T O M J O H N S O N , M A , L I C D C - C SPA M J O H N S O N , L P C C - S , L I C D C - C S

THE OFFICE OF COMMUNITY SUPPORT PRESENTS:FACTORS IMPACTING APPALACHIA BEHAVIORAL

HEALTH ACCESS AND TREATMENT

CULTUREWHAT IS IT?

CONCEPTS OF CULTURE

•…the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving.•…the systems of knowledge shared by a relatively large group of people.

CULTURE IS…

• A culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.• Culture is symbolic communication. Some of its

symbols include a group's skills, knowledge, attitudes, values, and motives. The meanings of the symbols are learned and deliberately perpetuated in a society through its institutions.

FIGURE 1. MANIFESTATION OF CULTURE AT DIFFERENT LEVELS OF DEPTH

Retrieved from: http://www.tamu.edu/faculty/choudhury/culture.html

WHAT ARE THE COMMON CHARACTERISTICS ASSOCIATED WITH THE CULTURE OF THE

APPALACHIAN REGION AND PEOPLE OF OHIO?

AND THE SURVEY SAYS….

A COUPLE OF ELEPHANTS

2013 NEEDS ASSESSMENT DATA

A D E N A R E G I O N A L M E D I C A L C E N T E RW W W. A D E N A . O R G / F I L E S / R E S O U RC E S

HEALTH RANKINGS

Pike

• Out of Ohio’s 88 counties, Pike County is ranked in the bottom 25% in the 2013 County Health Rankings at 80 for health outcomes and 86 for health factors.

Ross

• Out of Ohio’s 88 counties, Ross County ranks in the bottom 25% in the 2013 County Health Rankings at 78 for health outcomes and 83 for health factors.

MENTAL HEALTH CARE

Pike

• For every mental health care provider in Pike County there are 27,909 patients. This ratio is much worse than the rest of the service region (12,571:1) and Ohio (2,181:1).

Ross

• Ross County has twice as many patients (5,075) for each mental health provider as compared to Ohio (2,181) but still less than Adena’s 12-county service region (12,571).

GRANDPARENTS

Pike

• No comparable data given

Ross

• Of the grandparents living with their grandchildren in Ross County, more than 50% are the primary caregiver for their grandchildren. This is notably higher than the Ohio (44.4%) and U.S. (46.8%) averages.

LIVING IN POVERTY

Pike

• The number of individuals living at poverty level in Pike County is 22.5%, which is higher than the rest of its service region (20.4%), Ohio (14.8%) and the U.S. (14.3%).

Ross

• The percentage of individuals living at poverty level in Ross County is 17.5%, which is better than the service region (20.4%) but higher than Ohio (14.8%) and the U.S. (14.3%).

CHILDREN IN POVERTY

Pike

• The number of children living in poverty in Pike County is 31%, which is higher than the rest of the service region (27.7%) and much worse than Ohio (21.7%) and the U.S. (20%).

Ross

• The percentage of children living in poverty in Ross County is 24.4%,

UNEMPLOYMENT RATES

Pike

• Unemployment in Pike County - 10.7%

• much higher than the Ohio (6%) and the U.S. unemployment rates. Approximately 44% of the population in Pike County is not in the work force as compared with 35.4% in the rest of Ohio and the U.S. (35.2%).

Ross

• Unemployment in Ross County - 7.9%

• on par with the U.S. unemployment rate (7.7%), but still higher than Ohio’s 6% unemployment rate. Approximately 43% of Ross County residents are not in the work force, as compared with 35.4% in the rest of Ohio and the U.S. (35.2%).

HEALTH FACTORS & PUBLIC OPINION

Pike

• Overweigh/obese• Joint/back pain• High blood pressure• Mental/behavioral

health, including addiction• Smoking

Ross

• Overweigh/obese• Joint/back pain• High blood pressure• Mental/behavioral

health, including addiction• Smoking

TOP 3 HEALTH ISSUES

Pike

• Stress, obesity and drug abuse were ranked as the top 3 community health issues.

Ross

• Stress, obesity and drug abuse were ranked as the top 3 community health issues.

APPALACHIAN REGIONAL COMMISSION DESIGNATED DISTRESSED COUNTIES,

FISCAL YEAR 2015

• Ohio (6)AdamsAthensMeigsMorganPikeVinton

FROM ARC – SUBSTANCE ABUSE

• Prescription Painkillers: Admission rates for primary abuse of prescriptions painkillers (opiates and synthetics) are higher in Appalachia than in the rest of the nation. This is especially true in coal-mining areas. Admission rates are rising across the nation, but are rising at a faster pace in Appalachia. Appalachia's rate, which doubled from 2000 to 2004, is more than twice the nation's.

