Culture and Implementation as Conceptualized Through Adolescent Mental Health Intervention in the Appalachian Region
The mental health of adolescents is a concern in terms of illness onset, prevalence, underdiagnoses, and disparities of appropriate resources. According to the World Health Organization, globally, up to twenty percent of children experience mental disorders, and half of all illness begins by the age of fourteen; three quarters of illness begins by the mid-twenties. Early onset of mental illness is largely seen within the younger years of life and if untreated can lead to increasing difficulties. Disparities in resources, barriers to implementation, and one size fits all approaches, all play key roles in adolescent mental health, however, taking into account cultural context of a region may work to accommodate disparity through culturally appropriate and effective implementation of resources. This paper serves to explore the Appalachian region through ethnographically based intervention and resource implementation for adolescent mental health services. This implementation is partially explored through the education system in regards to rurality, poverty, and barriers. Holistic intervention is arguably more effective than the opposition of not considering the cultural context of an area while implementing resources. This paper attempts to demonstrate this concept through theoretical and real life implementations in regards to both cultural values and social determinants of health in both the education system and outside of the education system. Some may argue for a “one size fits approach,” however, implementation is most effective when utilizing many factors and not considering the holistic area may lead to less effective results.
Culture, while difficult to define, is important to conceptualize. It is all around us, encompassing our “sets of beliefs, values, activities, practices, and symbols” (Keefe 2005). Culture is learned and therefore transmitted through generations, and as such may influence such things as “social structure, economic adaption, religious beliefs, and political organization.” (Keefe 2005). Placing focus on these structures, and the individuals whose agency may influence these structures, may provide significant insight into how mental illness manifests within individuals and structures. It is these individuals who share meaning and who are inherently affected by practices in which meaning is created, so the importance of studying these individuals and culture is dire. There is no one size fits all approach to tackling mental illness, and resources that may fit within one community may not fit as effectively in another.
There are large disparities within low economic and middle income countries, including the social risk factor of poverty, and the quantity of mental health practitioners. This translates to the population level, with poverty being correlated with poor mental health (Kohrt and Mendenhall 2015). Populations that are in economically distressed communities may face social determinants of health that are characterized by larger structure in which enhances less than equal socioeconomic systems. Social determinants of health include “stressful living conditions associated with poverty, such as interpersonal violence, political violence, food insecurity, limited access to health care, untreated physical illness, and a variety of other variables (Kohrt and Mendenhall 2015). Per example, rural schools, small schools, and those schools that are in the Midwest and southern region of the country are less likely to offer counseling as a mental health service.” (Macklem 2011). It is important to understand what health service may fit into a context such as poverty or rurality and what the barriers to such implantation are and have been.
Appalachia is no stranger to economic distress. As characterized by the Appalachian Regional Commission, Appalachia is a region that follows the spine of the Appalachian Mountains from southern New York to Southern Mississippi (although it may be found that characterization of the area may differ). This includes 420 counties and 13 states of which are home to a population of 25 million people. Graphs produced by ARC indicate that that there are currently 84 counties in Appalachia that are economically distressed, which are counties that rank within the top ten percent of economically distressed counties in the country. There are also 114 at risk counites. The system for measuring distress takes into consideration county averages for three economic indicators: three-year average unemployment rate, per capita market income, and poverty rate—with national averages; index values are then summed and averaged. One such indicator, the poverty rate, although having declined, has been measured at 17.2 percent over the 2010-2014 period. Appalachia also reveals mental health professional shortages in rural areas, however, primarily an effect of education and race/ethnicity predictors; fewer high school graduates in a county are more likely to be designated professional shortage areas (Hyndryx 2008).
As professional mental health shortages exist in rural areas, so does the need for implementation. Adolescent stressors prevail throughout schooling, as do the social determinants of health as indicated by socio economic status. Mental illness or psychiatric disorder may also be indicated by poor academic performance and inconsistent attendance. It is also a contributor to half of students who do not finish high school. One study outlined by Macklem indicates that only half of approximately a 3,000-student sample sought treatment. (Macklem 2011). Rural areas in Appalachia have mental health professional shortages, as indicated by fewer high school graduates, and as mental illness prevails in adolescents who are within the education system as well as those who drop out of high school, it is only viable to consider possible implementations for adolescents within the education system. It is also important to consider implementation in regards to healthy development and the opportunity for adolescents to lead fulfilling and productive lives. However, as stated, when working with implementation, it is important to consider context to maximize efficiency; the role of the anthropologist must “continue to emphasize the centrality of local cultural context- both to understand the casual chain of psychological suffering and to optimize the effectiveness of interventions” (Khort and Mendenhall 2015).
