CULTURALLY SENSITIVE TRAUMA
INFORMED CARE WITH PERSONS FROM
APPALACHIA
RICH GREENLEE, PH.D.
DEFINITION OF CULTURE
• A system of shared beliefs, values, customs,
behaviors, and artifacts that the members of
society use to cope with their world and with one
another, and that are transmitted from one
generation to another through learning.” (Bates
and Plog).
CULTURAL FACTORS THAT INFLUENCE
CARE (HEALTHCARE TOOLBOX)
• Cultural factors that influence individuals and
families
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Vulnerability to trauma and trauma stress
Expression of distress
Response to trauma treatment
Help-seeking behaviors
Communication between family members
Willingness to disclose information to providers
CULTURALLY SENSITIVE
(HEALTH CARE TOOLBOX)
• Health care providers should:
• Recognize cultural variations in the perception of trauma
• Ask consumers what trauma means to them and
incorporate these beliefs into assessment and treatment
• Listen to and integrate the family’s own terms for what they
are experiencing
• Understand how your role is perceived and know family
dynamics and decision making
• Be open to kinship networks as resources
• Respect cultural values that are different than your own
DEFINITION OF TRAUMA
(THE TRAUMA INFORMED TOOLKIT)
• “Trauma refers to experiences or events that by
definition are out of the ordinary in terms of their
overwhelming nature. They are more than merely
stressful—they are also shocking, terrifying, and
devastating to the victim, resulting in profoundly
upsetting feelings of terror, shame, helplessness, and
powerlessness.” (Courtois, 1999)
THREE COMMON ELEMENTS OF EMOTIONAL
TRAUMA (TRAUMA TOOLKIT)
• It was unexpected
• The person was unprepared
• There was nothing the person could do to stop it
from happening
WHO CAN BE TRAUMATIZED?
(TRAUMA TOOLKIT)
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Individuals
Families
Communities
Cultures
Service providers (vicarious trauma)
TRAUMA INFORMED SERVICES
(HELGA LUEST)
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Consumer driven
Hopeful
Safe
Nurturing
Trust-building
Respectful
Empowering
Person centered
Individualized
flexible
TRAUMA INFORMED SERVICES
(HELGA LUEST)
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No power struggles
No mandates
Collaborations and concensus
Building self-esteem
Not punitive
Not shaming and blaming
“CONSUMERS ARE THE EXPERTS”
• “Consumers are the experts on their experiences.
The professional is the expert who guides the
consumer using concepts, theories, and
techniques.”
• (Helga Luest, President and CEO, Witness Justice)
TRAUMA IN APPALACHIA
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Extreme Poverty
Impact of War
Substance Abuse
Suicide
Accidents
Family Violence and Child Abuse
Natural Disaster
ADDITIONAL CAUSES OF TRAUMA
(THE TRAUMA TOOLKIT)
• Sudden job loss
• Relationship loss
• Discovery of life-threatening illness
Poverty
POVERTY AND UNEMPLOYMENT
A former coal miner reported what it was like after he lost his job at the coal mine:
It was just, I don't know how you'd really explain it except to say, you know, a lot of depression. A lot of sleepless
nights, and knowing', well my kids, can't have
shoes or clothes. Even the simplest things now, we say hey,
we ain't got the money. Like I say, it's still many nights, ya
know. It's just like the first day you lost your job. Maybe you
go through it three or four nights. Maybe some bill or the
taxes are up and you think, dog gone, another nail
in the coffin. And I don't know . . . we never really had anyone really close to us die in the
family, but it's got to be a little bit on that order, but ya know, it takes a long time to heal
and get over.
His wife goes on to say:
It destroyed his morale. He was useless, he was a
nobody, but after 2 years he's kind of comin' out of
it, a little bit.
POVERTY AND UNEMPLOYMENT
Then there is anxiety and worry. The families worry about disconnection notices and not
being able to pay their bills. For some of them the stress of it all has caused physical
problems.
I used to worry about a lot of things and my hair fell out. Big
bald spots on my chin here and big bald spots on my head.
The doctor said it was worry and stress. I guess I couldn't
handle it. It was affecting me internally somehow.
