What Is Agricultural Behavioral Health?

Background

In 2017, two years after completing a doctoral degree at East Carolina University (ECU) in medical family therapy, I incorporated my own family therapy and consulting firm dedicated to serving the mental health and behavioral health needs of the farming community. It was never my intention to start a consulting business, but as there were no job listings for a farm-therapist, I found myself organizing a consulting firm. I would later discover the agricultural organizations that specialize in agricultural healthcare, but agricultural behavioral health was still developing.

The agricultural behavioral health niche and specialization exists in agricultural health and safety and some psychology circles, areas which I was still yet to discover.¹ Nevertheless, my aim upon completing my graduate work was to serve the families who make their living working on family farms.

My purpose in writing the following article is to give the reader a brief overview of what agricultural behavioral health is, to explain why and how I pursued this path, and to offer information, recommendations, and resources to others who might be interested in working in this niche or specialization. Incidentally, agricultural behavioral health is both a “niche” and a “specialization.” It is a niche because the agricultural population is a specific segment of the broader population, and it is a specialization because it will require mental health providers to understand the culture of the people and the culture of the occupation in order to provide the most effective assessments and interventions.

Additionally, I offer the reader my own experiences and knowledge based on what I have learned over the years working with this culture as a mental health professional. The world of agriculture is unique, with a professional circle of healthcare providers who are skilled in working with this population. While I am not new to the culture of farmers and farming, I am certainly late on the scene to agricultural healthcare.

Introduction to agricultural behavioral health

I first encountered the term “agricultural behavioral health” in an online publication by Dr. Mike Rosmann. Dr. Rosmann is a clinical psychologist and farmer and was the first to develop a mental health response in the state of Iowa during the farming crisis of the 1980s (Rosmann, n.d.). Iowa was known as the “epicenter of disastrous events that brought generations of farmers to their knees” (excerpt from the documentary The Farm Crisis; Iowa PBS, July 1, 2013). During the ‘80s farm crisis, many family farms were confronted with foreclosure, farm families across the country lost everything, and farmer suicides sky-rocketed (2013). Dr. Rosmann has been instrumental in developing the new specialty of agricultural behavioral health, and has remained at the forefront of the mental health response to farm families. His latest book, titled Agricultural Behavioral Health, is to be released this year (Rosmann, n.d.)

Crises in agriculture are not new (Melichar, 1977), and the associated mental health crises for farmers are certainly not new, just perhaps unacknowledged in the social sciences in decades past (Cogner & Elder, 1994). As of today, a quick search through the literature will expose a wealth of recent, global mental health studies focused on the farming population (Daghagh Yazd et al., 2019), and demonstrates a growing interest in farm-related mental health research; however, evidence of effective interventions is still lagging (Hagen, et al., 2019; Younker & Radunovich, 2021).

Farm policy

Modern farm policy in America was built on the events that stretched from 1970 to 1989, an era that has been compared with the era of World War I, where farm policy originated (Coppess, 2018). Through the 1970s and 1980s the agricultural sector in America began to expand into larger national and global economic systems, which subsequently made it more vulnerable to economic and political influences (Barnett, 1993). Incidentally, since farming is now a global industry, food security also means national security.

My Story

My family’s farm (the Woodlief Homeplace, 1881). I purchased the house and farm from my grandfather in 1983 – Operating today as Bell & Wood Botanicals

It was the farming crisis of the 1980s that prompted my interest in mental health support for farming families and my pursuit as a family farm therapist. My early years were spent on my own family’s farm working alongside family members in the fields, at the barns, in the stables, the pastures, and in-and-out of pick-up trucks. We owned a small-scale farm just south of the North Carolina-Virginia border. We grew the traditional row crops of tobacco, sweet potatoes, soybeans, and corn; and we raised small livestock. This farm had been in our family for many generations, and as is typical for multi-generational family farms, our entire family worked on the farm. In addition, many of our family members also lived on the farm property. Consequently, several families were dependent on the viability of this one farm, a phenomenon still seen throughout the farming population.

