Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

In Brief

Fall 2016 • Volume 9 • Issue 2 

Rural Behavioral Health: 

Telehealth Challenges and Opportunities 

This In Brief looks at common acceptability, availability, 

and accessibility barriers to mental and substance use 

disorder (behavioral health) treatment and services in 

rural*

* There are many definitions of rural, even within the federal government.17 This In Brief uses the word rural in a general sense to refer to areas of

the United States that are sparsely populated. 

 communities and presents ways telehealth can 

help surmount some of these barriers. Challenges to 

implementing effective telehealth services in sparsely 

populated areas are also discussed. This information is 

designed to be useful to behavioral health practitioners and 

many other professionals—such as attorneys, behavioral 

health training program faculty, clergy, pharmacists, 

and primary care practitioners—who are concerned 

with behavioral health in their communities. These 

professionals may be local centers of influence to whom 

others turn for behavioral health information and help. For 

more information on the use of telehealth for behavioral 

health services, see Treatment Improvement Protocol 

(TIP) 60, Using Technology-Based Therapeutic Tools in 

Behavioral Health Services.

1 

The term telehealth†

†

 “Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine 

refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, 

and continuing medical education, in addition to clinical services.”18 

 refers to using internet and 

communications technologies (ICTs), such as 

videoconferencing, chat, and text messaging, to provide 

health information and treatments in real time. Telehealth 

also includes exchanging information and delivering 

services asynchronously, such as through secure email, 

webinars, or “store-and-forward” practices, which include 

videotaping a client encounter and forwarding the video 

to a professional who is offsite, for analysis at a later 

time. As access to at least some types of ICTs increases 

across the United States, the potential for telehealth also 

increases. Increasing levels of access create opportunities 

for providers to address rural–urban disparities across the 

behavioral health continuum of care (see Exhibit 1).2,3 

Exhibit 1. Telehealth Across the 

Behavioral Health Continuum of Care2,3,4,5,6 

Service Telehealth Example 

Assessment Online substance use 

questionnaire 

Treatment Cognitive–behavioral therapy 

through videoconferencing 

Medication 

management/ 

monitoring 

Text message reminders to take 

medications as directed 

Continuing care Group chats for relapse 

prevention 

Education Webinars for clients and 

providers 

Collaboration Interactive video for consultation 

Nearly one in five U.S. residents lives in a rural area.7 

According to most estimates, individuals living in rural 

locations experience mental and substance use disorders 

at rates that are similar to (and sometimes higher than) 

those of their urban counterparts.8,9,10,11,12,13 In a survey of 

rural health stakeholders, when participants were asked 

to identify the top 10 rural health priorities from a larger 

list of focus areas, they ranked mental health and mental 

disorders fourth and substance abuse fifth.14 

Despite having a similar need for services, people in rural 

areas have less access to the behavioral health continuum 

of care than do people in urban areas.15,16 Although funding 

cuts, workforce shortages, and other systemic issues 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

2 

In Brief

hinder access to timely and appropriate behavioral health 

treatment and services in urban and rural areas alike, 

people in rural areas face additional barriers, such as a 

lack of adequate internet infrastructure,19,20 a need to travel 

long distances to see specialty providers, and a lack of 

anonymity about receiving treatment.21 

The idea of using telehealth to expand access to care 

first surfaced in the 1960s.22 Technology can facilitate 

the delivery of behavioral health services to people in 

rural areas in two main ways: (1) by linking clients to 

behavioral health practitioners located at a different site, 

and (2) by connecting nonspecialists in rural areas— 

commonly primary care practitioners—to networks of 

behavioral health specialists throughout the country for 

case consultation.23 

Acceptability Barriers 

Treatment acceptability refers to whether patients consider 

treatment to be relevant, beneficial, and worthwhile. 