When night comes I usually have a hard time sleeping cause
there's a lot on my mind. It has brought me to the point of
thinking that I was having a heart attack. It put me in coronary care twice. It caused me to have a heart cath which was no treatment. But that's
where it got me. And the doctor
said, "It's nothing but stress." He did the heart cath, and he
says, "Will, there's nothing there . . . and he says, "It's
stress." He says, whatever is causing it, you have to find a
way.., he says, get counseling. Find something as an outlet.
THE APPALACHIAN INHERITANCE: A CULTURALLY
TRANSMITTED TRAUMATIC STRESS SYNDROME?
(CATTELL-GORDON)
• “The roots of the principle problem of the poor lie
outside of the individual and the culture.”
• A culture of contradictions:
• Warm and hospitable, yet suspicious of outsiders
• Proud of their independence, yet uncertain about their
sense of identity
• Determined to fight injustice, but often submissive and
alienated in the face of exploitation
• Resourceful people, but when trouble comes they can
become depressed, filled with rage, helpless, anxious and
fearful.
SOCIAL TRAUMA OF POVERTY AND
UNEMPLOYMENT(CATTELL-GORDON)
• Years (generations) of individual and collective
trauma
• Reputation for being able to endure hardships and
be resilient
• But also displaying a sense of resignation, deep
depression and feelings of helplessness and
dependency.
SOCIAL TRAUMA OF POVERTY AND
UNEMPLOYMENT (CATTELL-GORDON)
• “It is my thesis that traumatic stress, wrought by
exploitation, altered the patterns of human
relationships and the socialization experiences of
children to the point that the new pattern became
encoded within the overall culture. Pieces of this
culture are handed down from generation to
generation such that when the present generation
faces a crisis of chronic unemployment their
responses are drawn from this collective pool of
bitter memories and feelings; it represents the
formation of a culturally transmitted traumatic stress
syndrome, one induced by external forces of
exploitation.” (p. 49)
IMPACT OF CHRONIC UNEMPLOYMENT
(CATTELL-GORDON)
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Shock, denial, depression, and resignation
Joblessness becomes way of life
Sense of anomie (normlessness)
Numbness of spirit
Rage
Anxiety
Retreat to fatalism
Permanent state of shock
REDEFINING THE PROBLEM
(CATTELL-GORDON)
Need to move beyond blaming the victim
Blaming the culture
Problem not caused by personal or cultural flaws
Chronic problems of poverty and unemployment
can lead to traumatic stress
• Need to focus on strengths of people and culture
• Acknowledge the extremely difficult environment in
which they live and work
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SOCIAL DISTRESS AMONG ADOLESCENTS IN
WEST VIRGINIA (BICKEL AND MCDONOUGH)
• Persistent poverty and lack of opportunity leads to
recklessness and rational response to deteriorating social
and economic circumstances.
• Dropping out of high school: when post-high school
economic opportunities increased high school
completion rates increased.
• Teen pregnancy: young women who live in areas with
economic opportunity have more incentives to avoid
teen pregnancy.
• Violent death: the absence of opportunity and loss of
connectedness with socially stable community leads to
increase in suicide and homicide among youth.
Appalachian
Culture REVISITED
APPALACHIAN CULTURE REVISITED
• Abercrombie and Fitch, “West Virginia, It’s all
relative.”
• CBS plans to develop proposed “Appalachian”
reality show.
• Diane Sawyer’s visit to Appalachia
CULTURAL IDENTITY OF THE SCOTS-IRISH THAT
SETTLED IN APPALACHIA
(JAMES WEBB, BORN FIGHTING)
Individualistic (self-reliant)
Egalitarianism (everyone equal)
Stubbornness
Toughness
Mistrusted any form of aristocracy
Patriotic,
Shaped by thousands of years of fighting (heavily
Scots-Irish WV ranked first, second or third in military
casualties in every U.S. war in 20th century).
• Culture founded on guns (NRA)
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CORE APPALACHIAN VALUES
(KEEFE, 2005)
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Independence
Individualism
Egalitarianism and Personalism
Familism
A Religious Worldview
Neighborliness
Love of the Land and Place
Avoidance of Conflict
THE ETHIC OF NEUTRALITY (HICKS)
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One must mind his or her own business
One must not call attention to oneself
One must not assume authority over another
One must avoid argument and seek agreement
CARE SEEKING BY DEPRESSED WOMEN
(BROWNING, ANDREWS, & NIEMCZURA)
Fear of illness
Physical strength vital
Only symptom labeled as physical acceptable
Women don’t come for help until there is a
“paralytic crisis.”
