Building therapeutic alliance with farmers seeking mental health care: a qualitative study of providers’ perspectives and recommendations

Introduction: Rural and remote communities remain hard-to-reach populations, with persistent barriers to accessing timely, appropriate, and culturally relevant mental health care. Within these settings, farmers face a wide range of unique work-related stressors that can contribute to mental health challenges. Research shows that farmers experience higher levels of depression, anxiety, and suicide compared to the general population, yet have low rates of seeking mental health support. Low rates of help-seeking among farmers have been linked to mental health stigma, cultural norms of stoicism and independence, and skepticism toward non-farming professionals. As awareness about farmers’ urgent mental health needs grows, there is increasing pressure on policymakers, industry groups, and healthcare organizations to provide support. However, without culturally responsive approaches that reflect the realities of farming, these efforts risk falling short. Mental healthcare professionals (MHCPs) who already work with farmer clients are well-positioned to inform the development and implementation of policies, practice, and training aimed at addressing farmer mental health issues. Therefore, the purpose of our study was to address this gap by exploring the experiences of MHCPs who work with farmers to identify the strategies they use to effectively engage and build trust in a therapeutic setting. 

Methods: Using descriptive phenomenology, we conducted individual semi-structured interviews between March and May 2024 with 25 MHCPs practicing in Alberta or Ontario, Canada. All participants lived in a rural area, had been practicing for at least 12 months, and provided counselling services to farmers. Interviews were conducted virtually through Zoom or by telephone. Interviews were recorded and transcribed verbatim. Data were analyzed using thematic analysis. 

Results: Our analysis revealed five themes that were deemed important for effectively engaging and building trust with farmer clients: Understanding the unique stressors of farmers, setting the tone, building trust, providing psychoeducation, and tailoring therapy and sustaining connections. We translated these themes to create a conceptual model, called the Farmer-Centered Therapy Framework, which provides a visual summary of the stepwise approach MHCPs use working with farmer clients to achieve therapeutic alliance.

Conclusion: Effectively engaging farmers and building trust in therapeutic settings is a multifaceted process that begins with understanding the distinct culture, values, stressors, and lifestyle of farm life. This study addresses a critical and timely gap in the literature by exploring the experiences of MHCPs who work directly with farmers on their mental health issues. The findings have important implications for rural and remote health policy and practice by highlighting the need for culturally informed mental health services that align with the values and lived experiences of farmers. Presenting our findings through the Farmer-Centered Therapy Framework can guide culturally responsive approaches for supporting MHCPs who have farmer clients. Furthermore, integrating this knowledge into provider training and service delivery models can reduce real and perceived barriers to services, increase engagement, and improve the mental health outcomes in farming communities. 

Keywords: agriculture, farmers, help-seeking, mental health, rural mental health, therapeutic alliance.