There is evidence that some rural communities normalize 

substance use and certain types of mental illness, such as 

depression, making it difficult for residents to judge when 

their condition warrants treatment.21,24,25,26 Numerous other 

factors influence whether individuals believe treatment is 

an acceptable response to their condition. For instance, 

a history of the U.S. agricultural population’s behavioral 

health care cites a culture of self-reliance as one reason 

this population tends to “avoid seeking behavioral 

healthcare even when needed.”27 Two major acceptability 

barriers facing individuals living in rural locations are a 

lack of privacy about receiving treatment for behavioral 

health conditions and a lack of culturally appropriate 

care.21,27 

Lack of privacy 

Individuals living in rural locations commonly identify a 

lack of privacy as a barrier to receiving treatment.15,28,29,30 

Associated with the lack of privacy is the desire to avoid 

being the subject of gossip or being marginalized.21,30 In 

small communities, residents may recognize whose car is 

in a therapist’s parking lot, for instance. Focus groups have 

revealed that certain cultural attitudes and beliefs may also 

contribute to a lack of privacy, exemplified by one study 

involving a faith community of rural African American 

individuals (see textbox at right).21 

Lack of culturally appropriate treatment 

Some rural communities harbor negative perceptions about 

treatment for mental disorders or about treatment and 

service professionals.21,31,32 At the same time, skepticism 

may be warranted if treatment and service providers do not 

deliver culturally sensitive diagnoses or care, cannot offer 

a full complement of services, or cannot provide services 

for the length of time required to see positive outcomes. 

American Indians and Alaska Natives, for instance, 

have criticized mental health services as being culturally 

unsuitable.31 

Culturally appropriate treatment accommodates clients’ 

beliefs and practices, preferred languages, individual and 

family histories, differences in symptoms, and preferred 

approaches to treatment. A significant challenge to 

providing culturally appropriate treatment in rural areas 

is their racial, ethnic, and cultural diversity. Although 

between 79 and 82 percent of the residents of rural areas 

and small towns are non-Hispanic Whites,9

 rural areas 

have become more racially and ethnically diverse in the 

past decade. In fact, racial and ethnic minorities accounted 

for 83 percent of the population growth in rural areas from 

Depression in a Rural African American 

Community21 

Focus groups with rural African Americans in a faith 

community revealed individual and cultural barriers to 

seeking treatment for depression. Participants said that 

private information spreads easily through rumors in their 

small community, increasing the likelihood that individuals 

experiencing depression would be judged by others they see 

regularly. Fear of being labeled “crazy” prevented people 

with depression from seeking care. In addition, participants 

wanted to keep their “personal business” to themselves, 

and also did not want to pry into anyone else’s business. 

These attitudes sometimes kept them from knowing that 

friends needed help, as one participant discovered when 

he happened to visit a friend who had just taken pills in an 

attempt to take his own life. 

Another barrier was the belief that depression is a normal 

part of everyone’s life. In a depressed environment, one 

participant said, individuals may not even recognize that 

they are depressed; the condition is viewed as a norm, not 

as an illness that requires treatment. 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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Rural Behavioral Health: Telehealth Challenges and Opportunities

Fall 2016, Volume 9, Issue 2

2000 to 2010.33 However, as in urban areas, factors besides 

race and ethnicity contribute to the formation of distinct 

cultures. In a rural area, these factors include the economic 

base (e.g., farming, forestry, manufacturing, tourism); 