Appalachia has received attention in the recent past, but there is very little attention directed toward aiding health care and social service professionals. Some may argue that they have not come by a single piece of literature with specific attention toward cultural approaches in the Appalachian context (Keefe 2005). Anthropology can serve to provide this insight, and is demonstrated through Anthropologist Susan E. Keefe’s Appalachian Cultural Competency: A guide for Medical Mental Health, Social Service Professionals. Culture, while difficult to define, is elaborated on in the Appalachian context through history, values and features, identity, politics, practice. It is also important to note that most ethnography has been focused primarily on central and southern Appalachia. This centrality, such in Eastern Kentucky, is where the highest concentration of economically distressed areas are located and may have a possible correlation in terms of research need or interest.
Ethnographers largely agree on several core values and cultural features of which are prevalent to the Appalachian culture. These values and features include a distinctive linguistic dialect, a society based fundamentally on family ties, social structure based on kinship, ties to community as a source of identity and social organization, an independent and sectarian Protestant religious heritage, strong sense of place, and also the emphasis of sovereignty and self-reliance.” The idea of self-reliance can be reinforced through a qualitative study, in which utilized purposive sampling and semi structured interviews, that addressed treatment seeking patterns and perceptions of depression among twenty-eight depressed and low income women living in Eastern Kentucky. It was found that self-reliance was an expectation for and described by women in the rural setting, as well a gendered taboo on negative thinking, implicating treatment seeking (Snell-Rood et al. 2016). Participates also indicated that perception of treatment quality had lead them to not seek treatment. Half of the participants did however report treatment, but as mentioned, quality of treatment was concerning to some of the participants. In this regard, as values may be shared from generation to generation, it is may be viable to consider that this value may be reinforced within adolescents. However, social institutions may also be shaped from “mountain culture”, and through which may be influenced by these values. These dominant social institutions may include schools, churches, and political elections (Keefe 2005).
To the extent in which education is influenced by these factors may not be largely researched by anthropologists, but these cultural values and social determinants play a key role in beginning to understand how a resource may fit into the education setting by tailoring to the culture itself,
It may be possible that the effects of self-reliance influence mental health treatment seeking patterns, however, in this sense, the education system must again, tailor to these effects of self-reliance. They may pose as a barrier while implementing resources, especially with a lack of literature, and can be shown through lack of treatment seeking. Barriers can be formidable while developing mental health programming and include barriers under the categories of monetary and other resource concerns, school staff issues, programmatic/planning issues, myths and attitudes, administration issues, student and family issues, as well as other barriers including a lack of community support or reassignment of the person in charge of a mental health program (Macklem 2011). However, research must again look to understand how cultural value and social determinants of health might influence barriers. Per example, barriers may include difficulties in transportation or lack of inadequate training.
In terms or social determinants of health, being within geographic isolation and in par with, at times, lower education and socioeconomic status, rural schools are more likely to have fewer resources, of which include “fewer teachers, teachers’ aides, support staff (e.g. counselors and psychiatrists), administrators, and fewer curricular and extracurricular activities (handbook of culturally responsive). Mental Health and Rural Schools: An Integrated Approach with Primary Care explores the benefits of psychologists being implemented into primary care settings, partially arguing against primary care in schools. Arguments include reduced stigma, as many parents in rural communities may be “hesitant to seek help for mental health problems that they are facing with their children,” which is “largely due to the stigma that is associated with seeking and receiving such services,” communication among health care professionals, improved identification of mental health problems, improved access to care, and follow through with physician recommendation. It is also explained that one central location, the integration of a mental health professional in a primary care setting, would allow for more individuals in the community and abroad access to the healthcare professional. Putting a professional in a school might disallow individuals in other school systems equal access. However, it is also explained as s supporting argument for primary care access, that in Nebraskan outreach clinics, it may be common for families to travel large distances, sometimes 120 miles, to receive mental health services. However, in this regard, it may be viable to consider primary care settings for proper treatment, but also how schools, where children spend large amounts of time, act to alleviate mental distress. While primary could potentially be of benefit, traveling 120 miles is still a much larger distance than appropriate; not to mention other barriers including lack of insurance.
