Culturally sensitive trauma informed care with persons from appalachia

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 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

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 stressful—they 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, It’s all relative.” • CBS plans to develop proposed “Appalachian” reality show. • Diane Sawyer’s 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 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

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 (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.

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 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.”

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 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)

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.”