• Religion played a major role in women’s decisions
about suicide
• Need to be understood by practitioners
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A CHANGING ENVIRONMENT
Young continue to leave
Population aging
Housing stock deteriorating
Increase in service jobs/loss of manufacturing jobs
Still lower levels of education attainment, more
poverty and higher unemployment, etc.
• Oil/Gas Industry: the Great Panacea
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Hiring local workforce?
The New Millionaires
The land poor stay poor
Environmental Concerns
CHANGING
FAMILY
DYNAMICS
APPALACHIAN MALE ROLES (RAYFC)
Primary breadwinner and provider
Traditionally patriarchal structure
Crucial role being challenged by the labor market
Increasing role confusion and hostility
Unclear lines of authority and definition of gender
roles
• Father makes most major decisions
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APPALACHIAN TRADITIONAL FEMALE
ROLES (RAYFC)
• Traditionally more authority within the home and
primary caretaker of the younger children
• Increasingly going back to school and working in
the community
• Role confusion emerges in the family
CHANGING ROLES IN APPALACHIA
• Father generally has more to do with older children
• Some fathers have become more temperamental
due to economic stress
• Alcoholism frequently involved
• Secondary roles give sense to meaning (Fire
Dept/Little League Coach)
• Males often resist change and fall back on
traditional activities of hunting and fishing (Beagle
Story)
RETURNING
APPALACHIAN
VETERANS
WOMEN VETS (WOMEN’S BUREAU)
• Women are now 20% of new recruits and they
make up 14% of military force.
• 81 to 93% of female veterans have been exposed
to some type of trauma/half experienced before
they entered service
• 20% of female veterans who served in Iraq or
Afghanistan have been sexually assaulted.
• 20 to 48% have been sexually assaulted and 80%
have reported being sexually harassed.
SUICIDES OUTPACING WAR DEATHS FOR
TROOPS (WILLIAMS, NY TIMES, JUNE 8, 2012)
• 154 suicidal deaths in 2012/124 fatalities from
combat caused by trauma exposure, financial
problems, relationship problems, etc.
• Commanders have been reminded that those who
seek counseling should not be stigmatized
• “Getting help is not a sign of weakness; it is a sign of
strength.”
• “Commanders and supervisors cannot tolerate any
actions that belittle, haze, humiliate or ostracize any
individual, especially those who require or are
responsibly seeking professional services.”
WHY HIGH SUICIDE RATE?
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Longtime and multiple deployments
Easy access to loaded weapons
Exposure to horrors of war
Force that is overworked
Stigma that prevents them from going for treatment
50% who killed self suffered failed relationship*
VETERANS’ ATTITUDES TOWARDS MENTAL
HEALTH SERVICES (HOGE, ET AL. &
BEHRINGER & FRIEDELL)
• Military veterans less likely than general population
to seek mental health services.
• Appalachians resistant to mental health treatment
or help of any kind
• Appalachian veterans unlikely to seek help for
depression, anxiety or PTSD.
• Need comprehensive education and outreach
WORKING WITH APPALACHIAN
VETERANS (GREENLEE)
• Treat individual with dignity and respect (egalitarianism)
• Treat them like a person (personalism) and not a
number/empower the veteran to make own decisions
about treatment decisions
• Utilize church and pastors as support services
• Services need to be provided close to home and they
may need transportation assistance
• Providers must listen to them define and describe their
own problems with “nerves” and the need for “nerve
pills.”
• Many physical complaints are psychologically based
stress disorders
WORD OF CAUTION REGARDING
APPALACHIAN VETS (GREENLEE)
• “If they (providers) do not listen, they will not hear,
or they may not even be told, what is really going
on in the patient’s life and subsequently, prescribe
the wrong treatment for the wrong problem.”
• They have learned to “make do, make it last and
do without.”
• “They rarely ask for help, but when they do ask, they
ask that they be listened to in a respectful manner,
so that their voices can be heard, and they can
have some influence over their own lives and health
care.”
