Learning about rural culture

Julia Martinez ‘03
Ozarks Medical Center

Many psychology students feel that psychiatric internships are best done in the city, concluding that urban healthcare facilities provide the most opportunity to learn about mental health. Prospective interns argue that city hospitals, which are generally larger than rural facilities, would allow students to not only interact with a greater number of patents but also to encounter a wider variety of mental illnesses. They would see many different cultural attitudes and how they influence treatment. This is important for people who want exposure to the field of mental health, often persuading students to seek internships in urban areas. But disagreeing with the idea that a city hospital is the only favorable setting for psychiatric study, I completed my Dartmouth Partners in Community Service (DPCS) internship at Ozarks Medical Center; a rural hospital in West Plains, Missouri. Because I enjoyed the internship and learned a great deal, I now feel prepared to discuss why a psychiatric internship at a small rural hospital is a valuable experience, perhaps more challenging and enlightening than an urban internship. First, I will consider how patient diversity exists in both urban and rural internships. I will then discuss how diversity affects a student’s contact with patients, something that is an important element in a psychiatric internship, especially in a rural hospital. By reflecting on my own experiences, I hope to illustrate how patient contact is one of the most significant benefits of a rural internship.

First, I should describe my own experience in more detail before looking at the advantages of rural and urban internships. Every one to two weeks I observed a different behavioral department at the hospital. The first week, I started at the inpatient psychiatric unit talking with staff and patients and participating in and planning activities. Next I observed the outpatient psychiatric departments. I shadowed psychiatrists, talked with therapists, participated in child and adult day-treatment programs and attended therapy groups. I helped at the Safe House, where teenagers can live in a secure environment. I also traveled with crisis workers and community support workers on rounds to client homes, nursing homes and residential care facilities. I participated in a non-violent crisis intervention class and attended clinical meetings that look at clients and their progress. I also attended general all-staff meetings. I completed some intake assessments, talking with new clients and helping start their records. I administered some mental status and mini mental status examinations. And of course, I asked a lot of questions.

Feeling exhausted at the end of each day, I realized that a psychiatric internship does not only teach about mental illness, but it also teaches business, budgeting, social interactions and how an organization operates. Of all the things I learned though, I most enjoyed talking with clients, both about everyday life and mental health. I am not the only person that feels this way; most students in search of good internships consider the amount of one-on-one interactions that they can have with clients. It makes sense that students hope to make a lot of contact with patients, because they are the focus of behavioral healthcare. But again, this means a student might apply to an urban-area internship thinking that since city hospitals are larger and have a more diverse patient population than rural facilities, city hospitals might also provide more opportunities for making contact with patients.
It is worthwhile however, to think about how the diversity of both urban and rural hospitals would affect an intern’s contact with patients. A patient population can be diverse first by the number of illnesses and second by the number of different cultures among the clients. It seems logical that a hospital, which cares for a large number of people, would have more diversity than would a small hospital.

But let’s consider how the first kind of diversity, the number of different kinds of mental illnesses among psychiatric patients, exists in a rural internship. When I finished the internship, for example, I had seen all of the major mental illnesses. This confused me because it would seem that a student would not see as great a variety of mental illnesses in a rural hospital as he or she would see in an urban hospital. So I thought about the meaning of diversity in mental health, using the Diagnostic and Statistical Manual as a conceptual tool. Just glancing through the text, which describes and gives names for different behaviors, one can find statistics on how often different mental illnesses or diagnoses occur in an area. But the book is not large, considering the size of the world and its diversity. I realized that this manual helps a mental healthcare provider to connect an entire list of patient behaviors, or symptoms, with an established name and treatment. There are not supposed to be countless illnesses; the manual helps simplify the complexity of human behavior and life.

So what is the diversity that students are looking for if it is not just seeing a variety of psychiatric diagnoses or names for mental illnesses? Perhaps diversity comes from other differences among people, specifically behaviors and personal characteristics. Each psychiatric patient receives a treatment plan for their diagnosis that, although based on things we know about psychology, is always a little unique because it must be tailored to individual characteristics. Variables like medical problems, drug dependence and multiple diagnoses, imprisonment, poverty and obesity can all affect a person’s treatment and progress in different ways. People also react differently to life and to their own treatment. Mental health professionals of ten years or more have told me that they never saw two people with the exact same story. Diversity in this case is not a variety of diagnoses, but is instead a variety of patient’s lives, treatment plans and reactions to therapy or psychiatric care. A student can see this kind of variety anywhere he or she interns.

