1. Appalachia Endless Mountains

2. CONTEXTUAL HISTORY & CHARACTERISTICS

3. History of Appalachia First inhabitants – Iroquois Confederacy and the Shawnee to north – Chickasaw, Cherokee, Choctaw and Creek tribes to south Majority of Early Pioneers – Scotch-Irish and German descent – Settled in isolated mountains to separate from coastal immigrants

4. Appalachia Region

5. Unique Features A shared culture, with Appalachians reporting health as a valuable commodity and self-reliance and traditional life ways said to be of utmost importance 67% of Appalachian counties are rural – Compared to 21% of U.S. counties Poverty rates exceed national average – 15.4% v. 13.5% Barriers to enhancement of health coverage: – Health professional shortage – Less commercial health insurance coverage – Fear, lack of knowledge and distrust of the medical system

6. Economic Status Residents of non- distressed counties, with higher incomes and levels of education, tend to be of higher socioeconomic status (SES) Sixty-nine percent of Appalachian counties and 91% of the distressed counties are designated as Health Professions Shortage Areas

7. Region History “In reality, when Appalachians are viewed as opposing ‘progress,’ it is because much of what has been offered to them as progress has resulted, instead, in personal and environmental exploitation.” – Constitution written to favor business over agriculture – Labeling as “hillbillies” by lumber and coal companies looking to profit from natural resources – Acquisition of land rights through intimidation and shady legal practices – Low wages from mining companies that necessitated child labor (Sarnoff, 2003, p.126)

8. Contemporary Issues in Rural Appalachia In the poorer counties in the region, reports of drug abuse and general mental health problems are significantly higher than in the rest of Appalachia – Proportionately more Appalachian adults abuse prescription drugs than in the nation – Greater incidences of addiction and abuse among Appalachian adolescents than among Appalachian adults Moonshining and tolerance of illegal trafficking Personal failings rather than community issues – Public’s support for social programs is relatively low – Meager public funding has made it harder for communities to respond to problems

9. Contemporary Issues in Urban Appalachia Great Migration: 1940-70s Most families overcame the social and economic barriers they found in the cities by either assimilating or becoming bicultural Pattern of stigmatization exists

10. Diversity within the Culture “Too often, persons living in or migrating from the Appalachian region are simply referred to as being rural or poverty stricken.” Range of subcultures Do not appreciate the culture and history of the region at the expense of recognizing its modern diversity Do not ignore cross sections of race, gender, class, etc. that exists within the region (Anglin, 2004 ; Fickey, 2010; Keller & Helton, 2010, p. 142)

11. Belief System Intrinsic to Appalachian Culture Jones 1994 – Ten unique cultural values of Appalachian people Religion Independence Self-reliance and pride Neighborliness Familism Personalism Humility and modesty Love of place Patriotism Sense of beauty Sense of humor

12. Familism Familism: interests of an individual family member come second to the interests of the family as a whole (Crissman, 1989) Greenlee & Lanz (1993) interviewed Ohio Appalachians in hard times – Found that extended family members were the greatest support

13. Neighborliness Strong community connection (Keller & Helton, 2010) Greenlee and Lantz found that after family, the church community was next greatest support – Buy groceries or give money – Buy Christmas presents for children – Provide small jobs for pay

14. Independence v. Familism? Strong sense of extended family and desire to be self-reliant can be held simultaneously as the family support serves as the foundation from which one learns to be independent (Keller & Helton, 2010)

15. Language-Southern Mountain English Most recognized “difference” between Appalachians and others English dialect Critical for practitioners and professionals to learn if working in region Could result in bad feelings or withdrawal if ignored

16. Language-Southern Mountain English Greetings – When see someone on street or in car, an informal greeting (eye contact, nod, “howdy”) is normal – However, men and women rarely greet each other or are very formal in greetings, unless man and woman are: Known kin (related biologically) Fictive kin (“brother” and “sister” in church, or treated as kin by family) One speaker has respected status (preacher, teacher, judge, etc.) – Elaborated greeting One speaker tries to “place” the other – Geographical-”I’m from Laurel Creek” – Familial-”I’m John Doe’s boy” Important to be able to be “placed” in community – Therefore outsiders have difficulty fully joining community

17. Language-Southern Mountain English Directions given in relation to mountain – “Down to mom’s”=downstream direction – “Over the mountain” vs. through it Orders and Requests – “Please” replaced by “If you don’t care to” – Do not like to be told what to do – Imperatives are orders, i.e. “Drive the car” – Instead, replace imperative with “would” statement “If you don’t care to, would you drive the car?”