proximity to urban centers; and any major subpopulations, 

such as seniors or veterans. Medical and behavioral health 

researchers and practitioners working in rural areas have 

noted the dire need for behavioral health treatment and 

service practitioners who understand the needs of farmers 

and ranchers, veterans, and tribal communities and other 

ethnic and racial minorities.27,31,34,35,36 

Addressing Acceptability Barriers 

One of the most promising contributions of telehealth is 

its potential to provide confidential therapies, enabling 

individuals living in rural locations to access treatment 

and services without inadvertent disclosure to their 

communities. For instance, one prevention intervention 

used email to treat subthreshold depression before it 

became clinical. Participants who had been screened 

online were sent automated emails containing advice and 

self-help strategies.37 However, commonly used programs 

and services such as Skype may not meet Health Insurance 

Portability and Accountability Act (HIPAA) requirements 

for the protection of private health information.38,39 

Treatment relying on sophisticated telehealth equipment 

systems could be accessed from hospitals, clinics, 

educational institutions, professional offices, and other 

settings that offer privacy. For example, an individual may 

go to a primary care provider’s office or a community 

clinic and obtain an assessment or treatment for a mental 

or substance use disorder via telehealth without other 

patients knowing the purpose of the visit. 

Telehealth models can be used to educate healthcare 

professionals about behavioral health issues.40,41 In 

addition, telehealth can be used to train behavioral health 

practitioners on the technical, ethical, cultural, and 

professional competencies they need to work effectively 

with rural clients.4,42 

Burke, a community mental health services provider in 

rural eastern Texas, offers comprehensive emergency 

psychiatric services entirely by telepsychiatry, covering 

400,000 people dispersed over 11,000 square miles. The 

center operates an 8-bed, 48-hour observation unit with 

capacity for involuntary patients; a 16-bed residential unit 

for voluntary patients; and a mobile crisis outreach team. 

The center is staffed by registered nurses, mental health 

technicians, licensed counselors, licensed vocational 

nurses, and a caseworker. Within 1 hour of arrival (no 

matter the time or day), patients are assessed and engaged 

via videoconference with a psychiatrist. (A psychiatrist 

is also available by phone within 5 minutes.) The center 

contracts with psychiatrists at a private behavioral health 

telemedicine practice in Houston. Burke is also equipped 

to offer detoxification services.43,44 

Availability Barriers 

Even when individuals living in rural locations want 

treatment, they may have few services and providers in 

their areas, and they may have less access than urban 

residents to evidence-based practices (EBPs). 

Lack of services 

One report estimated that outpatient substance use 

treatment services are almost four times less likely to be 

available in rural hospitals than in urban hospitals (12.1 

percent and 43.7 percent, respectively, with treatment 

services offered either directly or by arrangement).45 

Hospitals in large rural areas are about twice as likely 

to offer substance use treatment services (17.9 percent) 

compared with hospitals in small or isolated rural areas 

(8.2 percent and 8.5 percent, respectively). Rural facilities 

also provide fewer services along the continuum of 

care. Rural areas are particularly short on detoxification 

services.46 Moreover, although individuals living in rural 

locations report higher rates of prescription opioid misuse 

than do urban residents,12 only about 3 percent of all opioid 

treatment programs are situated in rural areas.46 

Telemedicine Funding for Opioid 

Addiction Treatment in Appalachia
 

In June 2016, Secretary of Agriculture Tom Vilsack 

announced the awarding of Distance Learning and 

Telemedicine grants totaling almost $1.4 million for 

projects in rural central Appalachia (Kentucky, Tennessee, 

and Virginia) to address the growing opioid addiction crisis 

in this region of the United States.47 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

In Brief

Lack of practitioners 

Rural areas have few behavioral health practitioners, 

particularly ones who are qualified to provide specialty 

treatment4,48,49,50 or EBPs.48 More than 75 percent of all 

U.S. counties are mental health shortage areas,51 and half 

of all U.S. counties have no mental health professionals at 

all.52 

No national count of behavioral health workers exists, 

making it difficult to accurately assess shortages of 

substance use treatment and service practitioners. 

However, the Substance Abuse and Mental Health 

Services Administration has documented difficulties in 

recruiting and retaining staff to replace the country’s aging 

behavioral health workforce.50 The Health Resources and 

Services Administration estimates that more than 7,700 

professionals are needed to fill existing behavioral health 

workforce gaps.50 

Challenges to recruiting and retaining substance use 

treatment staff in rural areas include:53 

■ Low pay compared with peers in other settings. 