EXISTENTIAL TREATMENT WITH COMBAT
VETERANS (LANTZ AND GREENLEE)
• “Neither the Vietnam veteran nor the social worker
can change the amount of horror that the veteran
observed during the war. What can be changed is
the Vietnam Veteran’s opportunity and ability to
discover a sense of meaning in her or his memories
of the Vietnam War. This kind of meaning discovery
can provide considerable relief from emotional
pain.” (p. 41)
EXISTENTIAL TREATMENT WITH COMBAT
VETERANS (LANTZ AND GREENLEE)
• Desire to discover meaning is a primary and basic
motivation for most human behavior (Frankl)
• If person cannot find, recognize or discover
meaning in his or her life, the will experience
existential vacuum.
• Often filled with Anesthesia, Rage, Anxiety,
Depression, Intrusive thoughts, flashbacks and
substance abuse in the case over veterans
• Basic treatment is to side with his or her “will to
meaning.” (Frankl)
EXISTENTIAL TREATMENT WITH
VETERANS (LANTZ AND GREENLEE)
• Existential Reflection
• Use questions, comments, interpretations and sincere
personal interest to stimulate and facilitate client reflection
on meaning opportunities in the clients past, present and
future
• Network intervention
• New social activities, social relationships & social
opportunities
• Social skills training
• Help with social communication and problem solving skills to
better use meaning making opportunities
SUICIDE
SUICIDE (HAVERSON)
• Appalachian residents have higher rates of
depression, psychological distress and suicide
• Highest rates are among men 35 or older
• Ready access to firearms
• Longer travel distances to services
• Use services later in course of mental illness
• Abuse of prescription opiates and synthetics higher
in Appalachia
UNEMPLOYMENT AND SUICIDE
(RURAL SUICIDE PREVENTION)
• Events that lead to humiliation, shame and despair
(lost jobs, financial status, and home foreclosure)
• Change in living situation
• Lack of support and increasing isolation
• Easy access to guns, illicit drugs and medications
• Legal difficulties
• Barriers to health care and lack of insurance
• Loss of relationship (divorce or separation)
OTHER COMMON RISK FACTORS
(OHIO RURAL MENTAL HEALTH)
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Feeling hopeless
Purposelessness
Withdrawing and isolating from family and friends
Increase in alcohol and drug use
Risky behavior (reckless driving)
History of depression and mental illness
Family history of suicide
MENTAL ILLNESS AND SUICIDE
(RURAL SUICIDE PREVENTION)
• “Mental illness is neither a necessary nor sufficient
condition for suicide, but is strongly associated with
suicide.” (p. 4)
• 90% of people who die by suicide have a mental
health or substance abuse disorder.
• 50% have major depressive disorder
• “Key factor to reducing suicidal behaviors is the
effective diagnosis and management of major
depression.” (p.7)
RURAL APPALACHIANS AND SUICIDE
(ORMH)
• Found that the majority of participants reported
coping with depression at home and not seeking
professional help
• There is a lack of public knowledge
• National suicide rate 10.7 suicides per 100,000
people
• Adams County, Ohio, 20.9/per 100,000 people
EASY ACCESS TO LETHAL MEANS
(BARBER, 2005)
• “Where there are more guns, there are more
suicides.”
• Miller, Azrael, and Hemenenway found that rural
residents have the same level of depressive
symptoms as urban residents
• And both are likely to attempt the same amount of
suicide
• But rural people are more likely to attempt with a
firearm
• Firearms more likely to result in death
BARBERS’ THOUGHTS ON FIREARMS
• “Not all suicide victims have a sustained desire to
die. For some, their impulse is short-lived, and what
weapon they reach for determines if they live or
die.”
• “Eliminating guns would not eliminate suicide, but
research suggests it would reduce the number of
suicides.”
THE PROCESS FOR MALES
(KAY REDFIELD JAMISON)
Less likely to recognize depression in themselves
Less likely to seek treatment for it
More inclined to drink heavily when depressed
More likely to reach for firearms or other highly lethal
means
• I might argue/Appalachian males are even more
like to not recognize, nor seek treatment
• And let’s not forget returning veterans….