18. Language-Southern Mountain English Teaching/Instructions – Prolonged eye contact by learner is considered rude – Cultural norm is to focus on work Eyes should be on hands if teaching knitting, feet if teaching dancing, etc. Interviews – Difficult Naturally create superior and inferior roles of interviewer and interviewee Require use of imperatives If not local interviewer, then can’t be “placed” and will not be received well by interviewee – Younger person should not interview older person – Interviewer should be same gender as interviewee – Useful to have member of community act as interviewer – Allow interviewee to be in charge of conversation – Frame interview as “helpin out”

19. INTERVENTION STRATEGIES

20. Implications for Practice Stages: Contact Where Contact Might Occur… – School Settings – Social Support Service – Health Care System Making the First Step as a Strength… – “From a counseling standpoint, the Appalachian value of self-reliance may seem stronger than the client’s desire for help; that is, the client does not want to appear to be indebted to another. Being aware of this value, the practitioner needs to reframe the helping process from one wherein the client seems dependent to one wherein he or she feels empowered (Keller & Helton, 2010, p. 143)”

21. Implications for Practice Stages: Problem Identification & Assessment Want to please and get along with everyone – Will say they will do something but have no intention of doing it – To counteract this have to work to make goals that both counselor and client want Have belief that “what will be will be” – Due to religion – Can cause hopelessness because do not believe personal actions will make a difference Self reliance can seem stronger than desire for help – Social worker needs to frame process so that client feels self-reliant and not dependent in order to be effective Environment can limit resources – “Environmentally competent” social worker recognizes that isolation of community limits resources Client may shop at mini mart Only walkable roads are dangerous to walk on

22. Implications for Practice Stages: Problem Identification & Assessment Determine to what degree the individual identifies with Appalachian culture – Insider – Cognitive Outsider – Residential Outsider Determine if they have internalized negative stereotypes held in the dominant culture (Salyers & Ritchie, 2006)

23. Successful Strategy Incorporate culture into model/policy formation/literature Toberg, Meyer, & Mande (1997) – Looked at successful tobacco-cessation materials in Appalachia – Successful if: Appeal to family, family ties, or family loyalty Reflect sense of community Appeal to independence, self-reliance, or empowerment Written at level readers in region understand Draw on oral or written traditions of region Avoid negative stereotypes Use images familiar to most people within region

24. Immersion into Appalachian Culture

25. Strength based approach Learning from interviewing community leaders Matching pace of interaction Open body language Termination of conversation

26. Creating Relationships Reoccurring themes: Knowledge How do you get it? Tradition Who keeps it? Skill Who has it?

27. Devolution of Identity Devolution: transference (as of rights, powers, property, or responsibility) to another; especially : the surrender of powers to local authorities by a central government -Merriam Webster Dictionary Identity: Who am I? Rites of passage Trust Influence

28. Are you an Urban Appalachian? The role of Urban Appalachian Council is to support descendants of Appalachia by developing affirmative discourse through strength based language, intervention, and programming Outreach – Implement youth programs – Integrate new learning approaches in schools – Employment readiness programs – Adult learning

29. The Impact “There are things that I try to cover up within myself and this (program) gives me the chance to express what is inside. I needed it. Thanks.”

30. Implications for Practice Stages: Interventions Narrative Therapy “The goal of narrative therapy is to help the clients first understand the stories around which they have organized their lives and then begin to challenge these “truths.” During this process clients will be able to perceive their strengths, thus enabling them to change their perception of their story and create new realities for improving their lot in life.” (Kelley, 2002 in Keller & Helton, 2010, p. 145)

31. Implications for Practice Stages: Interventions Listening to the client’s stories Externalize the problem Demonstrate empathy and curiosity Respect for family privacy & history Rich tradition of storytelling Informal communication style Non-confrontational Relationship-focused (Keller & Helton, 2010 ; Russ, 2010)

32. Implications for Practice Stages: Interventions Humanistic Approach – Recognizing human capabilities – Focus on the “here and now” – Strengths-based – Recognize growth, self direction, and responsibilities (Todd & Bohart, 2005)

33. Implications for Practice Stages: Interventions Humanistic Therapies – Person-centered counseling Client leads Humans have desire to reach full potential – Gestalt Therapy Promote self awareness Encourages focus on “here and now” (Todd & Bohart, 2005)

34. Implications for Practice Stages: Interventions Existential Therapy – Making sense of human existence – Responsible for own lives—clients are NOT victims – No predetermined destiny – Natural limits exist in life but choose how to deal with them See them as barriers or as healthy challenges Do as much as possible with what one has – Goal of therapy Client becomes aware of own goals Client makes authentic choices Client isn’t held back by what “society” expects – Counselor Very “present” Authentic

35. Implications for Practice Stages: Interventions Existential Therapy with Appalachian Clients Helpful Appalachian Characteristics: – Self-reliance and responsibility Client has the power to change situation Client is responsible for own choices – Individualism/desire of freedom from external constraints Goal of therapy is to make choices without consideration of what society expects – Personalism Existential therapists make authenticity #1 priority Challenging Appalachian Characteristics: – Religion/belief in destiny Appalachians tend to believe they have no power over own destiny…existential therapy believes there is no predetermined destiny

