Rural Mental Health in Teletherapy: Bridging Cultural Gaps in Remote Practice


August 17, 2023 | Reading Time: 6 Minutes

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The mental health landscape underwent a significant transformation with the sudden rise of teletherapy services during the COVID-19 pandemic. In particular, rural, remote, and indigenous communities saw a substantial increase in accessibility to teletherapy services. However, these communities present unique cultural challenges, often overlooked in conversations around teletherapy. This article defines indigenous people as per the United Nations and outlines several facts that telehealth practitioners need to understand before trying to be helpful. The article will also outline the importance of cultural competency and safety in rural mental health settings when providing teletherapy services. A Part II article will provide a case study for the reader to evaluate.

Overview of Indigenous Communities

According to a 2020 systematic review of telehealth with indigenous populations worldwide, Indigenous communities form a rich tapestry of diverse cultures and traditions, each preserving its unique identity separate from the dominant societies they are part of. The United Nations, recognizing the broad range of these communities, has yet to provide a strict definition but rather a description of what makes up an Indigenous group. These criteria include the following.

  • Self-identification as Indigenous
  • Historical continuity with pre-colonial societies
  • Strong ties to territories and surrounding natural resources
  • Distinct social, economic, or political systems
  • Unique languages and cultures, and 
  • Being a non-dominant group in society.

These communities exist globally, with an estimated 370–500 million individuals residing in over 90 countries, representing a vast spectrum of more than 5,000 distinct cultures. Even though these communities comprise roughly 5% of the world’s population, 15% of the world’s most impoverished individuals are from these groups. This economic disparity often results in higher malnutrition rates and inadequate resource access.

Moreover, Indigenous peoples’ life expectancy is typically 20 years shorter than non-Indigenous populations worldwide. This gap is primarily due to inadequate healthcare, lack of health information, and a higher susceptibility to infectious diseases such as malaria, tuberculosis, HIV, and AIDS. Today’s blog post will explore how telehealth could address these health disparities within Indigenous communities.

The Distinctiveness of Rural Mental Health

Historically, rural communities have been underrepresented and underserved in psychological services, making the advent of teletherapy a significant development in rural mental health. However, the assumption that rural areas are merely smaller versions of urban centers is a fundamental mistake.

Rural communities come with diverse geographies, economic conditions, and cultures, which significantly differ from one another and urban centers. The unique dynamics of rural life, such as weather impacts, social norms, privacy concerns, and community roles, can significantly affect teletherapy services. Therefore, teletherapy professionals must practice cultural humility and ensure a culturally safe therapeutic setting for their rural clients.

The Importance of Cultural Competence and Safety

Cultural competency and safety are integral to effective psychotherapy. They involve understanding and respecting a client’s culture, ethnicity, beliefs, and values and viewing them as assets. This respect empowers clients to be proactive in managing their health.

Cultural humility, a cornerstone of culturally competent practice, involves ongoing self-reflection of one’s views and biases. Practitioners must be willing to acknowledge and explore personal areas of ignorance and weaknesses, as these can hinder the therapeutic relationship.

On the other hand, cultural safety addresses power imbalances inherent in the healthcare system, striving to provide an environment free of racism and discrimination. Ignoring cultural safety can lead to loss of relationships and compromise therapy effectiveness.

Researchers Shelley L. Goodwin and colleagues conducted a study of…..and published it in the Journal of Rural Mental Health (2023) regarding cultural competency issues that can arise when counseling individuals of indigenous tribes in Canada. Their article outlines considerations for providing culturally competent telepsychological services and practices. The article below summarizes the issues discussed and expands the context to delivering teletherapy to members of indigenous tribes in the US.

Applying Cultural Competency and Safety in Rural Mental Health

Given the distinctive characteristics of rural communities, teletherapy providers need to be culturally competent to provide effective care. This process begins with understanding the client’s community, lifestyle, local conditions, and available resources. Moreover, it’s important to remember that most treatment protocols are developed by urban-based psychologists working primarily with urban-dwelling individuals. This urban-centric approach may only sometimes be suitable for rural settings. Thus, teletherapy professionals need to adapt their strategies and approaches to suit the unique needs of rural communities.

Bridging the Gap for Rural Mental Health

Recognizing and bridging the disparity between urban and rural regions is pivotal to successful teletherapy. Understanding the intricacies of cultural diversity and geographic isolation within rural mental health is critical to this task. As we continue to evolve our understanding and use of telepsychology, we must ensure that these efforts are not made in isolation. Collaborating with local organizations, individuals, and governmental bodies can amplify these services’ potential success and reach.