FROM ARC – SUBSTANCE ABUSE

• Methamphetamine: Usage and admission rates for methamphetamine are lower across Appalachia than in the rest of the nation, although the Region's rates are rising faster than the nation's.• Alcohol: Alcohol is still the predominant

substance of abuse nationally and in Appalachia.

FROM ARC – MENTAL HEALTH

• Mental health diagnoses for serious problems independent from substance abuse are proportionately higher in Appalachia than in the rest of the nation.• Mental health problems are not equally

distributed across the Region: the study found higher rates of serious psychological stress and major depressive episodes in central Appalachia than in northern and southern Appalachia.

THE GOOD NEWS FROM ARC ABOUT TREATMENT

• Adults in the Appalachian Region with mental health problems reported a somewhat greater likelihood of having received outpatient mental health treatment or counseling in the past year, compared with adults outside the Appalachian Region • The vast majority of Appalachian treatment

facilities offer some substance abuse treatment.

LET’S MAKE IT MORE COMPLEX

CULTURE IS…

• A culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.• Culture is symbolic communication. Some of its

symbols include a group's skills, knowledge, attitudes, values, and motives. The meanings of the symbols are learned and deliberately perpetuated in a society through its institutions.

WE ARE MULTICULTURAL

CULTURE WITHIN A CULTURE WITHIN A CULTURE

THERE ARE SOME REAL BARRIERS

From ARC:• Stigma;• Transportation;• Payment options;• Privacy issues;• Choice of facilities; and• Cultural or family barriers.

IMPLICATIONSFOR BEHAVIORAL HEALTHCARE PROVIDERS

THE CALL

The mission of the American Counseling Associationis to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity and diversity.

MORE FROM THE CODE OF ETHICS 2014

• Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.

PROFESSIONAL VALUES

• Professional values are an important way of living out an ethical commitment. The following are core professional values of the counseling profession:

1. enhancing human development throughout the life span;

2. honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts;

3. promoting social justice;4. safeguarding the integrity of the counselor–client

relationship; and5. practicing in a competent and ethical manner.

CORNERSTONE

• Trust is the cornerstone of the counseling relationship, and counselors have the responsibility to respect and safeguard the client’s right to privacy and confidentiality. Counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve. Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process

N O T S O W I T H C O U N S E L I N G

ONCE YOU MASTER THE SKILL OF RIDING A BIKE

•Understanding the collective history (social norms and traditions)•Understanding community history (norms, traditions, resources and barriers)

Towards cultural competence from Linscott, 2014

DO NO HARM

• Look at the individual’s family history (family values, roles and traditions)• Look at the individual and their personal history (values, traditions, roles, personal goals)

Towards cultural competence, from Linscott, 2014

DO NO HARM

CULTURAL VALUES

Loyal Jones, 1994

• Independence, self-reliance, pride

• Neighborliness• Familism• Personalism (be polite, avoid

conflict)• Religion• Humility and modesty• Love of place• Patriotism• Sense of beauty• Sense of humor

Jamie Linscott, 2014

• Familism• Religion/faith• Neighborliness/sense of

community• Love of place/sense of beauty• Humility, modesty,

personalism• Independence, self-reliance,

pride• Sense of humor• Patriotism• Education/love of learning

POSITIVE DEVIANCE

• Ability for someone to thrive in an at-risk environment despite others who are around them who are not able to thrive• Ability to overcome challenges in spite of those

challenges

But….ItRequires Opportunity

• Positive groups (youth groups, AA, Celebrate Recovery, treatment groups)• Positive adults (coaches, mentors, sponsors, counselors)• Positive activities (giving back, being involved, making a difference)

More than ‘doing no harm’

SUPPORTING RESILIENCE

THE RELATIONSHIP IS KEY

• DATOS• Nemec, P. B. (2011). What works? Unpacking the helping

relationship. Psyccritiques, 56(6), doi:10.1037/a0022233 • Dunn, K. (2012). A qualitative investigation into the online

counselling relationship: To meet or not to meet, that is the question. Counselling & Psychotherapy Research, 12(4), 316-326. doi:10.1080/14733145.2012.669772

• Feller, C. P., & Cottone, R. (2003). The Importance of Empathy in the Therapeutic Alliance. Journal Of Humanistic Counseling, Education And Development, 42(1), 53-61.

