Tom Johnson, MA, LICDC-CS Pam Johnson, LPCC-S, LICDC-CS

1. THE OFFICE OF COMMUNITY SUPPORT PRESENTS:Factors Impacting Appalachia Behavioral Health Access and Treatment Tom Johnson, MA, LICDC-CS Pam Johnson, LPCC-S, LICDC-CS

3. Culture What is it?

4. 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.

5. 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.

6. Figure 1. Manifestation of Culture at Different Levels of Depth Retrieved from: http://www.tamu.edu/faculty/choudhury/culture.html

7. What are the common characteristics associated with the culture of the Appalachian region and people of Ohio? And the Survey Says….

8. A couple of elephants

9. 2013 Needs assessment data Adena Regional Medical Center www.adena.org/files/resources

10. Health rankings Pike 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. • 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.

11. Mental health care Pike 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). • 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).

12. Grandparents Pike 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. • No comparable data given

13. Living in poverty Pike 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%). • 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%).

14. Children in poverty Pike Ross The percentage of children living in poverty in Ross County is 24.4%, • 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%).

15. Unemployment rates Pike 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%). • 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%).

16. Health Factors & Public Opinion Pike Ross Overweigh/obese Joint/back pain High blood pressure Mental/behavioral health, including addiction Smoking • Overweigh/obese • Joint/back pain • High blood pressure • Mental/behavioral health, including addiction • Smoking

17. Top 3 Health Issues Pike Ross Stress, obesity and drug abuse were ranked as the top 3 community health issues. • Stress, obesity and drug abuse were ranked as the top 3 community health issues.

18. Appalachian Regional Commission Designated Distressed Counties, Fiscal Year 2015 • Ohio (6)
Adams
Athens
Meigs
Morgan
Pike
Vinton

19. 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.

20. 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.

21. 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.

22. 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.

23. Let’s make it more complex

24. 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.

25. We are multicultural

26. Culture within a culture within a culture

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

28. Implications For behavioral healthcare providers

29. The Call The mission of the American Counseling Association is 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.

30. 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.

31. Professional values • Professional values are an important way of living out an ethical commitment. The following are core professional values of the counseling profession: • enhancing human development throughout the life span; • honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts; • promoting social justice; • safeguarding the integrity of the counselor–client relationship; and • practicing in a competent and ethical manner.

32. 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

33. Once you master the skill of riding a bike Not so with counseling

34. Understanding the collective history (social norms and traditions) • Understanding community history (norms, traditions, resources and barriers) Do no harm Towards cultural competence from Linscott, 2014

35. 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) Do no harm Towards cultural competence, from Linscott, 2014

36. Cultural values Loyal Jones, 1994 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 • 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

37. But….It Requires Opportunity 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

38. Positive groups (youth groups, AA, Celebrate Recovery, treatment groups) • Positive adults (coaches, mentors, sponsors, counselors) • Positive activities (giving back, being involved, making a difference) Supporting Resilience More than ‘doing no harm’

39. 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

40. 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.

44. 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

45. 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

46. 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 isolategeographically, socially, and emotionally. What the participants want counselors to know From the Martin Study 2013

47. “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

48. 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

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

50. 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