Rich Greenlee, ph.d.

1
Culturally sensitive trauma informed care with
persons from appalachia

• Rich Greenlee, ph.d.

2
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).

3
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

4
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 familys 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

5
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 stressfulthey are also shocking,
  terrifying, and devastating to the victim,
  resulting in profoundly upsetting feelings of
  terror, shame, helplessness, and powerlessness.
  (Courtois, 1999)

6
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

7
Who can be traumatized? (trauma toolkit)

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

8
Trauma informed services (Helga luest)

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

9
Trauma informed services (Helga Luest)

• No power struggles
• No mandates
• Collaborations and concensus
• Building self-esteem
• Not punitive
• Not shaming and blaming

10
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)

11
Trauma In appalachia

• Extreme Poverty
• Impact of War
• Substance Abuse
• Suicide
• Accidents
• Family Violence and Child Abuse
• Natural Disaster

12
Additional Causes of trauma (the trauma toolkit)

• Sudden job loss
• Relationship loss
• Discovery of life-threatening illness

13

• Poverty

14
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.

15
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.
•  

16
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.

17
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.

18
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)

19
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

20
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

21
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.

22

• Appalachian Culture REVISITED

23
Appalachian Culture revisited

• Abercrombie and Fitch, West Virginia, Its all
  relative.
• CBS plans to develop proposed Appalachian
  reality show.
• Diane Sawyers visit to Appalachia

24
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)

25
Core Appalachian values (Keefe, 2005)

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

26
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

27
Care seeking by depressed women (browning,
andrews, niemczura)

• Fear of illness
• Physical strength vital
• Only symptom labeled as physical acceptable
• Women dont come for help until there is a
  paralytic crisis.
• Religion played a major role in womens decisions
  about suicide
• Need to be understood by practitioners

28
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

29

• CHANGING FAMILY DYNAMICS

30
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

31
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

32
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)

33

• RETURNING APPALACHIAN
• VETERANS

34
Women Vets (Womens 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.

35
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.

36
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

37
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

38
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

39
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 patients 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.

40
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 Veterans 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)

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)

42
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

43

• SUICIDE

44
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

45
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)

46
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

47
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)

48
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

49
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

50
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.

51
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 lets not forget returning veterans.

52

• SUBSTANCE ABUSE

53
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

54
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.

55
Impact on community

• Drain on local economy
• Workforce weakened
• Treatment is costly and not always available
• Family stability compromised
• Increase in rural crime

56
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 prosecutors
  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

57

• ACCIDENTS

58
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

59
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.

60
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

61

• DOMESTIC VIOLENCE

62
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 womans ability to seek help
• Impacting womans ability to receive help
• Law enforcement and prosecutors may handle it
  differently because they know the abuser

63
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.

64
Barriers to Leaving (Deborah Moore)

• Geographical distance
• Social isolation
• Lack of confidence
• Poverty
• Lack of education
• Fear of safety
• Lack of confidentiality

65
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)

66
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

67
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 cant 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

68
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)

69
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

70
Factors associated with child abuse and neglect
(child trends)

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

71
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.

72

• NATURAL DISASTERS

73
PIPE AND WEGEE CREEK FLASH FLOOD
74
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

75
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

76
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.

77
Psychosocial impact (Erikson)

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

78

• PRACTICE CONSIDERATIONS

79
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

80
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

81
Approaching appalachians in counseling

• Status not important and promotes suspiciousness
• Dont be too verbal
• Listen to what the client has to say
• Dont use rote questioning technique
• Build personal relationships first
• Interaction takes time (be patient)

82
Practice considerations (RAYFC)

• Household may include many other people
• Dont 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

83
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 patients feelings
• Spend time with client

84
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

85
Structured Behavioral outpatient rural therapy
recommendations (Univ of kentucky)

• Engagment
• Motivation
• Assessment
• Case management
• Social skills training

86
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

87
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 clients motivation and
  commitment to change
• Mobilize clients inner resources and ability to
  use supportive relationships

88
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

89
Case management

• Use these activities to link to community
  resources
• Need money, food, clothes and transportation
• Coaching is usually necessary

90
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

91
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

92
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

93
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

94
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

95
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

96
Barriers and challenges to services (child trends)

• Majority report funding decreases
• Waiting lists
• Cutting programs or staff

97
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

98
Eco-existential perspective (greenlee)

• Focus on dual environments (Chestang and Norton)
• Sustaining Environment
• Economic
• Educational
• Political power
• Nurturing Environment
• Family
• Friends
• Church
• Local Community

99
Eco-existential perspective (greenlee)

• Seek good personenvironment 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

100
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.