Implementation within the school system might include group setting intervention. Appalachian schools might benefit from this form of intervention, tackling adolescent perception of failure. Failure among adolescents in the classroom may have several implications, including low self-efficiency (Harpine 2008). Low self-efficiency may become problematic and distressful for students, and although research is lacking, may possibly have implications for students who embrace the cultural ideal of self-reliance. Students who perceive themselves as having failed, losing the ability to cope with pressures, may perceive themselves as having a lack of ability to control their environment or the ability to recover from setbacks (Harpine 2008). This may in turn add to a cycle of failure, of which may be detrimental to a community with low education and high prevalence of mental health issues. To offset the perception of failure, group intervention acts to treat effects and causes; children must then experience success in a group setting, of which is accompanied by peers. The ideal of peer community may also correlate to the value of Appalachian community ties. It is in these community ties where identity is partially formed. If the group setting further acts as community, then the identity of success may be enacted among the classroom and among peers. This could possibly have positive implications on mental health, healthy risk decisions, and academic performance, ultimately decreasing dropout rates within the community and helping students reach a sense of coping and fulfillment. Implementation of group settings that require self-efficiency and the rebuilding of the belief that tasks can be completed, may act to incorporate cultural values, although, may at time require adequate training or counselor or psychologist intervention. Some barriers to school implementation may include healthcare professional shortages while the mental health shortages. In such a case, alternative models of care as well as program development to address those barriers are researchable and able to be implemented.
One such initiative involved trauma informed training for educators and on site mental health intervention within the education system. This is largely done through partnerships between schools and agencies and has been shown to improve teacher confidence and hopefulness in impacting child behaviors, decreasing negative attributes in the preschool environment, and increasing a teacher’s rating of child resilience (Shamblin et al. 2016). The goal of the initiative was to build capacity among teachers to prevent, identify, and reduce the impact of mental health problems among young children.
The Partnerships for Early Childhood Mental Health Program collaborated with Project LAUNCH. The partnership program provided consultants and collaborated within the school, of which utilized training and support for teachers and delivery of mental health services to students. Project LAUNCH is a program that influences the wellness of children from birth to the age of eight; they offer multiple services. The programs had collaborated to form a consultation model and was thus evaluated to assess the impact of consultation services and to assess the impact of teacher capacity and child resilience. (J.A Mental Health) Several methods were used to measure outcomes including those that measured teacher confidence and competence, quality of the preschool environment, the functional assessment of children, and teacher satisfaction and relationship with consultant. These were measured with scales, surveys, and observations. While being tailored to meet the needs of rural, impoverished, Appalachian schools, the collaboration revealed an increase in teacher confidence and competence as well as an increase in resiliency for students.
Through this evaluation, it may be shown that programs may be implemented and tailored to accommodate regional disparities and the onsets of such disparities. Even in areas of limited mental health services, high rates of poverty, mental illness, and in those areas where individuals face traumatic events and regional stressors, programs may be implemented to fit such factors; particular to the education system, as shown through the results of the preschool collaboration.
Holistically considering culture while implementing resources is a consistent theme in efficient intervention. This has been demonstrated through the education system in consideration of values, barriers, implementations, and results, all in tandem with Appalachian context. This context is lacking in literature in terms of culturally appropriate mental health intervention, however necessary it might be; there is a lot of room for growth and research within the mental health and anthropological fields. A child’s education is a viable place to begin with addressing mental health interventions, however, it is not the only place able to reduce mental distress or to provide resources that endorse the quality of life.
Intervention is conceivable in many forms and in many settings. The education system, the community, and even the home are all settings that have the potential to provide individuals with a sense of fulfillment and a decrease in mental distress. The options for intervention may take form in something as simple as an activity or a lesson, or as important as disputing widespread stereotype. Intervention can be found through counselor implementation, the teaching of skill sets, a group gathering, and teacher training. While the options are vast, one thing is arguably necessary to understand, there is no one size fits all approach, such, there are no counselors being mass produced to fit the needs of every population, and even if so, the perceptions on approaching counselors may differ cross culturally. Intervention must fit into local context and if not, may otherwise be ineffective.
In 1991, Gallia County Children’s Services developed a rites of passage program for adolescent Appalachian males from three counties in Appalachian Ohio (Keefe 2005). Gallia, Meigs, and Jackson counties were integrated into the program, as was the history and cultural value of Appalachia in southern Ohio. The program was designed to “help fill the need for belonging to a family, yet teach the importance of self-reliance as an integral part of manhood.”
Rites of passage can be found cross culturally through baptisms, bar mitzvahs, graduation, military induction, and so forth. When they are available, they provide the opportunity to move to a higher level of development both socially or educationally and act as orderly life course transitions; when they are not readily available, individuals may create abnormal rites of passages. Appalachian adolescents within inner city neighborhoods may sometimes view juvenile detention as a rite of passage. Getting pregnant, and in an extreme form, gang commission of murder may also act as a rite of passage. Providing Appalachian adolescents with a program that “substitutes or supplements what young people have missed in terms of socialization,” can allow for an improvement in self-concept and sense of responsibility, to self and community. This responsibility seems viable given the trending value of self-reliance and the value of family and community.