Collaborative Efforts in Enhancing Rural Mental Health

A united, dedicated effort from the mental health field, governmental bodies, communities, and Indigenous leaders is crucial to ensure that the specific needs of rural communities are addressed adequately. Teletherapy services must be accessible and adaptable to these communities’ diverse needs and cultures, guaranteeing culturally safe psychological care for everyone, irrespective of location.

The Importance of Cultural Competency in Rural Mental Health

There is no one-size-fits-all approach to dealing with the complexities of cultural competency in rural communities. Understanding and respecting each community’s unique culture, history, and the collective and individual experiences of its people is crucial. This process requires a continuous commitment and not a one-time effort.

Privacy and Gossip in Smaller Communities

  • Community Events and Social Interactions. In a small rural town, community events and social gatherings significantly influence people’s lives. If someone is absent from a community event or misses a gathering, it can lead to speculation and gossip. This kind of gossip can affect their mental well-being, especially if they are going through a difficult time and prefer to keep their personal matters private.
  • Sharing Personal Information. In tight-knit rural communities, information spreads quickly, and people tend to know much about each other’s lives. While this can create a sense of closeness and support, it can also lead to challenges in maintaining privacy. This lack of privacy can be distressing for individuals who prefer to keep certain aspects of their lives private.
  • Community Reputation. Rural communities can place significant importance on reputation and how individuals are perceived. For instance, if someone in the community struggles with mental health issues, there might be worries about how this revelation could affect their standing in the town. The fear of being judged or stigmatized may prevent some individuals from seeking the help they need, leading to potential adverse effects on their mental well-being.

Understanding and navigating these dynamics is crucial for mental health professionals working in such areas to provide culturally safe and effective care to their clients.

Embracing Resilience in Rural Mental Health

As telehealth moves forward, we need to acknowledge the unique challenges that rural communities face and celebrate the strengths and resilience within these communities. By recognizing and capitalizing on these strengths, we can build robust and sustainable telepsychology services that foster cultural safety and provide much-needed support to these communities.

Promoting Research in Rural Mental Health

We encourage health services, universities, and other research institutions to focus on research that explores and illuminates rural communities’ unique challenges and strengths. Such research is a critical step toward advancing our understanding and practice of providing these communities with effective and culturally competent psychological care.

Recommendations and Conclusion

Practicing in rural settings requires an emphasis on cultural competency to foster cultural safety. With the significant increase in teletherapy services in rural communities, it is vital to ensure these services are accessible, appropriate, and effective. Practitioners may want to consider undertaking training that prepares them for the unique challenges posed by rural mental health.

In conclusion, recognizing and respecting the distinctive aspects of rural communities is crucial in providing culturally safe and competent teletherapy services. This awareness can significantly enhance the quality of care provided, ensuring that rural mental health receives the attention and understanding it deserves.


Abbott, D. M., Pelc, N., & Mercier, C. (2019). Cultural humility and the teaching of psychology. Scholarship of Teaching and Learning in Psychology, 5(2),169–181. Agency for Clinical Innovation. (2022). Culturally responsive practice: Consumer enablement guide.

First Nations Health Authority. (2015b). FHNA’s policy statement on cultural safety and humility.

Goodwin, S. L., Lints-Martindale, A., Carlson, A., Dean, M., Kinley, J., & Walker, S. (2023, July 27). A Review of Rural, Remote, and Northern Competency in Canada: Cultural Safety Considerations for Telepsychology and Traditional Psychological Practice. Journal of Rural Mental Health. Advanced online publication.

Hilty, D. M., Maheu, M. M., Drude, K. P., & Hertlein, K. M. (2018). The need to implement and evaluate telehealth competency frameworks to ensure quality care across behavioral health professions. Academic Psychiatry, 42(6), 818–824.

Smalley, K. B., & Warren, J. (2012). Rurality as a diversity issue. In K. B. Smalley, J. C. Warren, & J. P. Rainer (Eds.), Rural mental health: Issues, policies, and best practices (pp. 37–47). Springer Publishing Company.

Sobel, S. (1984). Independent practice in child and adolescent psychotherapy in small communities: Personal, professional, and ethical issues. Psychotherapy, 21(1), 110–117.

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