United States Senate

Committee on Veterans’ Affairs Field Hearing

Scottish Rite Auditorium

Cambridge, Ohio

April 5, 2010

Appalachian Culture and Veterans

Richard W. Greenlee, Ph.D.
Associate Professor of Social Work
Dean, Ohio University Eastern Campus

Introduction

As a veteran of the both the U.S. Army and the U.S. Air Force, where I served as a social work/psychology specialist in the Army and clinical social worker in the Air Force, I am honored to be asked to speak to you today about Appalachian culture and veterans.  My family came to Belmont County, Ohio, in the early 1800’s.  My roots in Appalachian Ohio run deep, and my commitment to the region is strong.  Having grown up in a coal mining family, I vividly remember the challenges I faced in adapting to the military culture when I moved from Bethesda, Ohio, to Ft. Knox, Kentucky, to Ft. Sam Houston, Texas, to my permanent duty station at Walter Reed Army Medical Center in Washington, DC.  I learned to co-exist simultaneously within two very unique and different worlds.  This life experience, along with my education and training as a social worker, have shaped my current understanding that culture is all encompassing.  There can be little doubt that my Appalachian cultural experience, has had a significant impact on how I perceive and respond to the world around me, as it does others who come from the region.  

Definition of Culture
 
 Culture as defined by Bates and Plog (1990) “is a system of shared beliefs, values,
customs, behaviors, and artifacts that the members of a society use to cope with their
world and with one another, and are transmitted from generation to generation through learning.”   It “is the lens through which all things are viewed and how it is interpreted,” (Briggs, Briggs, & Leary, 2005, p. 95).  Subsequently, culture impacts all that we see and how we experience events in our lives.

Appalachia Defined

According to the Appalachian Regional Commission (ARC), Appalachia is a region defined by federal legislation that extends from Mississippi to New York, through 13 states, 420 counties, 205,000 square miles with 24.8 million people.  West Virginia is the only state completely encased in the Appalachian region.  Thirty-two counties located in the southern and eastern sections of Ohio are considered to be part of the Appalachian region.  Appalachia is characterized by slow population growth and a greater proportion of the population being over the age of 65 than the rest of the nation.  According to the 2000 census data, Non-Hispanic Whites account for 88 percent of the Appalachian population (20.1 million people).  Twelve percent of the population are minorities with 8 percent being Non-Hispanic Blacks (1.9 million people), 2 percent Hispanic (465,000 people) and 2 percent defined as Other Races (471,000 people) which may include:  American Indians, Asians, Pacific Islanders and multiracial persons (Pollard, 2004).

Appalachians Defined
The term Appalachian can be ambiguous and difficult to define.  As noted by Keefe (2005), the term Appalachian is largely one used by outsiders and scholars and not commonly adopted by members of the Appalachian communities in which they reside.  However, Friedl, (1978, p.2) provides us with a working definition for our purposes.  He states, “…any person who was born, or one of whose parents was born, in a county designated by the federal government as falling within the Appalachian region” can be defined as an Appalachian.

Lack of Minority Status
In general, the residents of Appalachia are not protected as a racial or ethnic minority and as previously noted, most Appalachians do not recognize the term Appalachian, nor do they see themselves as part of this group.  Nevertheless, Appalachians do, in many ways, reflect the characteristics of a minority group as defined by De Hoyos, De Hoyos and Anderson (1986): 
Any group whose members have limited access to conditionally rewarding roles, and therefore, are typically deprived of such social rewards as money, respect, social status, security, recognition, challenges, new experiences, opportunities to grow and so forth.  (p. 64)

Throughout its history, Appalachia has faced chronically high rates of poverty, unemployment, substandard housing, low educational attainment and poor health care.  These challenges continue to be concerns as is evident in the recent findings of an Appalachian Regional Commission report (2010) entitled, Socioeconomic Overview of Appalachia 2010:

 116 counties with a poverty rate 1.5 times the U.S. average
 Lower college completion rate than U.S. at large (17.6% Appalachian to 24.4% U.S.)
 Lower per capita market income than U.S. ($24,360 Appalachian to $32,930 U.S.)
 Two-thirds of Appalachian counties now have higher unemployment rates than the United States as a whole (276 of 420 counties)
 More Appalachians have become discouraged workers and have given up searching for jobs
 Between 2000 and 2007 Appalachia lost more than 35,000 jobs in farming, forestry and natural resources and another 424,000 jobs in manufacturing (22% loss)