■ Professional isolation. 

■ Difficulty for spouses to find work. 

■ Few social outlets and educational opportunities. 

■ Difficulties adjusting to rural life. 

Lower use of EBPs 

Some research shows that behavioral health facilities in 

rural areas are more likely than their urban counterparts 

to be independently operated and less likely to collaborate 

with a university to train providers on EBPs.48 At the same 

time, most studies that support EBPs are not conducted in 

rural areas or on rural populations.48 

Addressing Availability Barriers 

Telehealth has the potential to help bridge the rural–urban 

treatment gap by linking rural clients to high-quality 

behavioral health services and providers located in more 

populated areas. Among the various technologies currently 

in use, video telehealth seems to provide the intervention 

most similar to office-based treatment, and research shows 

that video telehealth users have satisfaction levels and 

outcomes similar to those of clients receiving in-person 

therapy.35,54 

The single area where improved 

patient care could be realized is 

in the significant expansion and 

active use of telehealth.32 

Telehealth can also mitigate rural practitioner isolation and 

increase collaboration.4,55,56 New Mexico’s Project ECHO 

(Extension for Community Healthcare Outcomes) began 

when the University of New Mexico Health Sciences 

Center adopted teleconferencing to train rural primary care 

practitioners to effectively treat patients with hepatitis C. 

The ECHO model links specialist teams at an academic 

“hub” using multipoint videoconferencing to conduct 

virtual clinics with community providers. Primary care 

practitioners, the “spokes,” become part of a learning 

community, where they receive mentoring and feedback 

from specialists. The model, now used in both urban and 

rural areas, has since expanded to include training on 

treating mental and substance use disorders, along with 

other illnesses and chronic conditions.57 

When clinicians join Project ECHO, they receive 2 days 

of in-person orientation. Then they join disease-specific 

learning networks that engage in weekly videoconferences. 

Training is through case-based learning, including 

consultations with specialists. Project ECHO now operates 

more than 90 hubs—in the United States and in 16 other 

countries—that deal with more than 45 diseases and 

conditions.58 The Project ECHO model has also been used 

within the healthcare systems of the U.S. Department of 

Defense. 

Accessibility Barriers 

Having to travel long distances to receive treatment is a 

common accessibility barrier for individuals living in rural 

locations who may not have a driver’s license, a reliable 

car, or public transportation options. The percentage of rural 

families with access to a car between 2011 and 2013 was 

higher than the percentage of their urban counterparts with 

such access during this same period (96 and 90 percent, 

respectively).59 However, in 2005, the U.S. Department of 

4 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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Rural Behavioral Health: Telehealth Challenges and Opportunities

Fall 2016, Volume 9, Issue 2

Agriculture’s Economic Research Service reported that 

more than 1.6 million families living in rural locations did 

not have cars.60 Individuals living in rural locations who 

do have access to a car may not want to be away from their 

families or leave children with others for the many hours 

that a trip to a provider can take, and seniors may not feel 

safe driving after dark. 

Poverty is another significant barrier to accessing 

behavioral health treatment and services.36,61 Poor 

individuals living in rural locations may not be able 

to afford the cost of care and transportation to care.62 

Minorities in rural areas are more likely to be poor than are 

minorities in urban areas; for example, in 2014 the poverty 

rate for nonmetro Blacks was 36.9 percent, compared with 

26.0 percent for metro Blacks.63 

Despite the need for publicly funded treatment, only 

about 60 percent of U.S. counties have an outpatient 

substance use treatment facility that accepts Medicaid (the 

percentage is lower in certain Southern and Midwestern 

states).64 Counties with a higher percentage of rural, Black, 

and/or uninsured residents are even less likely to have a 

Medicaid-funded treatment facility.64 

Addressing Accessibility Barriers 

Telehealth can offer clients and providers more convenient 

ways to access services, which may result in reduced 

travel time and expense, less time away from families, 

and fewer missed appointments.35,65,66 Telehealth also 

saves institutions the expenses associated with their 

practitioners’ travel to distant sites. It can facilitate 

approaches that otherwise would not be feasible. 