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SUBSTANCE
ABUSE
SUBSTANCE ABUSE IN APPALACHIA
(DUNN, BEHRINGER & BOWERS)
• Major health concern in Appalachia
• Alcohol most abused drug in Appalachia
• Cigarette smoking more prevalent among rural
Appalachians
• 31.5% Appalachian Ohio versus 26.1% nonAppalachian Ohio
• Incidence and death rates from cancer higher
• Higher use of smokeless tobacco
• Nonmedical use of prescription drugs, particularly
painkillers higher in Appalachia
SUBSTANCE ABUSE IN APPALACHIA
(CONTINUED)
• Oxycontin is the most widely abused prescription
drug in Central Appalachia
• More than 340 individuals died from overdoses
related to synthetic narcotics in eastern kentucky in
a 16-month period
• 485 people died in Kentucky in 2008 from overdoses
of prescription drugs, including methadone,
oxycodone, morphine and fentanyl.
• Methamphetamine abuse on the rise in Appalachia
• 20 to 30% of rural meth labs discovered because of
fires and explosions resulting in burns and death.
IMPACT ON COMMUNITY
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Drain on local economy
Workforce weakened
Treatment is costly and not always available
Family stability compromised
Increase in rural crime
SUBSTANCE ABUSE IN SOUTHERN OHIO
(CLEVELAND PLAIN DEALER, FEB. 26, 2011
• Portsmouth, Scioto County, public health
commissioner declared public health emergency
• 360% increase in accidental drug overdose deaths
• Highest hepatitis c rate in Ohio
• 80 to 90% of the drug cases in the prosecutor’s
office involve prescription drugs and the most
common is oxycontin
• 64 babies (10 %) born with drugs in their system
• Break-ins and robberies have increased to pay for
drug addiction
ACCIDENTS
ACCIDENTS
(PROCTOR, BERNARD, KEARNEY & COSTICH)
• Unintentional injury: “is the term for injury that Is not
caused by human intent to harm oneself or another
person.” (p. 209)
• Most common UI:
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Motor vehicle crashes
Falls
Poisoning
Drowning
Burns
INJURIES IN RURAL AMERICA
• 30% of population lives in rural areas, but have 70%
of injury related deaths. (Proctor et al., p. 210)
• Most common cause of death MVC, falls next
• Adults and children have much higher fatality rates
in Appalachian Kentucky than non-Appalachian
Kentucky. MVC death rate 46.8% higher than
national rate in West Virginia.
• In Kentucky in 2006 alone, there were 270
hospitalizations and 46 deaths in All-terrain vehicles.
RURAL TRAUMA VICTIMS
(PROCTOR, BERNARD, KEARNEY & COSTICH)
• High rates of death due to trauma
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Poor roadways
Inefficient communication systems
Rural citizens more likely to be drinking
Less likely to wear seat belts
Lack of ambulance and other trauma related health care
services and training
DOMESTIC
VIOLENCE
DOMESTIC VIOLENCE IN APPALACHIAN OHIO
(OFFICE OF CRIMINAL JUSTICE SERVICES, STATE OF
OHIO)
• Appalachian culture views domestic violence as
family matter
• Not seen as serious crime
• Discourages victims seeking help
• Reinforces male as head of household
• Impacting woman’s ability to seek help
• Impacting woman’s ability to receive help
• Law enforcement and prosecutors may handle it
differently because they know the abuser
DOMESTIC VIOLENCE IN
APPALACHIAN OHIO (OCJS)
• Attitude of “What goes on in the family stays in the
family.”
• “Fear of shame, rejection, and not being believed
by the family can stand in the way of seeking help.”
• The abusers’ families often blame the victim for the
abuse.
• Women sought counseling because their children
were behaving similarly to the abuser.
• Women experienced guilt of keeping the children
away from their fathers, even when it was in the
best interest of the child not to see them.
