Rural residents tend to have the same mental health challenges and needs for services as urban residents. However, comparable mental health care services are often unavailable and rural areas have unique characteristics that affect utilization of services. For Nacogdoches County, these factors, combined with systematic funding cuts for community-based mental health services, narrowing of eligibility criteria for state funded mental health services, limited access to psychiatric inpatient services, reductions in third party payment programs, and the lack of mental health parity, have made it increasingly difficult for residents who have a mental illness to maintain their recovery and wellness in the community, especially those who have a chronic mental illness. These factors also hamper the efforts of local health and human services providers to deliver services that are imperative to maintaining recovery and wellness. For example, the lack of comprehensive community-based services increases the likelihood of a psychiatric crisis, which will most likely result in an inpatient hospitalization. And, the community-based services do not allow for adequate support of individuals returning to the community from an inpatient hospitalization. The end result being a “revolving door” between the community and inpatient services, which is counter to both recovery and wellness.
Recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration, 2012).
Better Together was established in July 2018 through a grassroots effort to improve the mental health, health, and well-being of all residents of Nacogdoches County. Our project began with key partners and citizens who sought to include community members in the process of developing a common agenda to guide our efforts.
Our activities are supported by the Hogg Foundation for Mental Health via their Collaborative Approaches to Well-being in Rural Communities Initiative. The first phase of the process (July 2018 – June 2021) was focused on working with community stakeholders to develop the common agenda. The second phase of the process (July 2021 – June 2026) involves working with community stakeholders to implement the common agenda.
The primary goal of Better Together is to improve the mental health, health, and well-being of all residents of Nacogdoches County. We understand that rural communities are unique and each one should be approached from a holistic perspective that incorporates strengths. Given this, our approach seeks to improve the following aspects of our community:
- Safety – Prevent violence across the lifespan and create safe physical environments.
- Trustworthiness – Foster positive relationships among residents, elected officials, police, schools, and others.
- Environment – Ensure that opportunities for growth are available for all.
- Collaboration – Promote involvement of residents and partnerships among agencies.
- Peer Support – Engage residents in opportunities to work together on issues of common concern.
- History, Gender, Culture – Values and supports history, culture, and diversity.
The concept of trauma-informed community is consistent with the population health and population mental health approaches, both of which emphasize improving the quality of care for all members of the community, while reducing inequities among groups (e.g. access to care, quality of care, cost of care). Furthermore, it allows for incorporation of resilience, well-being, recovery, and wellness.
Realizing and sustaining our goal of improving the mental health, health, and well-being of all residents of Nacogdoches County requires the entire community’s involvement in each step of the process. Therefore, we chose to employ appreciative inquiry to engage residents and organizations. Appreciative inquiry is a community-based participatory action research method that utilizes a bottom-up approach to identifying community strengths and leveraging them to bring about change. Activities include:
- establishing an appreciative inquiry team;
- collecting information (mental health, community well-being, collaborations, sustainable change, priorities, resilience and rural realities);
- sharing information;
- identifying strategies;
- and planning.
These activities were supported by a three-year grant from the Hogg Foundation through its Collaborative Approaches to Well-Being in Rural Communities Initiative. This phase of the project has been completed and our Appreciative Inquiry Team has given way to a Network Advisory Board. These individuals serve a two-year term with new members elected May of each year. The next election cycle will be May of 2024.
A common agenda is a typical outcome of an extensive appreciative inquiry. It enables the Appreciative Inquiry Team to plan educational activities, identify advocacy opportunities, address policies, and create change related to the well-being of the community. Our common agenda consists of specific actions identified by stakeholders that we can take to improve the mental health, health, wellness, and well-being of all residents of Nacogdoches County. The members of our Network Advisory Board are now continuing this important work. It is our hope that our common agenda will help our Network Advisory Board and community stakeholders make steady progress toward:
- meeting the safety needs of all our residents;
- including diverse groups in all aspects of life in our community;
- creating an atmosphere of open, inclusive, and continuous communication in our community;
- creating an environment that is conducive to the wellness and well-being of all our community members; and
- increasing the quality of care for all members of our community, while reducing inequities among groups (e.g., access to care, quality of care, cost of care).