RICH GREENLEE, PH.D.

CULTURALLY SENSITIVE TRAUMA INFORMED CARE WITH PERSONS FROM

APPALACHIA

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• 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)

• Individuals• Families• Communities• Cultures• Service providers (vicarious trauma)

TRAUMA INFORMED SERVICES (HELGA LUEST)

• Consumer driven• Hopeful• Safe• Nurturing• Trust-building• Respectful• Empowering• Person centered• Individualized• flexible

TRAUMA INFORMED SERVICES (HELGA LUEST)

• 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

• 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 ex- cept 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 coro- nary 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)

• 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

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)

CORE APPALACHIAN VALUES (KEEFE, 2005)

• Independence• Individualism• Egalitarianism and Personalism• Familism• A Religious Worldview• Neighborliness• Love of the Land and Place• Avoidance of Conflict

THE ETHIC OF NEUTRALITY (HICKS)

• 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

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• 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

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?

• 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)

• 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….

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% non-

Appalachian 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

• 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:• 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• 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)

• 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:• 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

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)

• Poverty• Teen parenting• Single parenting• Parents’ drug abuse• Parents’ mental health issues

CHILD MALTREATMENT

• Complex PTSD can occur due to (Trauma Toolkit):• 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

• 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)

• Lost navigational equipment• Lost cultural surround• Severe demoralization• Disorientation• Loss of connection• Suffered illness and lost identity• Illusion of safety broken

PRACTICE CONSIDERATION

S

KEYS TO WORKING EFFECTIVELY WITH APPALACHIAN TRAUMA SURVIVORS

• 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

• 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

• 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 low-

income 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

• 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)

• 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)

• 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)

• 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• 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 • 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.