BARRIERS TO LEAVING
(DEBORAH MOORE)
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Geographical distance
Social isolation
Lack of confidence
Poverty
Lack of education
Fear of safety
Lack of confidentiality
BARRIERS TO LEAVING (MOORE)
• “Most women in Appalachia would not want to live
anywhere else. There is a bond between
themselves, the land, the countryside and the way
of life. One must understand the difficulties women
experiencing domestic violence face in
Appalachian communities. Many women find it
impossible to leave when it means abandoning
their farm animals which are usually the livelihood
for the family. Children are concerned with having
to leave house pets behind…”. (Sister Mary Kay)
BARRIERS TO SEEKING HELP (MOORE)
• Traditional family values of family impede seeking
help:
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Family solidarity
Self-reliance
Pride
Fatalism
Mistrust of outsiders
Fear of the system
Tradition of taking care of your own
TOP NEEDS OF DOMESTIC VIOLENCE
VICTIMS (OCJS)
• Need improved court and law enforcement
response (awareness and education)
• Need child care and employment training
• Money for long-term housing
• Support groups needed to discuss feelings and
experiences (when they can’t talk to family)
• Transportation needed
• Domestic violence education and awareness
• Teach kids about abuse
• Did not know emotional/physical abuse not normal
• Did not know what services were available
TEACHING THE DYNAMICS OF A
HEALTHY RELATIONSHIP
• “The very most important thing is that relationships
need to be based on equality, not on power and
control of one partner over another. Kids should be
taught from an early age that they should have a
right in relationships to negotiate, to have a say, to
be heard, to be taken seriously. Those are the
things we teach both adults and kids.”
• (Judy King, Executive Director, Rape and Domestic
Violence Information Center in Morgantown, WV)
CHILD MALTREATMENT
(MATTINGLY AND WALSH)
• Pervasive problem in the U.S.
• Means physical or emotional harm and sexual
abuse
• Most studies have found equal prevalence in both
rural and urban areas
FACTORS ASSOCIATED WITH CHILD
ABUSE AND NEGLECT (CHILD TRENDS)
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Poverty
Teen parenting
Single parenting
Parents’ drug abuse
Parents’ mental health issues
CHILD MALTREATMENT
• Complex PTSD can occur due to (Trauma Toolkit):
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The earlier the abuse
The more prolonged it is
The closer the relationship with the perpetrator
The more severe the violence
Chronic suicidal behaviors, self-harming behaviors,
relationship problems, addictions and depression are
common.
NATURAL
DISASTERS
PIPE AND WEGEE CREEK FLASH FLOOD
BUFFALO CREEK DISASTER
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Killed 125 people
Injured 1000 more
Left 4,000 people homeless
507 homes lost
44 mobile homes destroyed
1,000 vehicles and 10 bridges destroyed
WHAT HAPPENED?
• Pittston Coal Company dam broke that was
composed of water, sludge and coal refuse
• Dam was 30 feet high and 550 feet across
• Two days of rain
• Dam broke and travelled 15 miles down Buffalo
Creek
• Washed out 13 towns
COMMUNALITY (KAI ERIKSON)
• “To underscore that people are not referring to a
particular village territory when they lament the loss
of a community, but to the network of relationships
that make up their general human surround. They
refer to neighbors.”
PSYCHOSOCIAL IMPACT (ERIKSON)
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Lost navigational equipment
Lost cultural surround
Severe demoralization
Disorientation
Loss of connection
Suffered illness and lost identity
Illusion of safety broken
PRACTICE
CONSIDERATIONS
KEYS TO WORKING EFFECTIVELY WITH
APPALACHIAN TRAUMA SURVIVORS
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Empathy
Able to talk openly
Self-aware
Flexible
Willingness to learn from survivors
Able to treat survivor as equal
Good listener
APPROACHING APPALACHIANS IN
COUNSELING
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Familiarize self with culture
Make self accessible
Adopt flexible services
Involve Appalachians in the system of services
Use action-oriented, crisis models of intervention
APPROACHING APPALACHIANS IN
COUNSELING
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Status not important and promotes suspiciousness
Don’t be too verbal
Listen to what the client has to say
Don’t use rote questioning technique
Build personal relationships first
Interaction takes time (be patient)
PRACTICE CONSIDERATIONS (RAYFC)
• “Household” may include many other people
• Don’t accept abusive practices due to blind
acceptance of multiculturalism
• Work “with” families rather than “doing to” families
• Develop empathy and understanding for lowincome Appalachian culture
