert Wood Johnson Foundation’s healthy county rankings, Hickory County in West Central Missouri is rated one of the worst in the state in terms of mental health. It’s so bad, residents say they experience just over a week’s worth of poor mental health days each month. They are also unhealthier and experience more poverty than the national average.
Charlotte O’Dell is trying to find a mobile home court or an RV park. She works as a counselor for Pathways, a community mental health center with offices all over Missouri.
O’Dell is driving through rural Hickory County, Missouri, winding through wide swaths of open land. She’s so far out in unincorporated territory that a GPS is no help. She has to rely on old fashioned maps.
“I’m probably going to have to stop and get my directions out of the back seat if I don’t see what we’re looking for pretty soon,” she said.
O’Dell is literally a traveling therapist, stopping in the homes of clients who otherwise wouldn’t be able to make it into the Pathways office because of debilitating mental illness.
“So you see these folks are marginal in many ways. Many of them are so depressed they won’t get out of bed for days. ”
She said her job is unpredictable, though on average she makes visits once a week, but it really depends on the client.
Today O’Dell is visiting Trish Woodell. She’s 26-years-old, unemployed, and diagnosed with bipolar disorder. She’s been in the Pathways program for about a year, but hasn’t seen a counselor in at least a few months.
“At this point I need to be sure she still wants to work on the goals and objectives that are on the treatment plan," said O'Dell. "For her progress would be being there to visit or showing up for appointments she’s had pretty bad track record at that. ”
Woodell greets O’Dell on the porch of her mobile home, pulling the door shut behind her. Her weight makes just coming to the door difficult. She wears a pink shirt, matching sweatpants and has her hair pulled back into a high ponytail. Standing on the porch, O’Dell launched right into the treatment plan.
They’re reviewing stuff that may sound really basic like grocery shopping and getting out of the house. Woodell shares her progress. Things like walking to the end of the driveway and back a few times a week for exercise. And attempting to bake her meals instead of frying them. A follow-up appointment is made for the next week.
Woodell said the program has helped her. She was already on Medicaid when she was referred to Pathways. Even then it took her a few months before she was able to get in to see someone about her bipolar disorder. And for someone with bipolar disorder, a few months can seem like an eternity.
There are 1.6 million rural residents living in Missouri many of whom have an even harder time accessing care.
Dennis Mohatt works at the Western Interstate Commission for Higher Education where he’s the director of the rural mental health research center.
“Rural people end up entering care later in the course of a disorder,” he said.
But it’s not just living out in the country-- the major barriers to getting mental health care are all over the map. Things like insurance, transportation, stigma, and a shortage of doctors.
“They can’t get there and there’s no one there locally and so things fester if you will, longer so that means when they come in for care instead of something being minor, it’s progressed,” Mohatt said.
In the last two decades, private insurance companies have reduced their spending in mental health. That’s left the public sector to fill the gap. And, Mohatt added, you have to be pretty destitute in order to qualify for Medicaid programs. So, what ends up happening to people who live in rural areas who really need mental health care?
“well most people suffer,” he said.
Hickory County resident Cindy Benedict is suffering. Three years ago, Benedict’s husband shot himself in front of her and their two youngest children. Since then she’s been unemployed.
She struggles with depression and post-traumatic stress disorder. And she’s also a single mother of four kids. Benedict has attempted to get on disability three different times. Each time she’s been rejected. Not surprisingly, her children have also had a hard time.
“They have their moments…we all do…my little girl is probably my biggest problem…probably about once a week or every two weeks she’ll start crying and all I can do is hold her, hug her, cry with her, you know tell her I’m sorry," she said. "That’s all I can do. ”
Neither Benedict nor her children are getting mental health treatment When Benedict’s husband was alive, he rejected treatment for his bipolar disorder. Cindy Benedict did seek help. But the first doctor she saw made inappropriate comment, the second was 45 miles away and she couldn’t afford the gas.
She also worries about being labeled mentally ill within her tight-knit community.
“Preston is a very small town everybody knows everybody," she said. "Yeah it’s definitely a judgmental town. Any kind of mental issue. People talk about it I hear them table about other people you know. How crazy that person is or what a nut, just crap. ”
This fear of stigma, particularly in small towns where everybody knows everybody, is another factor that keeps some people from getting help.
Back to Mohatt: “Most people who don’t get care they get sicker and something eventually will give and that’s why suicide rates in many rural places are higher than others, that’s why there are a lot of accidents in the workplace that maybe weren’t just accidents. And a lot of bad things can happen. ”
For now Benedict pulls through with the help of a trusted friend. A tattoo inside her arm is another source of strength.
“It says, 'live life to the fullest, we’re not promised tomorrow. Live, Laugh, Love'. I look at that, oh I’m going to start crying, every day to remind me that I gotta keep going. ”
All over rural Missouri, people like Benedict who are slipping through the cracks of the system have few options but that: to try to keep going. Without it, there are no other options left.