Tony Long-Drew of Still Waters Counseling in Estacada realizes his practice would be different if he worked in a big city.
"If you just hang a shingle saying you're a counselor, that won't work in a small town," he said. "You have to put yourself out there and establish rapport with the town."
Long-Drew and Laura Edwards, a counselor at Orchid Health's Wade Creek Clinic, are working to connect with local residents who have a need for therapy and other resources for mental healthcare.
Research shows that additional availability of these resources in rural areas could be beneficial. In 2017, a study by the Centers for Disease Control and Prevention found that from 2001-2015, rural counties had a suicide rate of 17.32%, compared to 11.92%t in large metropolitan areas.
"I think one element of that is feeling like there's a stigma . . . about what's OK to talk about. (There's the thought that) if you're still able to walk and talk, it's not a problem," Edwards said.
Though resources in smaller towns are sometimes limited compared to their urban counterparts, Estacada providers are working together to ensure that clients connect with what they need. For example, Long-Drew often receives counseling referrals from Orchid Health, and in turn refers clients to Orchid if he believes they may be experiencing a medication-related issue.
At Orchid, Edwards often connects with clients when they visit the clinic for other reasons.
"If there's anything going on, (staff will ask the patient), 'Hey, do you want to meet with Laura?'" she said.
Edwards also receives referrals through the Estacada School District. Because of a school-based health grant the clinic received, student visits are free and not billed to insurance, thus allowing them to remain confidential.
However, not everyone is aware of these resources, and some who do know of them might be hesitant to utilize them. "There's a stigma about being in counseling," Edwards said. "People are scared for other people to know about it. They're scared to be labeled as crazy."
Long-Drew noted that a mindset of self-reliance may also cause rural residents to avoid seeking services. "We pull ourselves up by our own bootstraps. Seeking help (is often seen as) big city stuff," he said.
Edwards is typically booked out three weeks to a month in advance and said "there's a triaging aspect" to scheduling clients. She usually sees clients every two weeks, although "If someone comes in crisis, I make room to see them weekly."
Edwards also noted that it is sometimes difficult for people to travel to other cities to receive counseling if they do not have a vehicle, so they utilize other opportunities such as talking with church pastors or using meditation apps.
Long-Drew, who lives in Estacada with his family, takes steps to ensure his clients' confidentiality. Particularly in a small community, it's not uncommon to run into clients outside of session.
"I'm very aware of what not to talk about," he said. "I'm not going to hide behind a bush or act fake, but it's keeping that professional awareness."
He is also a pastor at Estacada Assembly of God and avoids preaching from the pulpit. "My sermons could feel like they're directed at a person I've counseled," he said.
Edwards previously worked in Portland and sees several differences between practicing in rural and urban areas. "So many people are connected in this community. There are a lot of undercurrents, and sometimes it's hard to piece it all together while not letting on I know anyone else in their family. It's a careful dance. If I do an intake, I probably know someone in their family or will soon," she said. "There's a lot more connectedness for positive supports, but there's also shared trauma."
Comparing the time she spent working in urban areas to the time she's worked in rural areas, Edwards think suicidal ideation and intent seems to be more common in the latter, which she attributes to the stigma about discussing some topics.
Particularly common, Edwards noted, is passive suicidal ideation, during which a person "has no plans (to kill themself) but just doesn't want to feel the way they feel anymore."
"It's a risky category because only one change in impulse control can turn it into a decision they regret, or don't live to regret," she said.
Long-Drew said he often sees suicidal ideation and intent with younger clients.
"People will say 'go kill yourself' instead of saying 'buzz off' as a way to tell someone to stop bothering them," he said. "There's also a lot of cyberbullying."
Edwards, who works with clients ages three to 90 for a variety of reasons, noted that seeing a counselor is more common than many might expect. "I tell students, you'd be surprised about how many people at your school get counseling," she said.
While working with an individual with suicidal ideation or intent, Edwards and Long-Drew utilize safety plans and no-harm contracts, reinforce strengths and discuss ways of looking at life, among other strategies.
Though there is room for additional productive conversations about suicide, Long-Drew is glad to see the topic discussed in both rural and urban areas. "I love that we're finally addressing mental health," he said. "You'd go to a doctor for a broken leg, but there's still shame in mental health. Just because you see a counselor, you're not crazy. I love that we're beginning to normalize the issue of mental health."