Much like farming was in my family’s blood, so were other predispositions. Several members of my family, across the generations, demonstrated features of severe mental illness, but the associated stigma served as the deterrent for seeking help. My father, in fact, would eventually succumb to the stress associated with farming, be diagnosed with schizophrenia, and be in and out of hospitals for the remaining days of his shortened lifespan (he died at the age of 67). Though we did not lose the farm to the financial calamities going on around us, it was the stigma of mental illness that motivated my great-uncle to quietly rewrite his last will and testament, removing my father as heir to the acreage that had been promised to him, the land that my family had worked and lived on for so many years, the land that we depended on for our survival. We subsequently lost our entire livelihood, our entire lifestyle, our house and home; our identity. The grief was difficult for all of us to bear, and on more than one occasion, my father attempted to join the statistics of farmer suicides.²

Family farms in America: The numbers

In 1862, 90% of Americans were farmers and by 1920, this number was down to 30% (Public Broadcasting Service, n.d.). Beginning in 1940 and over the next four decades there was a dramatic decrease in the nation’s population living on farms. By 1981, there were less than 3% of the U.S. population farming (n.d.). In this same time, the average size of a farm more than doubled, and much of rural America branched out into nonagricultural industries (Cogner & Elder, 1994). Today, farm and ranch families comprise less than 2% of the U.S. population (American Farm Bureau Federation, n.d.). It is these 2% who subsequently provide food and fiber to the rest of us, and we need them to be successful.

Current mental health concerns in agriculture

Current global research indicates that family farms are in crisis (Daghagh Yazd, 2019). National reports of suicide among the farming population are at alarming rates, with some U.S. data indicating 3 times the suicide rates of the general population (Norrod et al., 2023; Peterson et al., 2020). Furthermore, we know from research that it is the occupation-related stressors that put this population at risk for suicide (Daghagh Yazd, 2019).

Occupational stressors identified in the farming population include many variables outside of a farmer’s control, such as variable weather patterns, volatile commodity markets, government regulations and administrative requirements (loads of paperwork), trade agreements, shortage of farm labor, and the maintenance of an employee workforce (Reed & Claunch, 2020), to name the more common. Risk factors associated with farmer stress and behavioral health include financial difficulties, working long hours in isolation, no sick leave or vacation time, physical health issues, easy access to firearms, and exposure to pesticides³, to name a few (Daghagh Yazd, 2019). Some of the more common mental health issues include adjustment disorders, problems in relationships, anxiety, depression, and substance misuse (Rosmann, 2016).

Today, of all farms in the U.S., 98% are family farms. Of these, 89% are categorized as small family farms (Whitt et al., 2020). In 2020, most small family farms had an Operating Profit Margin (OPM) of less than 10%—indicating a higher risk of financial problems. The OPM is the share of gross income that is profit, one way to gauge a farm’s financial performance. According to Whitt and colleagues, small family farms do not always earn a profit and sometimes may even lose money farming (42% in 2020 and 39% in 2011).

My Story, Continued …

It was later in my life that I turned my attention toward graduate training in marriage and family therapy. I was deliberate in my choice of degree, choosing the marriage and family therapy program because I understood from my own experiences the importance of relational interactions in relieving stress and effectively treating issues related to mental health within the family system, as well as within the farm system. I graduated with my doctorate in 2015 and entered the job market faced with the realization that there were no jobs out there for my area of expertise. The work was certainly available to me, as by now farm families had heard (by word of mouth, as is common in this population) that I specialized in working with farms; but finding a position that allowed me to provide these services and receive due compensation, there lay the challenge.

For decades, I had been involved with the migrant and seasonal farmworker (MSFW) population here in North Carolina through my volunteer work with community-based organizations (e.g., the Association of Mexicans in North Carolina [AMEXCAN], NC public school system) beginning in the late 90s. I then began working professionally with this population in 2010 during my master’s program at ECU. I had worked alongside MSFWs on my family’s farm when I was a child, establishing an appreciation for the culture.

By 2015, I was providing behavioral health services for the North Carolina Growers’ Association (NCGA), a member organization responsible for the nearly 10,000 H-2A farmworkers who come from Mexico to work on farms across the state of North Carolina. These farmworkers are employed through the NCGA organization to work on approximately 700 North Carolina family farms. After establishing a trusting relationship with the directors and some of the members of this organization, NCGA made it part of their protocol to contact me when there was a mental health crisis on one of the member farms. Finally, I was where I belonged! I was doing the work, but the path was not as illuminated as I had hoped it would be. There were still some things to figure out.