The U.S. Department of Veterans Affairs piloted a 

substance use treatment program using an in-home 

messaging device (IHMD), a hand-held device that 

connected to a telephone outlet but did not interrupt 

phone service and did not require an internet connection. 

Clients used the IHMD every day to access a combined 

behavioral intervention (CBI) for substance use disorders. 

CBI is a blend of cognitive–behavioral therapy, 12-Step 

approaches, and motivational interviewing. The aim of the 

program was to reduce delays in connecting clients to care, 

thereby preventing emergencies.67 

Every day for the length of the 27-day program, clients 

received text messages on the device to assess their 

condition on these measures: substance use in the past 

24 hours, level of craving, withdrawal symptoms, level 

of commitment to remain abstinent, and thoughts of selfharm. Clients pushed buttons on the device to indicate 

their answers, and follow-up questions proceeded logically 

from the responses. Client responses were transmitted via 

secure server to computers monitored by care coordinators. 

The program triaged clients’ responses, alerting care 

coordinators to any situation that required an immediate 

intervention. The care coordinator could then contact the 

affected client directly or refer the client to a primary care 

practitioner. The system also instructed the client to call 

911 or take other action, as needed. A second component 

of the program conveyed steps clients might take daily to 

build coping and other skills to achieve abstinence. 

A larger IHMD study (62 veterans) found that at 1-month 

follow-up, participants who received IHMDs had fewer 

drinking days and fewer binge drinking days compared 

with participants in a group-led (face-to-face) intervention 

with a therapist.68 At 3-month follow-up, the differences 

between the two groups were not significant in terms of the 

total number of drinking days. However, the IHMD group 

still had fewer binge drinking days. 

Challenges to Implementing Telehealth 

Services 

Telehealth can meet some of the need for increased 

access to behavioral health care in rural areas, at least 

for some clients, but it has yet to reach scale. Internet 

access remains a challenge to rural telehealth. The federal 

government has invested billions of dollars to improve 

internet access for rural communities.20 By mid-2015, 78 

percent of rural households had internet access, compared 

with 85 percent of urban households.69 However, 39 

percent of of all people living in rural areas do not have 

access to advanced broadband internet, and 19 percent lack 

access to even basic broadband—a factor that limits the 

types of telehealth services available to them via a home 

internet connection.19 

Another challenge to rural telehealth development 

has been the lack of insurance coverage for telehealth 

services. The number of states with parity laws for private 

insurance coverage of telemedicine has increased from 

1 state in 1995 to more than 30 states in 2016, with 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

6 

In Brief

pending or proposed legislation in another 7 states (see 

Exhibit 2).70 However, according to the Medicare Payment 

Advisory Commission, rural providers rarely use their 

current telehealth capability.71 A survey by the National 

Association of State Alcohol and Drug Abuse Directors 

found that, out of 37 state respondents, 25 reported use 

of some form of telehealth to treat mental disorders.72 

However, only 18 reported use of telehealth to treat 

substance use disorders. 

Exhibit 2. States With Parity Laws for Private Insurance Coverage of Telemedicine (2016)70 

* 

* Coverage applies to 

certain health services. 

* 

Telemedicine Parity Law Partial Parity Law Proposed Parity Bill No Parity Legislative Activity 

Adapted with permission from the American Telemedicine Association. 

Challenges facing providers 

Some researchers find that behavioral health treatment and 

service providers are reluctant to embrace telemedicine. 

