Project Profile: Mental Health at the Margins

What was Discovered
Next Steps

Mental Health at the Margins uses qualitative and participatory research methods to learn about the perspectives and experiences of low-income rural populations. This information will be used to recommend strategies for designing culturally-appropriate mental health supports with the longer-term goal of reducing rural mental health disparities.

Funding: Dartmouth Synergy Grant

Goals for the intervention:

  • Identify concrete strategies for improving mental health services
  • Create an infrastructure that promotes systematic learning from community members, direct services providers, and other mental health stakeholders


  • Conduct qualitative interviews with Haven service users
  • Establish and sustain a Project Advisory Board
  • Hold community forum discussions with Haven service users and staff
  • Create brief, multi- media stories with Haven service users and staff
  • Evaluate feasibility and acceptability of community-engaged research strategies

Research Team:  Elizabeth Carpenter-Song PhD (PI), Sara Kobylenski (Co-PI)

“This project gave us an opportunity to build on our strong partnerships and engage more directly with the upper valley and learn the mental health needs in our community”

– Elizabeth Carpenter- Song


The majority of people with mental illnesses in the U.S. do not receive treatment and the problem appears to be worse in rural areas (Wang,et al., 2005). Despite higher rates of depression and suicide, and substance use rates equal to those in urban areas, rural populations are less likely than urban populations to receive treatment. Low-income rural individuals are particularly vulnerable as both rural poverty and mental health disparities are increasing. Despite this increased risk burden, people in rural areas are less likely to receive mental health treatment compared to nearby urban areas. Accessing mental health services in rural areas is challenging for most people, as there is a lack of mental health providers, shortage of culturally competent providers, long distances to health centers and stigma making it difficult for people to access services.

“how many times I have spent days on the phone. I mean the phone battery dies because you’re trying to find a resource for this, a resource for that. And you can’t you can’t get anywhere.”

– Community Participant

In 2015 a community health assessment was done by Dartmouth- Hitchcock and other partner hospitals. The community health assessment identified mental health care as the highest priority issue and it was the second highest issue by community survey respondents. 8% of the community respondents had difficulty accessing mental health services in that past year. The purpose of this project is to create an infrastructure that promotes learning from lived experiences to inform individuals and use community centered strategies to reduce rural mental health disparities.

Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K.B., Kessler, R. C. (2005). Twelve-month use of mental health services in the united states: Results from the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 629-640. PMID: 15939840

What was Discovered: A Paradox of Help-Seeking

The research has documented how some members of a hard-to-reach rural population understand and engage with mental health and substance use services. Participants commonly had experience receiving mental health and substance use services. Many described tenuous or ineffective engagements with services despite being burdened by mental health and addiction problems – a phenomenon we term the “paradox of help-seeking.”

Some participants viewed clinical and social service professionals as “out-of-touch” with the harsh realities of living in poverty. In such cases, participants experienced difficulty connecting with middle class clinicians who “haven’t been through the same stuff.”

For other participants, medicalized understandings of mental health problems did not resonate. These individuals were often deeply critical of mental health services and felt that problems should be dealt with “on your own.”

Other participants identified as having mental illnesses and were heavily involved with numerous providers and countless organizations. Yet these substantial efforts to interface with professionals did little to mitigate families’ distress or catalyze recovery.

Largest factor in this study: “Identity”

“I think a support person would come in and go, ‘You’re in a crisis. You’re not just making this up, you’re not just in bad shape. You’re in a crisis and you need support’’. Not “you need help”. You know when you say, “Really, you need help” that makes you feel like a failure. You need support”

– Community Participant

Personal and Patient Identity:
Participants carefully managed their own identity and their “patient” identity due to the importance of their reputation in a small town. Participants also indicated that they were more inclined to use clinical language in the attempt to have their healthcare providers take their concerns more seriously.

Mental health is a large contributor to stigma in small town but other factors contribute equally such as being homeless or living in a shelter. Overall the results identified that access to mental health is challenging due to stigma, housing insecurities, poverty, medical care, addiction , welfare and legal issues.

Next Steps

Mental health at the margins  received funding to sustain the projects partnership through a Patient-Centered Outcomes Research Institute (PCORI) Pipeline-to-Proposal Tier II Award.

Currently in  the process of applying for funding to support new projects that build on findings from Mental Health at the Margins


Elizabeth Carpenter- Song