The family farm system: A new frontier for behavioral health

As I stated earlier, I was deliberate in my choice of degree. When searching for an appropriate graduate program and reading that the marriage and family therapy degree was “grounded in systems theory,” I knew I had found my home; and I took this idea with me to the farm. I see the farm as a system, and in North Carolina, this means that the farm family and the farmworkers are all part of the system. They affect, and are affected by, one another.

The initial years were difficult and there were no peers with whom to collaborate.⁵ Also, compensation was not without challenges.⁶ Though invoices were always quickly satisfied, there were other barriers. Conflicts of interest were the most prevalent issues I would run up against when charging for services. I keep my Code of Ethics close by. Providing behavioral health services in agriculture and staying out of conflicts of interest is always a challenge.⁷ When I am working with a farm, I am often working with multiple stake holders at any given time. There is the farm owner/operator (and the family members), and then the farmworker(s), various state and advocacy groups, and then often there is the farming entity who has contacted me and is paying for my services. I currently work with farm entities such as NCGA, NC Farm Bureau, the Veterans’ Farm of North Carolina (VFNC), the NC Agromedicine Institute, and other ag-departments at various other universities.

Currently, agriculture is cycling through a repeat of the earlier farm crises, with similar mental health issues that farmers experienced in the 1980s. In a 1994 book publication, Families in Troubled Times, the authors raised concerns that social scientists have historically ignored cyclical patterns of economic hardship and the associated recurring farm crises (Cogner & Elder, 1994). My own father attempted to take his life during these days following the loss of our land and home. I had assumed it was due to his mental illness; at least that is how his medical team made sense of it. However, as I began working “in the field” with farming families and MSFW families, I saw things from a new perspective, and important patterns began to emerge.

AgriCULTURE: Rural population? Or something more?

While our healthcare organizations are trained to utilize culturally sensitive methods in clinical practice, I was not aware of the cultural characteristics that make farming families unique and that make a difference in how they receive behavioral health interventions. In fact, farm owners/operators have been indifferently identified in research studies only by their rural characteristics (Cromartie & Bucholtz, June 01, 2008). However, throughout my graduate studies, I chose coursework that seemed relevant to my chosen path. I took classes in rural health, public policy, and courses in gerontology (the average age of a farmer is 58, and steadily increasing [USDA, 2022]).

My first internship was with palliative care and my second was with a community-based organization (AMEXCAN) to learn about the implications of farm and immigration policy. It would be some years later, during my fieldwork with NCGA, that I would understand there are differences that set farming families apart as unique in their behavioral healthcare needs. There are more culturally pertinent aspects to consider when working with farm families and the farm system.

Presently, there is a recent and growing ensemble of literature that differentiates farm culture from rural culture. For this reason, I have chosen to adopt Dr. Rosmann’s term of agricultural behavioral health to differentiate the behavioral health work I do with the farming population. Dr. Rosmann highlights that some behavioral and personality research data differentiate traits that are characteristic to individuals engaged in agriculture, a theory known as “the agrarian imperative” (Rosmann, 2010). From the publication abstract, Rosmann writes “The most recent National Occupational Research Agenda includes, as a goal, conducting research that enhances the understanding of psychological factors that affect the well-being of people engaged in farming” and “the author proposes a construct, the agrarian imperative, as an explanation for why people engage in agriculture” (2010, p. 1).

Laying groundwork: Organizing resources and identifying culturally competent providers

Congress passes legislation around farm policy in the form of the Farm Bill every five years or so. With lessons learned from the previous farm crisis that corresponded with a dramatic increase in farmer suicides, provisions supporting mental healthcare and farm-stress relief were included in the subsequent Farm Bills.

Read the latest about the Farm Bill here.

The last Farm Bill (passed in 2018 and simply extended in 2023) provided funds through the National Institute of Food and Agriculture (NIFA), a federal agency under the United States Department of Agriculture (USDA), for stress assistance to farms across the country—a program known as the Farm and Ranch Stress Assistance Network (FRSAN). This funding is funneled through universities throughout the U.S. by region. North Carolina (my state) is included in the region known as the Southern Ag Exchange Network (SAgE) which consists of 13 states and serves to organize and standardize stress relief programs and resources for the region. The funds in North Carolina come through the NC Agromedicine Institute, housed at ECU’s Brody School of Medicine, which is a University of North Carolina inter-institute whose partners are East Carolina University, North Carolina State University, and North Carolina A&T University.