To make matters worse, the public is still prone to promoting a fictitious image of the dumb, ignorant hillbilly who never existed (Slone, 1978).  Slone (1978) states: 
These lies and half-truths have done our children more damage than anything else.  They have taken more from us than that large coal and gas companies did by cheating our forefathers out of their minerals, for that was just money.  These writers have taken our pride and dignity and disgraced us in the eyes of the outside world.  When our children go into the cities for work or are drafted into the army, they are forced to deny their heritage, change their way of talking, and pretend to be someone else, or be made to feel ashamed, when they really have something to be proud of.” (pp. xii & xiii)

Not too long ago, CBS made plans to put on a proposed reality show to find the quint essential “Appalachian” family based on The Beverly Hillbillies and Abercrombie & Fitch sold t-shirts that said, “West Virginia, It’s All Relative.”  (Biggers, 2006, p. xiii) These kinds of culturally insensitive acts that promote stereotypes need to be confronted and instead, educational campaigns that promote the many achievements of Appalachian men and women need to be established.

Appalachian Cultural Traits

In a review of the literature, Susan Keefe identifies a set of core Appalachian values that include:  “egalitarianism, independence and individualism, personalism, familism, a religious world view, neighborliness, love of the land, and the avoidance of conflict” (Keefe, 2005, p. 10).
Egalitarianism is the “belief that fundamentally one man or woman is as good as another or at least can be if he or she tries” (Maloney, 2005, p. 328).  Subsequently, Appalachians judge a person by their actions and not the degrees or credentials they hold. 
Independence is a shared value among many Appalachians.  They cherish their freedom.  They tend to be antagonistic towards government regulation (Greenlee, 1993).  In a study of the working poor of Appalachian Ohio (Greenlee, 1991), the author of this paper asked the following question:  “Who do you trust around here to help you?” One respondent stated:

….family, close friends, but as far as the government I’d rather not deal with them if I don’t have to. (p. 70)

Another said:
I think the government has been the least helpful.  As for the needs and where to go for help, I think it has been individuals.  The church as been terrific…But the government agencies just don’t come knockin’ on your door sayin’ look this is available to you.  (p. 70)

Fiene (2005) found that women in alcoholic homes “guard family secrets”, are “reluctant to acknowledge family alcohol problems publicly,” avoid “reliance on co-workers for help,” and rely “mostly on independent self-help as a means of coping”
(p. 243).  I would argue that this is a common response for many Appalachians for personal and family concerns.
   
Individualism is the strong belief in self-reliance and the expectation that one will take care of his or her own problems without the assistance of others and that dependency on others for any reason reflects negatively on a person.  Subsequently, individuals tend to deny they have health problems until they are so severe they have to seek help and by the time they seek help it may be too late to effectively treat the disease.  In addition, as noted above by Fiene (2005), Appalachians will read books, consult with friends, and surf the Internet in an attempt to self-diagnose and treat their own problems.  This can create a whole other set of problems from misdiagnosis, to over analysis of the side effects of medication to rationalize not using them, and to the creation of a self-argument to discontinue seeing a physician because “he doesn’t know what he is doing.” 
Personalism is based on personal relationships, not titles.  Here, failure on the part of practitioners to establish a relationship with the patient first, by using rote questioning and maintaining rigid procedures held in place by bureaucratic red tape, may lead the patient to feeling like a number and ultimately to patient alienation. Appalachians will tend to reject these providers and their services when they perceive that they are not being treated as an individual.

Familism is a core value in Appalachia.  Family is the primary source of support in times of difficulty and the reason why many will not leave the region in times of high unemployment and limited opportunities.  They overwhelmingly prefer to stay with family and stick it out until times improve.
In times of difficulty, the most common support for Appalachians is their family and friends.  The second most highly regarded source of support is the church.  In a study conducted by the author of this paper, “governmental services were the most talked about, the least used, and the most negatively viewed of all three support systems” (Greenlee and Lantz, 1993).

Many Appalachians have a religious worldview.  They are distrustful of government agencies and services, but they trust in the church-based social services.  Even when poverty-stricken, the church provides them with a sense of identity and self-worth.  The church gives them opportunities to demonstrate their competence through volunteerism and provides them with a source of emotional and financial support.  This informal network also provides them with a host of support services such as food, small loans, transportation and personal assistance in emergencies (Greenlee, 1993).
The concept of neighborliness may be an asset that could be utilized by health care practitioners.  These practitioners could arrange for family, friends or other community members who are driven culturally to help their neighbors and who have had positive experiences with the health care system, to share their experiences and provide emotional support to Appalachian veterans who may be considering treatment options.

