Responding to Crisis: Farmer Mental Health Programs in the Extension North Central Region

Introduction

Farm families face both internal and external threats to their physical and mental well-being, including shifting farm and community structures, extreme weather events, strained finances, changing market conditions and trade policies, and workplace hazards, in addition to geographic and social isolation (Dudensing, Towne, & McCord, 2017; Fetsch, 2006; Garcia, Faul, & Massetti, 2017; Hull, Fennell, Vallury, Jones, & Dollman, 2017; Stoneman & Jinnah, 2015; U.S. Department of Agriculture Economic Research Service, 2018). Reporting in popular press articles has suggested that Farm Aid, the largest farmer advocacy group in the United States, experienced a 109% increase in the number of calls to its hotline in 2018 and that calls to the Legal Aid of Nebraska hotline are resembling those that occurred during the farm crisis of the 1980s (DeYoung, 2019, The Gazette, 2019). Farm advocates and practitioners are calling for action in response to the emerging mental health crisis on the nation's farms.

Universities in the land-grant university Cooperative Extension System are organizing a range of responses to address the growing mental health needs of the farm population. These responses are largely being delivered on a state-by-state basis with limited opportunities for Extension colleagues to evaluate the range and effectiveness of approaches. At the national level, the 2018 Farm Bill included funding for farmer mental health, and in June 2019, the U.S. Department of Agriculture released a request for proposals for the Farm and Ranch Stress Assistance Network Program, with the goal of establishing a network that connects farmers and ranchers to behavioral health and stress assistance resources (U.S. Department of Agriculture National Institute of Food and Agriculture, 2019).

To assist Extension staff as they mobilize to respond to the developing crisis, we provide herein a baseline typology of current mental health programs and response efforts offered by organizations throughout the 12-state Extension North Central Region. We focus on this region because in 2019 farm families in the Midwest have been simultaneously hit by (a) international tariffs and trade wars targeting commodity crops and (b) adverse heavy rains and spring flooding. In addition to cataloging the programs available, we identify opportunities to expand programming to further serve the needs of farmers.

Methods

To assess the types and natures of mental health services available to farmers and farm families in the North Central Region, we conducted an online scan of resources and related educational materials for farmers and farm families in need of mental health care services in Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. In accordance with a grant timeline for data collection, from February through May 2019, we searched online using the search terms anxiety, coping, crisis, crisis assistance, depression, employee assistance program, health, mental health, stress, suicide, and well-being in conjunction with the terms agriculture, farm, and farmers. To reduce bias and increase reliability, we entered search terms in two search engines: Google and DuckDuckGo (a search engine that does not customize results based on previous searches of the user). We also rotated and replicated one another's searches by state during April and May 2019 to ensure that we reached saturation.

During our initial search, for each mental health resource we identified, we noted the state, organization, program, date started, funding source, frequency, eligibility terms, and cost to user. Our focus was on publicly visible and available programming; we did not include work of internal committees or programs in development. We coded the data in a spreadsheet using a deductive descriptive coding approach (Saldaña, 2016) and created a typology of

• type of program (fact sheet/web page, hotline, in-person counseling, workshop, conference presentation, news article, other);
• target audience (service provider, farm population, general population); and
• delivery format (self-help, mediated, other).

Results

Types of Programs Available

Across the North Central Region, we identified a total of 121 distinct programs with 162 individual components. The programs were offered by a range of organizations, including Extension, farmer organizations, nonprofits, state agencies of agriculture, financial institutions, and religious organizations. Examining the program type category, we found that the programs fell into six categories:

• fact sheet or web page providing information on how to address stress, depression, and/or suicidal thoughts;
• workshop or conference for a public or professional audience;
• news article describing resources;
• in-person counseling;
• hotline; and
• other (including advocacy, primary care medical services targeting farmers, and radio broadcasts).

Fact sheets, web pages, and informational workshops focusing on stress management and communication were the most common types of resources being offered, whereas in-person counseling and hotlines were the least common (Table 1). Many of the resources being offered and replicated were farm stress workshops designed by Michigan State University Extension (https://www.canr.msu.edu/managing_farm_stress/managing_stress) and fact sheets and handouts written by North Dakota State University Extension (https://www.ag.ndsu.edu/farmranchstress), with a heavy focus on mental health first aid trainings.

With the increasing attention on stress and depression rates among the farm population, we examined whether and how counseling outreach efforts were manifested during the February through May 2019 period. In total, we found 19 resources (11%) that provided information on in-person mental health counseling for farmers and farm families. However, we noted considerable variation in what constituted "counseling." We found that counseling for the farm sector was largely embedded in traditional agriculture mediation services, with staff primarily focusing on land and financial disputes. These programs advertised assistance for farmers and farm families dealing with issues related to "stress." However, in these cases, stress was largely defined as financial stress, and the degree to which these programs explicitly addressed mental health needs was unclear. Additionally, the extent to which these programs coordinated with or referred clients to licensed mental health providers was unclear as mental health counselors were not discussed or identified on the websites.