Family and community structures have been weakened throughout the economic and social upheavals intertwined in Appalachian history, and have since introduced devastating effects to some communities, as well as a role displacement within men. As stated, “The Appalachian male, all too often, has lost his way.” The rite of passage program developed for southern Ohio takes into account “just fine” and “kin look after their own” values, while attempting to replace what was partially lost through said economic and social upheavals in terms of community, worth through confirmation and competency.
The program was used for Appalachian males transitioning from group living to living on their own, however, was designed to allow for development of other curriculums for differing populations, adaptable for use in the home setting. The program lasted twelve weeks; 12 sessions, each the length of two hours, each acting as preparation for the passage ceremony. The objectives of which the curriculum is based focuses on knowing where one is from, being proud of where one is from, and being proud of who one is. Finishing school is also a priority as is being able to skillfully deal with negative stereotyping. The twelve sessions included hands on activities and discussion, including encouragement of emotional expression, lessons on history and trips to historical sites, storytelling, music and crafts, a report on a community service project, etc. A ceremony in the middle of the program serves to acknowledge accomplishments. The passage celebration at the end of the program brings together the community. Friends, relatives, teachers, and mentors gather in ceremonial celebration as those who completed the program accept the responsibilities of manhood as described by a preceding adult. When accepted, approval is given and a dinner is held.
The program was evaluated with a pre and post survey given to two different groups of boys from the three-county area that measured changes as a result of participation. Interviews, observations, and dialogue with a program developer were also methods used in evaluation. It was concluded that the program worked well in small group setting and that goals were being met. This is evident of participant feedback, as one individual had written, “I ain’t a hick, I’m an Appalachian,” while others liked, “getting together with everybody,” and recommended changes were slim if any. Recommended changes included more activities and a summer camp.
Anthropologists can use this implementation as an example of cultural context and as a base for further implementation. The program was designed to enable trainers to develop other suitable curriculums, and could be further investigated in a research setting. Hundreds of the manuals have been distributed, and as such, could be further implemented and analyzed. Per suggestion, the program could be developed to serve as a parallel for young Appalachian women.
As stated in Global Mental Health: Anthropological Perspectives, “Medical interventions tend to offer “one size fits all” approaches, often assuming that pilot projects can be scaled up with little concern for the idiosyncrasies of local context.” This may derive from presumption of difficulty or a preconception of marginal benefit. Culture needs to be understood, as does how a program may fit said culture. As such, task shifting is being implemented to tackle global access disparities; there is no conveyor belt spitting out counselors, and as such, programs are implemented to train locals. Even so, perception, manifestation, experience, verbalization, of mental illness all differs cross culturally, and needs to be understood to tackle access disparities and mental health. Perhaps a country has only ten or so psychologists and a population over the ten million mark, and differences in culture? How might implementation fit a local context? This paper demonstrates how several ideas may be better work to impact effective implementation.
In conclusion, adolescent mental health is a cross cultural concern that requires culturally sensitive approaches when developing effective resources. Appalachian regions highlight several disparities that come with implementation barriers, however, understanding the structure, determinants of health, values, perceptions, culture etc. of the area and individuals who live in different areas provides significant insight into how resources should be developed. Resources can be developed within the school system and outside of the school system. The ultimate goal is to improve life quality for the adolescents who do so deserve mental health resources. Those who work in the field need to approach Appalachia with an emic perspective, opting to understand an Appalachian culture as any other without othering the population. The structural and social factors of mental health need to be considered as do the history and politics of the area. Cultural values, and culture itself, however difficult to define, must be approached, are of importance and must also be considered and observed during the research process.
Citations
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Keefe, Susan E. 2005. Appalachian cultural competency: a guide for medical, mental health, and social service professionals. Knoxville: University of Tennessee Press.
Kohrt, Brandon, and Emily Mendenhall. 2015. Global mental health: anthropological perspectives.
Macklem, Gayle. 2011. Evidence-based school mental health services: Affect education, emotion regulation training, and cognitive behavioral therapy Springer
“The Appalachian Region.” The Appalachian Region – Appalachian Regional Commission. Accessed May 01, 2017. https://www.arc.gov/appalachian_region/TheAppalachianRegion.asp.
Hyndryx M.2008. “Mental health professional shortage areas in rural Appalachia”. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association. 24 (2): 179-82.
Snell-Rood C, E Hauenstein, C Leukefeld, F Feltner, A Marcum, and N Schoenberg. 2016. “Mental Health Treatment Seeking Patterns and Preferences of Appalachian Women with Depression”. The American Journal of Orthopsychiatry.
Harpine, Elaine. 2008. Group interventions in schools: Promoting mental health for at-risk children and youth Springer
Shamblin, S., Graham, D. & Bianco, J.A. School Mental Health (2016) 8: 189