Love of land and place are key ingredients in the character of Appalachians.  It is important for them to own land and to look after it.  This connection with the land provides them with a sense of meaning, safety and security that may go back several generations on the old home place.  Loss of a home place can be very detrimental to the Appalachians sense of self and identity and promote disorientation.

Appalachians often seek to avoid conflict at all cost.  This can create problems when health care practitioners try to impose their will on clients by strongly encouraging them to adhere to certain aspects of a treatment plan without true agreement on the part of clients.  Appalachian clients will often nod their heads in seeming agreement and approval of the suggestions, when they really do not agree and do not intend to follow through on the recommended treatment. 

In a qualitative study of a group of women in Appalachia who had been diagnosed with depression (Browning, Andrews and Niemczura, 2000), the researchers discovered that fatalism and the stigma of a mental health diagnosis caused these women to delay seeking treatment for their depression.  Browning, et al. (2000) found that the women were afraid to tell others about their symptoms for fear of being made fun of or not being taken seriously.  This resulted in an isolation that at some point results in a “paralytic crisis,” and a critical juncture in which they would finally seek professional help for their depression.  These women reported that their husbands never asked what was going on and they never told them.  Participants in the study “felt an overwhelming need for health care providers to understand the nature of their depression” (Browning, et al., 2000, p. 30).  Many of them presented their problems as physical problems that are culturally more acceptable or referred to their depression as “nerves.”  In addition, the researchers found that it was vitally important for medical practitioners to take time to listen to what the patient was really saying so they could accurately diagnose the depression and prescribe the appropriate treatment.

Veterans Attitudes Towards Social Services

Military veterans have been found to be less likely than the general population to seek mental health services due to perceived stigma (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, (2004).  Combine this with the Appalachians resistance to seeking mental health treatment or help of any kind (Behringer and Friedell, 2006), and the combination of the two cultures, one military, the other regional affiliation, and it is highly unlikely that Appalachian veterans will voluntarily seek help for depression, anxiety or post traumatic stress disorder that they may be experiencing upon returning home from the service. These attitudes will require comprehensive education and outreach efforts to help them upon leaving the military. 

Strengths of Appalachian Veterans

Many of the Appalachian veteran’s cultural values can be positive attributes and curative factors if an astute health care provider can marshal them as resources.  If the practitioner treats the individual with dignity and respect (egalitarianism) there is hope that a therapeutic relationship can be established where mutual respect can lead to effective implementation and follow through with a treatment regimen.
If the practitioner can tap into the strength of the individual who needs to be treated like a person and not a number and empower them to make their own decisions about their diagnosis and treatment decisions, then their resistance to becoming dependent on others can be a good thing for long term efficacy of interventions. 

If the health care workers utilize the church pastor and friends who patients respect in the community, they are more apt to listen to their advice and utilize the support services that they provide due to the greater degree of trust they have in these organizations and people. 
It is important to recognize the safety, security and identity that come with Appalachian individuals being able to stay in their own homes, on their own land and in their own communities.  Whenever possible, services need to be provided as close to home as possible to increase the likelihood that patients will follow though with these support services, not to mention their ability to find transportation to make appointments located long distances from their homes. 

Finally, it is important that medical providers listen to clients describe in their own words what they believe the problems are and how they can best be assisted.  They need to listen to concerns about “nerves” and the need for “nerve pills.”  They need to tune into the underlying message that may come with a myriad of physical complaints that may actually be psychologically based stress disorders.  If they do not listen, they will not hear, or they may not even be told, what is really going on in that patient’s life and subsequently, prescribe the wrong treatment for the wrong problem.

Historically, the residents of Appalachia have faced chronic and severe poverty, substandard housing, inadequate schools, and poor health care for many generations.  Despite these many challenges, they have survived and in some situations flourished.  Resilience is a major component of their constitution.  The ability to get knocked down on many occasions, get back up, take care of their families and themselves with limited outside help is commendable. Their environment has often required them to learn how to make do, make it last and do without (Greenlee, 1993).  They don’t ask for much from others. 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. 

Barriers to Providing Services to Appalachian Veterans

The following are cultural barriers to effective utilization of health care services in the region, even when they are available, as identified by Behringer, Friedell, Dorgan, Hutson, Naney, Phillips, Krishman and Cantrell, 2007:

• There is a general sense of distrust of health care professionals and a “fear of being taken advantage of by ‘the system’”, (Behringer and Friedell, 2006, p. 3).