Even if diversity exists in both city hospitals and in smaller hospitals however, why should a student choose a rural internship over an urban one? The answer involves one of our greatest concerns, which is a student’s contact with patients. A benefit of my internship was that I not only could meet patients, but that I could talk with mental healthcare providers, I could go with a caseworker to see where and how some patients lived and I could sometimes meet patients’ families. I got to know many patients by their names and faces. Having the ability to know a patient on such a close level was an important part of my internship. I could observe and try to understand how a person struggles with his or her mental illness in daily life.
But it takes time to learn about a person’s diagnosis, psychiatric history and reactions to treatment. Clearly an intern wants to see as much as he or she possibly can. But a large hospital could quickly be overwhelming when an intern tries to read about a patient’s psychological history, to look at the Diagnostic and Statistical Manual, to talk with the client or to observe a mental health care provider’s interaction with the patient all at the same time. The intern might be so concerned with learning about as many patients as possible in a day that he or she may not have the time to get to know patients more closely. It would make sense to choose a setting that offers the chance for detailed study.

The benefit of detailed study is also important when looking at cultural diversity; the second kind of variety that students want exposure to in the mental health field. When I use the word culture, I am not describing race. Instead, I am referring to the different beliefs that social groups have. Different social beliefs can influence a person’s view of the world and his or her reactions to situations; they are therefore very important in mental health. It is true that many small communities have their own culture, making the study of other cultures difficult. West Plains, Missouri is not different from other small towns in this respect. But just getting to know about one kind of culture is a challenge.

For instance, during my rotation in the Crisis department there was an elderly schizophrenic patient who had to talk to a doctor about someone that had attacked him in his residential care facility. He told some nurses that he had some “cat killing to do”, meaning that talking to the doctor was something he considered unpleasant but necessary. This statement sounds alarming but a crisis worker told me that this once was a popular figure of speech in the area. The lesson to this story is that knowing about past popular culture is as important as knowing about current popular culture.

But it takes time to learn about the past, present and possible futures of just one culture, much less many different cultures. I am still learning about West Plains. But I am also learning that I do not need to know everything about all cultures to be useful in mental health care. My internship has taught me that it is more important to learn how to be sensitive to things I do not know about or might not be able to understand. In terms of student interactions with patients, this is important when talking with clients who might be emotional or vulnerable.

Thinking about diversity in culture and in illnesses can determine how we think about a student’s contact with patients, whether in a city hospital or a rural hospital. But what makes rural internships favorable when it comes to patient contact? The answer ironically is that, the smaller size of the community actually aids in student interactions with patients.

For example, West Plains has about ten thousand inhabitants. Although the hospital’s behavioral care facility serves seven counties, many clients live in the town. There are four grocery stores and one library. I often see familiar faces in public, which would be less common in an urban area. Recognizing clients from the Behavioral Healthcare facility allowed me to observe how people with mental illnesses function in the real world. Because I never saw anything really strange in public, I realized that mental illness is not some scary thing that only dangerous people in movies have. Mental illness is, for many, a part of everyday life. It is not rare or bad, but something that we all should think about.

Patient contact in a rural area, whether it is inside or outside the office, gives one a sense of community, which I think was an important part of the DPCS program. Seeing people I liked and knew from high school receiving care at the local Behavioral Care facility helped me think about mental illness more seriously. Also, learning about the town, its culture and its people gave me a better appreciation of West Plains than I had had in high school. I think the mentoring component of the internship was important because it combined several of my worlds. I got to talk with someone familiar with healthcare and life at Dartmouth, and I also got to share my experiences in West Plains with someone who could provide knowledgeable insights and comments. It was a very enjoyable experience.

At the end of the program, I understood that my wish to help people is not the only reason why my psychiatric internship was also a community service internship. Working in a rural area had given me a sense of community, reminding me that I am a part of society, not just some outsider who wants to help. This has greatly increased my motivation for community service. I learned that a rural internship not only has everything a psychology student could want, but it has more. An intern will see diversity in a small hospital. He or she will have contact with patients both during and outside of office hours. Students will also think more closely about community service when interning in a rural area. The DPCS program made my internship even more memorable by connecting me with a mentor. A psychiatric internship in a rural hospital is definitely a great opportunity for students. I extend my thanks and appreciation to everyone that helped make my experience possible and wonderful!