• Merten, J. (2005). Facial microbehavior and the emotional quality of the therapeutic relationship. Psychotherapy Research, 15(3), 325-333. doi:10.1080/10503300500091272

• Patterson, C. (2014). Clients' Pretreatment Role Expectations, the Therapeutic Alliance, and Clinical Outcomes in Outpatient Therapy. Journal Of Clinical Psychology, 70(7), 673-680.

• Leibert, T. R. (2011). Relationship between the working alliance and social support on counseling outcome. Journal Of Clinical Psychology, 67(7), 709-719.

• Wolfe, S., Kay-Lambkin, F., Bowman, J., & Childs, S. (2013). To enforce or engage: The relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients. Addictive Behaviors, 38(5), 2187-2195. doi:10.1016/j.addbeh.2013.01.017

• Martin, M. (2013). Female Client Perception, Experience, and Understanding of Psychotherapeutic Change in Rural Appalachia Ohio: A Phenomenological Study. Ohio University / OhioLINK.

WHAT IS MOST HELPFUL?

• Having a place where I’m not judged, where people understand

• Hearing from the other [group members] about how they deal with stuff

• Group is the only place I go that I know I can be me• My [12-step] meetings are safe…they’ve become my family. I

still love my real family but I can’t count on them. I can’t be around them.

• Knowing that if I come [to counseling], there will be someone here to listen

• Having someone get to know ‘ME’…as I am, not just another client. I know we are all addicts but I’m ME.

• Transportation to get my kids. I wouldn’t be able to see them without it

WHAT IS HELPFUL?

• Transportation to my appointments – at the agency and other places. My life is better because I can get where I need to go.• Food! I love having snacks during groups.• Being able to bring my kids sometimes. I know I

can’t do it all the time but when I need to I can. The counselor is very understanding. I wish there was a babysitter for when we’re in group

• Want counselors to treat them as independent thinking • Want to be involved in

the counseling process • Want counselors to

understand how living in a rural area with family and relatives can isolate geographically, socially, and emotionally.

From the Martin Study 2013

WHAT THE PARTICIPANTS

WANT COUNSELORS

TO KNOW

• “In order to meet the mental health needs of rural Appalachian women, helping professionals need to view each woman within her cultural context including her beliefs, her relationships, her barriers, and her resources.”

MARTIN, 2013

• Share example of a similar problematic experience helped to strengthen the client-counselor bond• Use general self-disclosure

with Appalachian clients to build trust into the relationship • A facet of the Appalachian

culture centers on the sharing of stories and perhaps the clients became more comfortable with this mutual sharing

SIMPLE STRATEGIES COUNSELORS CAN DO

• Be authentic people, without “airs” and without an attitude of an all-knowing expert• Be real• Be patient

SIMPLE STRATEGIES

• Another aspect that needs to be explored is the Appalachian female’s cultural identity, social identity, and self-identity in the 21st century. • “a newer version of the Appalachian woman.”

MORE FROM MARTIN, 2013

O N E C L A S S D O E S N O T C U LT U RA L LY C O M P E T E N T M A K E

DON’T ASSUME

“Counselors need to be aware of what happens in the space between the traditional identity of the Appalachian woman and the emerging identity of future generations.”

Martin, 2013

ANOTHER CALL

ADDITIONAL RESOURCES

• www.appalachianohio.org• www.arc.gov• http://ct.counseling.org/2013/09/multicultural-competenc

e-a-continual-pursuit/

• Martin, M. (2013). Female Client Perception, Experience, and Understanding of Psychotherapeutic Change in Rural Appalachia Ohio: A Phenomenological Study. Ohio University / OhioLINK.

• Chapman, M. (2012). Appalachia rising : stories of hope and achievement from Ohio's Appalachian hills and valleys / edited by Monica Chapman. Athens, Ohio : Ohio University Press on behalf of Ohio University, [2012].

• Linscott, J. (2014. Appalachian Cultural Resilience: Implications for Helping Professionals. Unpublished Disserttion

ADDITIONAL RESOURCES

• http://uacvoice.org/pdf/workingpaper20.pdf • http://www.tolerance.org/magazine/number-

31-spring-2007/feature/question-class• http://web.stanford.edu/~mrosenfe/urb_cult

ure_of_poverty.htm• Jones, L., & Brunner, W. E. (1994). Appalachian

values / by Loyal Jones ; photographs by Warren E. Brunner. Ashland, Ky. : Jesse Stuart Foundation, 1994.

LEARN MORE WWW.APPALACHIANOHIO.ORG