• Appalachians often fail to assert themselves in seeking health care.  This also promotes poor patient/provider communication and goal setting.

• The cultural need for privacy and pride often leads to low health care utilization and poor follow-up with referrals.

• For many rural Appalachians access to health care is limited due to limited income, insurance and access to reliable transportation.

• Availability of health care services locally may be limited.

• There continues to be a general sense of fatalism that “whatever will be will be” and there is not much one can do about it, leading to less utilization of services.

• Some health care providers lack sensitivity to the cultural needs and concerns of Appalachian patients and are therefore incapable of establishing the necessary rapport with patients to be helpful.  This is compounded by insider/outsider dynamics (McDonald), where providers will always be considered outsiders if they were not born and raised in the community, even after many years of residency.  These outsiders (often health care practitioners) are often seen as temporary residents who are not really committed to the community and are not to be trusted.  However, even though it may be more difficult for outsiders, once trust is established over time with members of the community, it is long lasting regardless of one’s insider/outsider status.

Recommendations for Effective Practice with Appalachian Veterans

1.  Health care providers should consider doing the following:  a) learn about the local culture; b) make themselves accessible; c) provide flexible services; d) build a personal relationship with patients first; and e) involve the patients in their own treatment planning. This will facilitate the development of a positive practitioner-patient partnership. If health care providers are to be effective in working with veterans living in the Appalachian region it is critical that they become culturally competent and adept at communicating with Appalachian veterans in such a way that they are able to establish rapport.
2.  Comprehensive public education programs are needed to help community members, social workers and clergy understand the signs and symptoms of diseases that veterans may be experiencing, so they can conduct interventions to promote the utilization of health care services by veterans in the community.
3.  Prevention, education and outreach services by agencies that are respected in the community must be employed to increase utilization of health care services.
4.  Veterans and their families need to be apprised of all the services that they are entitled to as a veteran of the armed services.  Aggressive outreach campaigns will be necessary and the establishment of a rural public transportation system to improve access to services.
5.  Key gatekeepers in the community must be educated about the mental health and health care needs of veterans and the services available to them.  Sponsors, preferably veterans, need to be identified who can vouch for the effectiveness of treatment.  Receiving help from people they know and trust is the most effective way for Appalachian veterans to overcome the fatalistic attitude of “it won’t make any difference what I do.”
6.  Health education is critical if we are to ensure that Appalachian veterans don’t base their health care decisions on inaccurate information they receive from family and friends, or wrongful interpretation of data they read on the Internet.
 7.  Browning, Andrews, and Niemczura (2000) suggest that practitioners: a) help patients find the words to describe their condition; b) be careful to assess the psychological aspects of physical complaints by patients; c) connect with the patients’ feelings; d) learn the local language for “nerve” conditions; and e) be prepared to spend an adequate amount of time with patients to effectively listen, learn and establish rapport with them.

Conclusion

 Appalachians value most their families and home place.  They respect others and expect to be respected by others regardless of their station in life.  They value the freedom to live their lives with limited outside or government interference.  And they take care of their own with minimal requests for outside assistance.  However, in dire emergencies, when they have ventured out to seek assistance from government agencies, they have found these agencies to be disrespectful, over wrought with bureaucratic red tape, with stringent eligibility criteria that often left them with little or no help. And for those who received assistance, many feel they have had to pay too high a price for it, with their very self-worth and dignity sacrificed in the process.  They have often encountered health care providers that have not treated them as a person, but rather as a case number, further alienating them from the health care system.  For these reasons, many Appalachian veterans and their families never seek help, and do the best they can through self-help.  This is often times not enough for the veteran who is encountering depression, anxiety or post-traumatic stress due to their previous combat experience. 

 Thankfully, this is not necessary.  If we are to effectively help the Appalachian veterans and their families, we will need to educate them and the public about the impact of the combat experience on these veterans. We will need to implement aggressive outreach programs informing veterans about the services that are available to them.  We will need to treat them with dignity and create a system that acknowledges them as people first, and patients second.  And we will have to be vigilant in our advocacy for veterans, when the system does not own up to its end of the bargain, that veterans signed on for when they joined the military. 
 If we do this, Appalachians will do as they have always done.  Their fighting spirit will rise again, and they will take on these challenges, and with the resilience that they are most famous for, they will put their lives back together, in the place they call home…Appalachia.