This initial reluctance can stem from concerns about 

privacy, confidentiality, security, setup costs, and technical 

difficulties (e.g., transmission interruptions) that could lead 

to disruptions in treatment.35 Significant differences in state 

laws are also a concern. For example, practitioners must 

be informed of licensing laws across states—that is, prior 

to providing telehealth services to a patient in a different 

state, the practitioner must learn whether there are specific 

licensing requirements for doing so.1,73 

Providers may also face difficulty getting reimbursed 

for telehealth interventions. Until recently, billing for 

telebehavioral health services was limited. However, this 

is changing as insurance carriers recognize that telehealth 

is able to provide evidence-based care in a cost-effective 

way.23,73 

The American Medical Association at its 2014 annual 

meeting approved a set of principles designed to 

ensure appropriate insurance coverage and payment for 

telemedicine services. The association’s then president, 

Robert Wah, M.D., stated that the policy created a 

foundation for using telemedicine to maintain relationships 

with patients, to enhance follow-up care, and to facilitate 

better care and management of chronic health conditions.74 
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Rural Behavioral Health: Telehealth Challenges and Opportunities

Fall 2016, Volume 9, Issue 2

Challenges facing rural clients 

Certain characteristics of rural populations—such as their 

treatment preferences, preferred languages, and comfort 

with technology—have been minimally studied; therefore, 

how to responsibly adapt telehealth to the diversity of 

rural populations is not well understood.5,36 Cultural 

competency experts have noted that “we do not know 

whether and what types of adaptations and modifications 

of an evidence-based program are needed to ensure that its 

implementation does not create or exacerbate disparities 

across cultural groups.”75 Which rural clients would 

benefit most from which technologies is still unclear. 

Although videoconferencing is a commonly studied 

telehealth approach, a systematic literature review on 

videoconferencing for psychotherapy showed that more 

research is needed on a range of issues, including consent, 

telehealth contraindications, and the effect of gender, race, 

and ethnicity on outcomes.54 However, a 2016 report found 

that there is sufficient research on telehealth effectiveness 

to support its use for remote monitoring, communication, 

and counseling of patients with chronic medical 

conditions, and for psychotherapy (for behavioral health).76 

Challenges facing facilities 

Telehealth for rural areas is a small part of the larger 

behavioral health treatment and service system and is 

subject to the same limitations, such as insecure funding 

for programs, low reimbursement rates for providers, 

and high rates of patient no-shows.22 However, telehealth 

programs also present with their own particular challenges. 

They can have high upfront costs, and studies to date 

on implementation and operational costs of various 

telehealth programs, as well as cost effectiveness, are not 

generalizable.5,77 To protect patient privacy, telehealth 

care systems require password-protected files, network 

firewalls, document encryption, and reliable technical 

support.3

 Data ownership and privacy standards remain 

to be settled.5

 Responsibility for being HIPAA compliant 

rests with the program or individual using any particular 

modality, because, as one study noted, “no accreditation 

system documents that a telemedicine system is in 

compliance. Prospective users must carefully evaluate 

whether or not the services meet the requirements of these 

regulations.”78 

Particular Challenges in Frontier Areas 

Frontier areas in the United States have their own particular 

challenges. Frontier areas are very remote, isolated, and 

sparsely populated areas that require long trips not only to 

obtain health care, but also to do everyday things like going 

to school or the grocery store. Seasonal conditions can make 

travel especially difficult. Snow, ice, or floods may require 

closing of certain roads. Some residents of frontier islands 

must rely on travel by boat or by air to obtain health care, 

and the weather can cause problems for both emergency 

and nonemergency medical transport. For frontier families 

with low incomes, or with family members who are elderly 

or have disabilities, the isolation and long distances can be 

enormous obstacles to getting needed health care. 

Telehealth 

Telehealth has the potential to give frontier patients 

access to primary care providers and medical specialists, 

improving the quality of care and health outcomes. 