RECOMMENDATIONS FOR WORKING WITH WOMEN
WHO ARE DEPRESSED
(BROWNING, ANDREWS & NIEMCZURA)
• Help patients find words to describe condition
• Assess psychological dimension of physical
problems
• Connect with patient’s feelings
• Spend time with client
CULTURAL VARIABLES IMPACTING
SUBSTANCE ABUSE
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Religion
Gatekeepers
Individualism/distance self from health problems
Fatalism
Family focus
Emotional restraint
Role confusion
Rejection of joining groups
Traditional masculinity
STRUCTURED BEHAVIORAL OUTPATIENT RURAL
THERAPY RECOMMENDATIONS
(UNIV OF KENTUCKY)
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Engagment
Motivation
Assessment
Case management
Social skills training
ENGAGEMENT
• Friendliness, empathy and respect
• Welcome in the waiting room, shake hands, and
hold the door
• Find common personal interests to discuss
• Use motivational interviewing to engage clients
MOTIVATION
• Give the client the autonomy and control in
determining direction and speed of change
• Assumption that responsibility and capacity to
change exists within the client
• Task of helping professional is to create environment
to enhance client’s motivation and commitment to
change
• Mobilize client’s inner resources and ability to use
supportive relationships
ASSESSMENT
• Strutured assessment okay, but need open-ended
format and questioning style
• Ask medical and reproductive questions carefully
• Questions about family of origin, spirituality and
religion are important
CASE MANAGEMENT
• Use these activities to link to community resources
• Need money, food, clothes and transportation
• Coaching is usually necessary
SOCIAL SKILLS TRAINING
• Best taught through story telling
• Close and intimate contacts between men and
women in rural Appalachia usually not done
through direct expressions of love
• Rural males tend to express anger as outrage
STRUCTURED STORYTELLING (SBORT)
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Rural people relate to storytelling
Pass on problem solving strategies
Used to reinforce social skills rather than role playing
Increase insight into our and others’ behaviors
Story used as framework for exploring and
practicing alternative behavioral choices
STRUCTURED STORYTELLING PROCESS
(SBORT)
• Brief introduction where clients share personal
stories related to topic
• Clients respond with relevant stories
• Prime the pump (if clients unwilling to share stories)
• Therapist models storytelling
• Therapist role to guide process
VALUE OF STORYTELLING (SBORT)
• Helps clients gain insight into behaviors
• May compare stories involving thought map
• May be asked to modify stories by inserting different
behavior or projected outcome
• Can explore alternative behavioral choices in a
safe place to find new behaviors
• Behavioral rehearsal occurs
CULTURAL CONSIDERATIONS:
WHAT TO DO (SBORT)
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Respect client regardless of educational level
Take strengths perspective
Avoid teacher/student dynamics
Appreciate rural humor
Avoid ridicule and sarcasm
Use stories, examples and metaphors
CULTURAL CONSIDERATIONS:
WHAT NOT TO DO (SBORT)
• Use jargon and “educated words”
• Overwhelm clients with paperwork early on
• Stereotype and/or depersonalize clients trying to
control or threaten
• Be humorless
BARRIERS AND CHALLENGES TO
SERVICES (CHILD TRENDS)
• Majority report funding decreases
• Waiting lists
• Cutting programs or staff
FAMILY POLICY CONSIDERATIONS
(RAYFC)
• Must continue to eradicate persistent rural poverty
and unemployment that impacts family system
• Reduce the marginalization of these families and
their children in school and the workplace
• See family as expert in their own situation
ECO-EXISTENTIAL PERSPECTIVE
(GREENLEE)
• Focus on dual environments (Chestang and Norton)
• Sustaining Environment
• Economic
• Educational
• Political power
• Nurturing Environment
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Family
Friends
Church
Local Community
ECO-EXISTENTIAL PERSPECTIVE
(GREENLEE)
• Seek good person:environment fit (Germain)
• Provide people with safety, security, status and
power
• Goal is to Promote
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Sense of meaning rather the purposelessness (anomie)
Human relatedness rather than alienation
Competence rather than inadequacy
Self-direction rather than dependence
Positive self-esteem rather than inferiority
FINAL WORDS
• I would like to conclude by encouraging all of you
to leave today with the Appalachian Spirit of the
Scots Irish, who came before you…
• Who were “Born Fighting.”
• We must continue to fight ignorance, stigma and
discrimination towards those we serve whether at
home, work, school or church.
• We must advocate and fight for increased funding
so we might provide our clients with the high quality
services they deserve.