Surprised by Joy: Rural, School-Based Social Work

Years ago, I completed my Master’s degree in social work and had idealized plans to save the world, one therapy session at a time. I had always anticipated working with adults, perhaps in a traditional office setting, billing private insurance, and handling presenting problems with aplomb and a surefire treatment plan. Perhaps, I thought, opening a private practice where I could set my own hours, limit my patient load, and enjoy lots of spare time dedicated to travel and relaxation. Sixteen years later, I find myself in a job I love but never anticipated. Rather than a traditional office, I serve a mobile school-based health center with only one other staff member, a Certified Physician Assistant. I am not only the physical driver of the clinic, but also serve as the receptionist, the cleaning staff, the basic repairwoman, and the mental health provider to an underserved adolescent population! Despite its challenges, I could not have foreseen the joy and fulfillment this type of challenging rural practice brings to both the teens with which I work and me.

Despite being educated in a program that emphasized rural health care and intervention, I was nevertheless unprepared for the challenges and rewards of actual daily practice. Most teens within the schools our clinic serves experience significant poverty and limited access to consistent mental and physical health care. Presenting problems are complicated and difficult to assess in their entirety. Adolescents are often suspicious of adult motives, making the development of rapport and trust essential to effective treatment. I spend a great deal of time being physically present and visible within the school culture, perfecting adolescent interview and communication skills, and cultivating an impression of openness, to create a nonjudgmental and easily accessible clinic with providers who are viewed as supportive, caring, and non-authoritative. It also became readily apparent that to be successful in our mission of providing care, many other considerations, and additional professionals would be needed for the best outcome.

Within the rural setting, the school health center is often confronted with adolescents so overwhelmed by circumstances outside of their control that it fosters both frustration and motivation on their behalf. Take for instance sixteen-year-old “Sarah,” mother to an infant under one-year-old and living with a drug addicted boyfriend who offers no parenting help or assistance other than to allow Sarah and the child to reside with him. Sarah’s mother is an alcoholic and is often homeless herself. Sarah’s father is in jail for assorted crimes and has not expressed interest in visitation with Sarah or her young child. Sarah experiences depression and anxiety, often compounded by her lack of sleep at night and the general stress of raising a child essentially on her own. Yet, she comes to school every day and is making excellent grades. She schedules counseling appointments regularly and consults with the medical provider as needed. She expressed tremendous relief when we were able to secure her own food assistance benefits, discover alternate housing options, and link her with a case manager at her primary care provider’s office to assist with continuing needs. Luckily, Sarah has a semi-reliable vehicle that enables her to travel to her primary care office and utilize local childcare during the day. Without such, Sarah would be far more limited in her ability to access resources, as there are no public transportation options in her town of residence.

Seventeen-year-old “Nathan” is struggling to make it to school each day and has been referred to truancy on several occasions. His depression often becomes so severe, he cannot make himself get out of bed. On days he does come to school, he is often angry and lashes out at others. He has at least two more years of high school before he can graduate because he dropped from enrollment temporarily after his mother kicked him out and moved out of state. He is currently staying with an adult he does not know very well but met through others. Relationships in this home are tenuous and fueled by drug abuse and...