Telehealth may also reduce the costs of both obtaining and 

providing health care.79 

One pilot project trained 12 therapists in telehealth, to 

deliver mental health services to veterans from 6 rural 

community clinics. However, 10 months later, only two 

clinicians were offering telehealth services. Unexpected 

hurdles included a lack of soundproof rooms for therapists, 

lost equipment, inadequate staffing, delayed therapist 

credentialing, staff turnover, and difficulty enlisting 

clients.80 

Conclusion 

Bridging the gap between rural and urban behavioral 

health services involves addressing many complex barriers 

and developing creative solutions to complex challenges 

that are often unique to rural areas. However, rural clients 

and professional service providers are not alone in tackling 

these issues. Professional journals such as the Journal of 

Rural Mental Health publish studies and innovations in 

rural behavioral health care, and professional organizations 

such as the National Association for Rural Mental Health 

support and promote the continuing development and 

replication of successful programs. Telehealth may be part 

of the solution to improving access to behavioral health 

services in rural areas and increasing the likelihood that 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

8 

In Brief

individuals living in rural locations will engage with the 

behavioral health system. In addition, telehealth presents 

an opportunity for tremendous growth—not only is 

technology continuing to advance at a rapid pace, but also 

changes in healthcare laws are extending coverage for 

telehealth services, making them available to an increasing 

number of individuals. 

Next Steps 

Behavioral health is not the exclusive purview of 

behavioral health professionals, especially in rural areas. 

This is especially true in frontier or rural areas where 

everyone depends on each other in a variety of ways. 

Behavioral health information and resources need to be 

promoted by all people of influence within the community. 

The following suggestions directly address those people of 

influence. 

If your community does not already have a community 

resource group that meets on a regular basis, work together 

to create one. As a group, consider working through 

resources such as the Rural Mental Health and Substance 

Abuse Toolkit and other tools available through the Rural 

Health Information Hub (see Resources). Additional steps 

that individuals can take to promote telehealth in rural 

communities include the following: 

If you are an attorney— 

■		Become familiar with the literature on and practice 

of therapeutic jurisprudence (see the web resources 

section of this document). 

■		Collaborate with other professionals to develop 

telebehavioral health resources in the community.
 

■		Network with other attorneys who specialize in 

working with clients who have mental or substance use 

disorders; such networking can be done via the internet 

and electronic mailing lists (such as TJlist+subscribe@ 

googlegroups.com). 

If you are a behavioral health practitioner— 

■		Collaborate with other professionals to develop 

telebehavioral health resources in the community.
 

■		Participate in committees or interest groups within 

your professional association that focus on rural 

behavioral health, such as the American Psychological 

Association Committee on Rural Health and the 

National Rural Social Work Caucus (see the web 

resources section). 

If you are a faculty member of a behavioral 

health training program— 

■		Collaborate with other professionals to develop 

telebehavioral health resources in the community.
 

■		Include the unique needs and challenges of frontier 

and rural communities as part of the curriculum on 

cultural diversity.81
 

■		Work with colleagues and rural community contacts 

to develop clinical training experiences within frontier 

and rural communities.81 

If you are a clergyperson— 

■		Collaborate with other professionals to develop 

telebehavioral health resources in the community.
 

■		Ask gentle, yet probing questions in conversations 

with parishioners during informal counseling sessions. 

■		Identify mutual-help resources within the community 

and those that may be available online (such as 

Alcoholics Anonymous). 

■		Learn about emergency services and ongoing 

treatment services in or near your community.
 

■		Provide education and information about behavioral 

health through classes, groups, and (when appropriate) 

sermons; include information that addresses 

misconceptions. 

If you are a pharmacist— 

■		Collaborate with other professionals to develop 

telebehavioral health resources in the community.
 

■		Identify mutual-help resources within the community 

and those that may be available online (such as 

Alcoholics Anonymous). 
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Rural Behavioral Health: Telehealth Challenges and Opportunities

Fall 2016, Volume 9, Issue 2

■ Provide customers with education and information

about behavioral health, especially information that

addresses misconceptions.

