When Everybody Knows Everybody: Mental Health in Rural Communities

I am approaching two years in my current role as a behavioral health provider in a community health setting. Having also grown up in a rural area, I have developed an understanding of the strengths and challenges of practicing in these communities. Rural areas carry rich traditions and are home to some of the most resilient people you will meet, but they also present barriers that shape how mental health care is delivered and received. While I am not a seasoned veteran, my hope is that sharing some of the lessons I have learned will help other clinicians work more effectively in similar settings.

Build rapport in close-knit communities

In rural towns, relationships often span generations. It is not just that people recognize the same faces at the grocery store or on the street. The person at the front desk may have once babysat your client; their cousin may have dated your client’s sibling; they may sit two rows behind your client at their place of worship. Sometimes people know the details of your client’s divorce, DUI or medical history before the client ever walks into your office. In rural settings, privacy can be a surprisingly rare commodity, and stigma around mental health can amplify the discomfort.

Providers can build trust by addressing concerns directly and being explicit about confidentiality. Even an acknowledgment, such as “I know it feels like everyone in this town knows everyone else’s business, but what you share here stays here,” can help clients feel more comfortable.

Understand local culture and community structure

Every rural community has its own identity, shaped by employers, schools, places of worship and geography. Learning about these structures helps providers understand what daily life looks like for their clients, whether people commute long distances, work rotating shifts at a plant or gather at the same diner every Saturday morning. These details shape how clients form their identities, what values they hold and how they view health and wellness. Adjusting language and examples in therapy that reflect these realities helps bridge the gap between clinical concepts and lived experience.

Stigma, confidentiality and logistical barriers

In many rural areas, seeking counseling still carries the perception of weakness or “airing family business.” This stigma is one of the biggest barriers to treatment in these settings. At the same time, logistical challenges make it even harder for clients to engage. Transportation options are limited, broadband is unreliable, and clinic hours are often rigid. In community health settings where resources are tight, these barriers cannot always be solved. What providers can do is adapt within the limits of what is possible: scheduling back-to-back visits for families who share transportation, allowing phone sessions when video is unreliable or offering appointment times that line up with school drop-offs and shift changes. These adjustments may feel small, but they show clients that you are willing to meet them halfway.

Another reality of rural practice is that confidentiality leaks happen. No matter how careful you are, information spreads quickly in close-knit communities. Sometimes it is through staff connections and other times through clients themselves. When it happens, providers need to help clients navigate the fallout rather than assuming it can be completely avoided.

Finally, self-disclosure can carry a different weight in rural contexts. Sharing a little about where you are from or why you care about the community can help clients view you as less of an outsider. Total opacity can sometimes come across as distant or even untrustworthy. Thoughtful, intentional self-disclosure can strengthen rapport without crossing professional boundaries.

Maintain boundaries in everyday encounters

Living and working in rural communities often means running into clients outside the office, whether at the grocery store, a school ball game or a place of worship. These chance encounters can be awkward, but they are inevitable. Addressing them proactively in session, asking clients how they would like you to respond and honoring their preferences strengthens the therapeutic alliance. It also provides an opportunity to model professionalism and discretion in a very public context.

Final thoughts

Working with rural populations requires more than clinical skill. It demands humility, adaptability and a genuine understanding of the fabric of community life. By grounding care in local realities, like knowing who the major employers are, respecting community values or finding workable solutions to barriers, providers can build trust and deliver effective, compassionate support. These considerations not only strengthen therapeutic relationships but also help reduce barriers to care, ensuring rural clients feel seen, respected and supported.

Guest Author: Zach Mildren, BS, LAMFT

Zach Mildren is a Candidate Ambassador for the National Mental Health Workforce Acceleration Collaborative — a National Council program funded by Kaiser Permanente. This innovative program addresses the mental health workforce shortage by supporting candidates pursuing professional licensure, increasing the number of licensed clinicians available to serve clients across the country. To learn more about the program, visit our website.