36. Implications for Practice Stages: Interventions Solution-Focused Interventions – Builds on client resources, skills and abilities – Time orientation is present and future focused, building goal picture – Focus on previous or formulated solutions and exceptions to problems – Encourages clients to do more of what works for them If it isn’t broken, don’t fix it If it works, do more of it If it is not working, do something different – Applications: Family therapy Traditional psychotherapy Domestic violence offenders Sexual abuse Substance abuse Social service agency Prisons Business applications

37. Implications for Practice Stages: Interventions Solution-Focused Techniques – Skeleton Key Question Between now and when we meet, I would like you to pick one thing you definitely want to keep happening – Miracle Question Suppose one night, while you are asleep, a miracle happened and fixed this problem. What would be different? How would you know a miracle happened? – Scaling Question Allows clients to take a stand on where they are about things, and communicate possibly negative things in a positive method

38. Implications for Practice Stages: Evaluation Interview with Jeanette Foster, Nationwide Children’s Hospital – Be aware of your own biases – Motivational Interviewing techniques are helpful – Partner with community leaders to gain trust and build relationship – Diversity within the population – Relationship = most important thing – Avoid –isms and harmful stereotypes

39. Implications for Practice Stages: Termination Build the relationship and keep the relationship open. “My bias is to treat them like I know my family would want to be treated…” Relationship is more important than anything.

40. Implications for Practice Stages: A Social Worker’s Perspective Individualism vs. Collective Group

41. Presence in Columbus

42. References Ahern, M., Hendryx, M. (2008). Health disparities and environmental competence: A case study of Appalachian coal mining. Environmental Justice, 1(2), 81-86. Anglin M. (Spring, 2004). Erasures of the past: Culture, power, and heterogeneity in Appalachia. Journal Of Appalachian Studies, 10(1 & 2):73-84. Retrieved February 2, 2013 from http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=7ccd8439-c3f5-45c3-b2b6- 99463c664ffc%40sessionmgr14&vid=1&hid=27&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh& AN=18617979 http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=7ccd8439-c3f5-45c3-b2b6- Ambrose, H., Hicks, R. (2006). Culturally appropriate counseling and human services in Appalachia: The need and how to address it. Retrieved from http://counselingoutfitters.com/Ambrose.htm Bradbury, B. L., & Mather, P. C. (January 1, 2009). The integration of first-year, first-generation college students from Ohio Appalachia. Naspa Journal, 46(2), 258-281. Retrieved March 11, 2013 from http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=aacd6dda-eded-4022-bc12- 492ac061a876%40sessionmgr15&vid=1&hid=27&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh& AN=44529075 http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=aacd6dda-eded-4022-bc12- Crissman, J. (1989). Family type and familism in contemporary Appalachia. Southern Rural Sociology, 6, 29-44. Fickey, A. (April 1, 2010). Commodifying my culture: An "Appalachian" reflects on her role in sustaining a limited discourse of Appalachia. Disclosure, (19), 35-37. Retrieved February 2, 2013 from http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=d1a97355-f69f-4884-a029- 10ed8f0cdf25%40sessionmgr14&vid=1&hid=27&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h& AN=73795068 http://web.ebscohost.com.proxy.lib.ohio-state.edu/ehost/detail?sid=d1a97355-f69f-4884-a029- Greenlee, R., Lantz, J. (1993). Family coping strategies and the rural Appalachian working poor. Contemporary Family Therapy, 15(2), 121-137.

43. Jones, L. (1994). Appalachian values. Ashland, KY: The Jesse Stuart Foundation. Keller, S., Helton, L. (2010). Culturally competent approaches for counseling urban Appalachian clients: An exploratory case study. Journal of Social Service Research, 36, 142-150. Russ, K. A. (2010). Working with clients of Appalachian culture. Retrieved March 1, 2013 from http://counselingoutfitters.com/vistas/vistas10/Article_69.pdf Salyers, K. M., & Ritchie, M. H. (July 01, 2006). Multicultural Counseling: An Appalachian Perspective. Journal of Multicultural Counseling and Development, 34(3), 130. Sarnoff, S. (2003). Central Appalachia: Still the other America. Journal of Poverty, 7(1-2), 123-139. doi: 10.1300/J134v07n01_07 Toborg, M.A., Meyer, M.G., Mande, M.J. (1997). An assessment of tobacco prevention and control materials used in the Appalachian mountain region. Landover, MD: Toborg Associates. Todd, J., Bohart, A. (2005). Foundations of clinical and counseling Psychology. Long Grove, IL: Waveland Press, Inc.