If you are a primary care practitioner— 

■ Collaborate with other professionals to develop

telebehavioral health resources in the community.

■ Consider developing an integrated practice (a practice

that includes treatment for both medical issues and

mental and substance use disorders).

■ Identify mutual-help resources within the community

and those that may be available online (such as

Alcoholics Anonymous).

■ Consider continuing education opportunities that offer

training and mentorship in telebehavioral health (see

Resources).

These are all important next steps that community leaders 

and professionals of various disciplines can take—both 

individually and together—toward the common goal 

of making behavioral health services more acceptable, 

available, and accessible to citizens in rural areas. 

Resources 

Relevant publications from SAMHSA 

(available through http://store.samhsa.gov) 

Considerations for the Provision of e-Therapy 

The TEDS Report: A Comparison of Rural and Urban 

Substance Abuse Treatment Admissions 

Treatment Improvement Protocol (TIP) 59: Improving 

Cultural Competence 

TIP 60: Using Technology-Based Therapeutic Tools in 

Behavioral Health Services 

Other publications 

The National Frontier and Rural ATTC 

www.attcnetwork.org/find/news/attcnews/epubs/addmsg 

/april2013article.asp 

American Telemedicine Association Practice Guidelines 

http://thesource.americantelemed.org/resources 

/telemedicine-practice-guidelines 

The Role of Telehealth in an Evolving Health Care 

Environment: Workshop Summary 

www.nap.edu/read/13466/chapter/1 

Telehealth Services (Rural Health Series) 

www.cms.gov/Outreach-and-Education/Medicare 

-Learning-Network-MLN/MLNProducts/downloads 

/TelehealthSrvcsfctsht.pdf 

Web resources 

American Psychological Association Committee on 

Rural Health 

www.apa.org/practice/programs/rural/committee 

American Telemedicine Association 

www.americantelemed.org 

Contemporary Rural Social Work (online journal) 

http://journal.und.edu/crsw 

Federal Office of Rural Health Policy 

www.hrsa.gov/ruralhealth 

International Network on Therapeutic Jurisprudence 

https://law2.arizona.edu/depts/upr-intj 

Mid-Atlantic Telehealth Resource Center 

www.matrc.org/telepsychiatry-telemental-health 

National Association for Rural Mental Health 

www.narmh.org 

National Center for Frontier Communities 

http://frontierus.org 

National Center for Rural Health Works 

www.ruralhealthworks.org 

National Frontier and Rural Addiction Technology 

Transfer Center 

www.attcnetwork.org/national-focus-areas/?rc 

=frontierrural 

National Rural Health Association 

www.ruralhealthweb.org 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

10 

In Brief

National Rural Social Work Caucus 

www.ruralsocialwork.org 

Rural Health Information Hub 

www.ruralhealthinfo.org 

Rural Health Research Gateway 

www.ruralhealthresearch.org 

Rural Health Value 

http://cph.uiowa.edu/ruralhealthvalue 

SAMHSA-HRSA Center for Integrated Health 

Solutions 

www.integration.samhsa.gov/operations-administration 

/telebehavioral-health 

U.S. Department of Veterans Affairs—VA Telehealth 

Services 

www.telehealth.va.gov 

Notes 

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Fall 2016, Volume 9, Issue 2

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In Brief 

This In Brief was written and produced under contract numbers 270-09-0307 and 270-14-0445 by the Knowledge Application 

Program (KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental 

Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Christina Currier and 

Suzanne Wise served as the Contracting Officer’s Representatives, and Candi Byrne served as KAP Project Coordinator. 

Disclaimer: The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the 

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2016). Rural Behavioral Health: 

Telehealth Challenges and Opportunities. In Brief, Volume 9, Issue 2. 

Originating Office: Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center 

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HHS Publication No. (SMA) 16-4989 

Published 2016 

In Brief, Rural Behavioral Health: Telehealth Challenges and Opportunities 

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