In all states, outreach efforts included referring farmers and their families to "hotlines." The vast majority of these hotlines were state suicide hotlines offered to the general population. According to descriptions on the websites, only a few states specifically offered farm crisis hotlines with trained staff fluent in farming culture and vocabulary and current agricultural issues. It is worth noting that many of these hotlines were vestiges of the 1980s farm crisis.

Target Audiences

Through our analysis, we identified four target audiences for farm-based mental health resources: (a) farmers and farm families; (b) general rural populations; (c) service providers, including those offering train-the-trainer programs; and (d) a combination of groups (Table 2). Two thirds of the programs (66%) directly targeted farmers and farm families through fact sheets/web pages, conference presentations, and in-person counseling. We found that many programs were aimed at a general rural audience and that less than 10% targeted service providers.

Delivery Formats

Finally, we categorized the mental health programs by delivery formats: (a) self-help, where information was processed and used by individuals on their own (e.g., recognizing the signs of stress, using breathing exercises to create calm); (b) mediated help, such as counseling, trainings, and hotlines, where help was available to an individual through a professional; and (c) other, which included a range of activities such as referrals to other agencies and programs (Table 3). Over half the programs (52.6%) were in the self-help category and were directly targeting farmers.

Discussion

All states in the North Central Region have made efforts to meet the mental health needs of farmers and farm families. We found that the majority of outreach efforts occurring during the time period of our study could be classified as self-help fact sheets or web pages that directly targeted farmers and farm families and focused on the identification of stress symptoms and methods of stress management.

Fact sheets and web pages can be efficient and low-cost forms of information delivery that raise awareness and may play a role in reducing the stigma surrounding mental health problems. However, their effectiveness for meaningful sustained treatment and prevention likely is limited. In regard to evaluation, it is straightforward to count the number of website hits and number of fact sheets downloaded or distributed, but it is more difficult to assess the larger impact these outreach materials have on alleviating stress and improving stress management in the short or long term. Extension staff developing future fact sheets and web pages should consider the following information:

• As a best practice, fact sheets and web pages should include information and links to specific mental health and financial assistance programs and providers.
• The types of support available to farm families during a crisis period can be expanded through provision of information and links to support households. Examples include housing, energy, and food assistance programs as well as information on health insurance tax credits and Medicaid eligibility.

We found that workshops were the second most common type of programming. This format provides an opportunity for direct contact, and, most importantly, it offers time for an exchange of information, self-reflection, and peer support. With specific outcome measurements, Extension staff can evaluate the short-term impact of a program as well as receive feedback on strengths and areas needing improvement. Over half the programs we identified directly targeted agricultural producers by addressing specific farm issues. And in every state, we found outreach materials directing farmers to suicide crisis hotlines and in-person counseling and therapy. However, the vast majority of hotlines appeared to be geared for the general population, and the efficacy of such hotlines may be limited if staff members are disconnected from the culture of agriculture.

To expand the reach of existing programs, Extension professionals working in the areas of agriculture and natural resources and family and consumer sciences can partner and coordinate efforts to take relevant actions such as these:

• Create incentives for Extension staff across all program areas to participate in mental health first aid certification programs (see https://www.mentalhealthfirstaid.org/) or other analogous programs that can train staff to recognize signs of stress among all clientele.
• Provide workshop participants with referrals to mental health counselors and household assistance resources as well as guidance on how to determine the types of mental and behavioral health services covered under insurance plans. Provide these resources not only in workshops focused on stress but also in more general farm risk management and farm succession meetings.
• Organize professional development trainings for mental health counselors and state hotline staff to educate them on the context of farm issues, farm culture, farm family dynamics, and the nuances of farm life. In a Journal of Extension article, Fetsch (2006) outlined 13 strategies Extension agents can use to identify mental health professionals and family consultants who have the skills to work with farm families; these principles may be useful in designing new programming and partnerships.
• Coordinate with local religious leaders, mental health counselors, and state rural health offices to identify mental and behavioral health services for farmers without adequate health coverage while continuing to provide workshops and meeting space for addressing emerging issues.

As the responses to farm stress continue to evolve, periodic benchmarking will be useful for information sharing, peer learning, and evaluating and understanding the relationships between interventions and outcomes. Additional research is needed to understand the perspectives, contexts, and nuances of the individuals and groups that develop and deliver farm stress and mental health programs in the North Central Region and nationally. Future research should identify best practices of culturally appropriate mental health care delivery for farm families while simultaneously reconciling how structural limitations such as the lack of mental health care providers in rural areas, rural hospital closures, cost of care, and access to health insurance intersect to affect access and delivery of mental health care that meets the needs of farm families in rural communities.

Acknowledgment

The research reported herein was funded through the North Central Regional Center for Rural Development 2019–2020 Small Grants Program.

References

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