Notably, there is a great and concerted effort to lay solid, long-term networks across the U.S. to get stress relief assistance to our farms. I was introduced to the NC Agromedicine Institute in 2019 as they were well immersed in their own behavioral health response. Eventually, I found myself in a synergetic partnership with the Institute. Certainly not every state is so fortunate as to have an Agromedicine Institute, but there is likely a local university that works with the FRSAN in every U.S. state.

Current efforts being undertaken in North Carolina include not only stress relief, program development, mental health trainings, and a clinical response, but also the formation of a Provider Support Network (PSN). There is a shortage of mental health providers across the country, especially in rural areas, but there is an even greater shortage of providers who understand the farming culture. The goal of a PSN is to offer providers who are from a farming background, or who are interested in working with farmers, a network of peer professionals working with the farming population to receive support, resources, and training. Its purpose is also to provide behavioral health professionals with a space to discuss the unique cases and challenges they encounter. The PSN is being established so that providers may learn from one another, access the relevant information, and feel prepared to work with farmers. Though the PSN that is underway in North Carolina may be unique to the state, the FRSAN will likely have similar PSNs in other regions that are suitable to those regions.

When the client is a farm: What therapy looks like

Agricultural Behavioral Health Provider—(the niche). Therapists working with agricultural clients will be most effective if they know the language of farming and understand the culture (I have provided a list of training modules and other resources below). Though there have been no studies identifying specific therapeutic interventions aside from peer farmer support groups and stress relief techniques, I have been pleased with Structural Family Therapy and Bowen’s Family Systems Theory as my chosen modalities. These models are in line with the farm family culture and the interventions make sense to farm families.

While farmers are often uninsured, they can be good candidates for the ACA enrollment. If they do have healthcare insurance, it will often be through a spouse’s employment with the state. AAMFT’s recent success in getting LMFTs covered by Medicare is a big plus and should be helpful. Especially since the average age of the American farmer is 58 years and steadily increasing.

Agricultural behavioral Health Consultant—(the specialization). If you are from a farming background and know the culture, you may want to consider consulting and contractual work. Contract work can include program development, research and evaluation, as well as professional presentations. Clinical work for me usually looks like this: I will get a call (from the farmer, primary care provider, the NCGA, etc.), I will communicate with the farmer, show up on the farm and assess the mental health situation, provide appropriate referrals and follow-ups with hospitals, community health centers, counseling centers, and farmworker outreach programs. I provide triage. I stay with the farm through the duration of the stressful event, while also providing support to the individual(s) being triaged.

I have encountered situations I could never have imagined. Case issues crossed a gambit of unknowns, such as: dealing with Immigration Control Enforcement (ICE) raids on farms during the Obama administration that left farmworker families traumatized and farm owners ladened with anxiety; encountering sex trafficking and subsequently collaborating with the U.S. Department of Labor; attending to a farmworker who became psychotic, broke into a store during an episode, and was apprehended by local police and sent to state prison (this case took months of work, engaging with the farmer, the prison system, the Office of the Mexican Consulate, and the court system before finally securing the worker’s release). I have encountered accidental deaths⁴, suicides which might have been prevented if only the farm had been aware of the signs of mental illness, I have stood in the doorway of a hospital room where the body of a farmworker lay, just to keep the nurse from removing his body before his farmworker friends could get there to say goodbye. I have sat with a farmer in a stable in the cold of the night as he put one of his livestock down to save her from an otherwise painful death. And I have stood in the kitchen of a farmhouse with a 9^th-generation farmer as he tried to come to terms with the fact that he would be the generation to lose the family farm. There is a lot of grief and loss in agriculture.

Hear an 18-minute presentation using real cases to describe what a farm consultation looks like. I gave this presentation to an audience of farmers at the NC Farm Bureau Policy Review Day 2023.

