Master's Project Title:

Providing Mental Health Care to Underserved Child and Adolescent Populations in East Central Minnesota: Therapeutic Services Agency, Inc. (Executive Summary)

MCH Student:

Nikki Tillman

Date of Defense:

October 5, 2018



Mental well-being is an important part of development for all children. However, children and adolescents with trauma histories are at significant risk for negative mental health outcomes in childhood and adulthood (Minnesota Department of Health, 2013). Of those who are at particularly high risk are young people in the foster care system with disrupted attachment with adults (Stinehart, Scott, & Barfield, 2012). Unfortunately for youth in rural areas of Minnesota, mental health services can be difficult to access. There is a workforce shortage of all types of mental health providers in the state that is significantly worse in rural areas (Minnesota Department of Health, 2018a). To address the rural disparities in mental health care access and health outcomes of youth who have experienced trauma, the mental health agency where I completed my field experience, Therapeutic Services Agency, Inc (TSA), serves clients in East Central Minnesota. TSA focuses services in communities without other mental health agencies, and on communities with increased and unmet needs, such as foster care children.


My learning objectives for this field experience centered on the unmet mental health needs in rural populations. The first objective was to learn about the epidemiology, especially disparities and health outcomes, and screening practices that are unique to mental health in rural Minnesota. My second objective was then to learn about how to prevent poor health outcomes for rural youth with mental health concerns, trauma histories, and other adverse childhood experiences (ACEs). Finally, I narrowed my focus to one specific population served by TSA, youth in foster care and/or youth with disrupted attachment and to learn about the prevention of poor health outcomes for these rural youth in particular. To achieve these learning objectives, I was an intern in the Day Treatment and Child & Adolescent Treatment Programs (CTP/ATP), providing therapy and skills group facilitation. Children and adolescents in these programs have mental health diagnoses and trauma histories. In addition, clients in the CTP/ATP programs are all in therapeutic foster care.


TSA is a for-profit mental health agency based in Pine City, Minnesota and was founded in 1978. TSA has expanded over the past forty years to provide a wide variety of mental health services across East Central Minnesota and into the Twin Cities metro, though rural populations remain their primary focus (see figure 1). TSA identifies populations at risk and in need of mental health services through collaboration with local counties and schools, community advocacy organizations, and by being part of a state legislative advocacy organization for youth-serving organizations called AspireMN. As the state of Minnesota has determined new populations at risk for poor health outcomes, TSA has expanded services to meet the need and provide preventative mental health services. For instance, they were one of the first mental health agencies in the state to start infant mental health services with a state grant (C. Smetana McHugh, personal communication, November 27, 2017). They have also expanded into communities affected by the disparities in access to mental health care. They host and have staff attend educational opportunities about the epidemiology of mental health in Minnesota to ensure they are meeting the identified needs of the various communities they serve. TSA uses the evidence-based Developmental Repair model to help kids form healthy attachments with adults. Repaired attachment helps youth decrease their risk for poor health outcomes (Gearity, 2009). Youth who experience TSA programming can take their new skills into their lives and communities, helping to disrupt the cycles of generational trauma and increase positive mental and physical health in future generations.

Lessons Learned

During my Field Experience, I learned many lessons I will carry with me into my professional practice. For one, I learned there are unique challenges in correcting the disparities in access to care experienced by rural populations due to factors such as lower rates of insured persons and significant travel time to the closest care facility. I learned that early screening and intervention are key tools to prevent poor health outcomes for rural adults and disrupt generational cycles of trauma. Developmental repair is possible for foster care children and/or those with disrupted attachment with adults and helps children break generational patterns. However, this is not possible without practices in place to screen early and well for youth at risk. Collaboration between mental health agencies, schools, epidemiologists, counties, and others is necessary for both prevention and effective intervention. Finally, engaging and educating youth about trauma, ACEs, and mental well-being are all important tools in creating healthy communities.


While TSA does extensive work in East Central Minnesota rural communities, they cannot meet all of the needs without greatly increasing their number of effectively trained staff. More generally, the mental health workforce in all rural parts of Minnesota needs to increase. This issue has been recognized by the Minnesota State Legislature and a workforce plan was put in place to increase the mental health workforce in rural areas starting in 2015 (HealthForce Minnesota, 2015). One large draw was adding mental health practitioners to the Minnesota Health Professional Loan Forgiveness Program for those who practice in rural areas, though that program is not currently accepting applications (Minnesota Department of Health, 2018). Another recommendation is increased early identification of child experiencing ACEs and trauma through coordination across schools, counties, and others. The earlier that screening and identification of at-risk populations can occur, the better the chance of disrupting unhealthy patterns and preventing poor health outcomes in communities. For children in foster care specifically, widespread education for families, schools, and childcare facilities about best practices in repairing disrupted attachment would be beneficial. Finally, more evidence-based interventions need to be implemented in rural areas. For instance, engaging and educating youth about the negative health outcomes of trauma and ACEs and providing youth with tools to prevent and intervene can positively affect the health of our rural communities.


Youth who have experienced trauma and/or disrupted attachment are at increased risk of poor health outcomes. Coupled with the disparities in access to mental health providers, youth in rural Minnesota are at increased risk. Prevention of poor health outcomes due to trauma is possible through effective, evidence-based interventions such as developmental repair. Attention, funding, and organizational collaboration are necessary to further meet these public health problems in rural Minnesota.


  1. Gearity, A. (2009). Developmental repair: A training manual. Minneapolis, MN: Washburn Center for Children. Retrieved from
  2. HealthForce Minnesota. (2015). Gearing up for action: Mental health workforce plan for Minnesota. Retrieved from
  3. Minnesota Department of Agriculture. (n.d.). Minnesota land by region [map]. Retrieved from
  4. Minnesota Department of Health. (2013). Adverse childhood experiences in Minnesota. Retrieved from
  5. Minnesota Department of Health. (2018a). Mental and behavioral health workforce reports. Retrieved from
  6. Minnesota Department of Health. (2018b). Minnesota rural mental health professional loan forgiveness guidelines. Retrieved from
  7. Stinehart, M. A., Scott, D. A., & Barfield, H. G. (2012). Reactive Attachment Disorder in adopted and foster care children: Implications for mental health professionals. The Family Journal: Counseling and Therapy for Couples and Families, 20(4), 355-360.