Current trends in mental health in agricultural populations

Farmer-to-Farmer peer matchups. Suicide rates among farmers are known to be higher than the general population in nearly every country (Rosmann, 2010). Barriers to farmers seeking help with stress include the stigma associated with mental illness, as well as cultural characteristics (Scheyett et al., 2024). For these reasons, ag-groups are utilizing a “farmer-to-farmer” support approach.

Mental health trainings. Many ag-groups (including the NC Agromedicine Institute and state Co-operative Extension Agencies) are conducting trainings around suicide prevention. Some of these trainings include: Mental Health First Aid; ASIST; Safe Talk.

New “beginning farmers.” These farmers are at higher risk for suicidal ideation (Montgomery & Scoggins, 2024). Furthermore, 30% of all farmers are beginning farmers (in business less than 10 years); their average age is 47 (American Farm Bureau Federation, 2024).

Women in Ag (WIA). Women-owned farms have been increasing. Furthermore, women serve as the “peacekeepers” and “buffers” in the farming family. Women are developing their own WIA groups to garner support from one another and access the resources they need to continue staying healthy despite the stress with which they live.

Veteran Farms. The Soldier to Ag Program (SAP) is the brainchild of Robert Elliott, Executive Director of the Veterans’ Farm of North Carolina (VFNC). The idea for SAP began 10 years ago to answer the growing need for farmers and to replace the farmers leaving agriculture. The program is also designed to address the suicide rates among veterans returning from active duty who are otherwise at high risk of suicide. VFNC partners with the NIFA and the USDA to present training and education programs designed for veterans who wish to enter the agricultural field as “beginning” farmers and ranchers. The program addresses the challenges related to establishing and sustaining a new farm operation, provides veterans with a new “mission and purpose,” and provides a long-term peer support network to veteran students.

Conclusion

Agricultural behavioral health is a new frontier for mental health providers. The health of our family farms directly impacts our nation’s food and national security. Agricultural research from across the globe indicates that family farms are currently in a state of crisis, with farmer suicides at alarming rates. Health and safety studies that focus on farming populations point to challenges that span biological, psychological, and sociological domains. While a family farm operation is necessarily co-located with the family home, many of these farms are also temporary work/home environments for many migrant and seasonal agricultural workers. As marriage and family therapists are systems thinkers, we understand the need for a holistic treatment approach. Since family farms are unique in many elements of culture, and because the health implications span biopsychosocial (BPS) domains, marriage and family therapists are well suited to work with this culture.

Footnotes

¹There have been efforts ongoing in various parts of the world to address mental health in farming and this has been steadily increasing.

²My husband’s uncle lost their family’s farm during this same period of time. He died from a self-inflicted gunshot to the head.

³Farmer depression and suicide have been linked to pesticide use (Daghagh Yazd, 2019).

⁴Agriculture is known to be among the most dangerous occupations compared to other occupations (bls, 2023).

⁵I want to extend a special thank you to Dr. Angela Lamson, a professor in the department of Human Development and Family Science, College of Health and Human Performance at ECU and my mentor. There have been so many times I have reached out to her for guidance, and she has always answered her phone and email. A sincere “thank you, Angela.”

⁶Farm families are often uninsured. When I am on-site, I always inquire about their access to health insurance and ask if they and any workers on the farm are connected to a primary care physician. If they are not, I ask if I may make some referrals and connect them.

⁷The farming community is a close-knit group, allowing opportunities for conflicts of interests. Though we see this in rural communities as well, the farming community is much more so. Farmers belong to organizations that exist across the country and connect with one another regularly, making confidentiality a challenge.

Resources

I worked with the NC Agromedicine Institute and eastern region Area Health Education Center (AHEC) to put together two behavioral health training modules (Where Farm & Family Intersect I: the Farm Family; and Where Farm & Family Intersect II: the Farm Worker). These modules are housed at NC AHEC and can be accessed for continuing education credit. I am currently working on two additional training modules that should be accessible by this year’s end (Grief & Loss on the Farm I: the farm family; Grief & Loss on the Farm II: the farmworker). NC AHEC has additional trainings available on health and safety that are relevant for behavioral health providers, such as modules on the issues of aging on a farm.

NC AHEC material

Staff at the NC Agromedicine Institute can be a great resource

Additionally, the FRSAN is actively engaged in relevant research and program development

Rural Response to Farmer Mental Health and Suicide Prevention