Mental Health In Appalachia Problems and Prospects In the Central Highlands Rum bd CAT. FOR PUBLIC HEALTH U.S.S.D. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE \.G Public Health Service P. p\..S. Put o.# 378 i '' 7 iT a} ''Mental Health in Appalachia Problems and Prospects in the Central Highlands A report based on a conference sponsored by the National Institute of Mental Health held in Bethesda, Maryland July 13-14, 1964 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Pusric Hearty Service e Nationa InstituTEs oF HEALTH National Institute of Mental Health Bethesda, Md. 20014 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C., 20402 - Price 15 cents ''CAT. FOR PUBLIC HEALTH ''Foreword THIS SUMMARY, a departure from the usual type | i of conference report, represents an effort to distill the essence of a meeting rather than report verbatim details. It has sought to capture the gist of this dis- cussion of a region’s mental health problems, and reflect the insights and perspectives of experts fa- miliar with the region, as helpful background for meaningful planning of mental health services. The extent to which this summary succeeds in its difficult and subtle task is indicated by the comments of the participants, who reviewed it in draft form and who felt that it succeeded remarkably in captur- ing both the spirit and substance of the discussion. iil '''' Preface The conference reported on the fol- lowing pages was sponsored by the Na- tional Institute of Mental Health. The participants were persons knowledge- able in the programs and problems of Appalachia. This report summarizes their views and recommendations. It has been prepared and distributed by NIMH as a contribution to program development in the central Appalachian area. It is intended as a statement of expert opinion, obviously not of official NIMH policy. A number of specific recommenda- tions and conclusions emerged from the conference. A central theme threaded its way through many of these. Appa- lachia is an area of extraordinarily poor employment resources. At the same time, it is an area of overwhelming human need. The conference participants re- peatedly urged that the many able hu- man beings available in the area be employed in programs designed to alle- viate the needs of their own neighbors. This calls for extensive subprofessional training and for the designing and re- designing of helping services of all sorts, including mental health services. Another conclusion of importance to central Appalachia is that the people of West Virginia, eastern Kentucky, and western North Carolina character- istically have enormous reserves of strength within them, reserves with which they struggle to meet any chal- lenge which appears hopeful of achieve- ment. This augurs well for programs built on the human resources of the region. '' i a ee al ''The Appalachian Dilemma For the people who live today along the creeks and in the hollows of the hill country of West Virginia and eastern Kentucky, a way of life is changing more rapidly and more dramatically than it has in all the years since the first settlement of these central highlands of Appalachia. In great part, change has been caused by economic and social forces operating outside the geographical area so the people who still live in the area are ill equipped to change their ways and solve their problems. Bred in the tradition of family culture, the people of Appalachia often are suspicious of anyone who is not kin and who says he wants to help them. Accustomed to isolation, they must now learn to live with things that come with roads and new methods of communication : such things as the consolidated schools that now replace the one room schools of their parents’ day. Where once a man could hunt and fish while “his woman” tended the vegetable garden and made a little egg money, the economic realities of today make it impossible for him to get along that way any more. Where a man who wanted to work in the past. would be pretty sure of work in the coal mines, most of the mines are now closed. No new industries have come to replace them. For thousands of families, the answer has been to leave. Migra- tion out of Appalachia continues and will continue. The population of some areas of eastern Kentucky has dropped in the past few years by as much as 50 percent. Since most of those who migrate are the young and the more resourceful, many of those who remain are the elderly, the illiterate, or those who have given up hope for the future and have been adjusting to poverty, ignorance, and public welfare assistance. While there are some men and women in Appalachia who believe they can reverse these trends, given the skilled manpower to help, for many people daily living has become life in a welfare society of which they can see no end. This hopelessness compounds itself, is handed on from father to son and brings with it psychologi- cal problems for a whole population. These are the problems to be surmounted if Appalachia is to become a productive part of the Nation. The major questions are: how and by whom. ''Appalachian Attitudes In discussing possible answers to these questions, the conference participants looked first at the services now available to residents of central Appalachia, which are related in any way to mental health, and they considered the attitudes of the people toward those services and toward the people who provide them. Appalachians, they agreed, live within basic contradictions. Their standards, mores, and culture are simultaneously prohibitive and provocative. Their counties vote “dry” but moonshine stills continue to send up smoke under the laurel trees in the hollows. Drinking—especially “spree drinking”—is a problem, but pathological alcoholism is not. Crimes are punished, but crimes of violence are somehow expected. Even in the face of hopeless poverty, the tradition of individual independence dies hard. A man may desperately want a job, but balanced against that need is his fear of being “job scared,” of becom- ing dependent on the fluctuating fortunes of industry or the whims of an employer. His world has changed greatly but his attitudes have not changed to suit. His conception of individual independence has been frozen in an obsolete mold. He seeks to assure his independ- ence by withdrawal and by rejection of situations which he feels would make him one of a mass. He shrinks from education and employment although they would, in fact, enhance his capabilities as an individual. Mental health professionals need an understanding of this concep- tion and the stereotypes to which it gives rise. Services designed with such an understanding of regional attitudes have excellent pros- pects for success For when services are available, when the people of the area know about them and have confidence in the individuals providing the service, many people will use them, some will want to be trained to help develop additional services and others will tell their neighbors about existing ones. The conference concensus was that progress is slow, but every participant cited instances in which progress occurs and continues, when trained personnel, through per- sonal contact, break through the hill people’s instinctive distrust of outsiders, whom they call “brought-on people.” 2 ''Mental Health Services and Needs The basic fact in the mental health field in Appalachia is that there are neither enough services available nor trained people to administer them—“brought-on” or not. There are mental hospitals in rural Appalachia, but the hospital may be separated from the person who needs treatment by 150 miles, where roads are few at best and nonexistent in many places. Some areas also remain where getting people to the hospital in the first place is further complicated by outmoded procedures. Sheriffs’ offices, charged with the responsibility of transporting the mentally ill to the hospital, are reimbursed only for transporting patients committed by the court. For anyone who wishes voluntarily to seek treatment, there is usually just no way for him to get to the place where treatment is available. If the mental hospital is to become the focus of a community mental health program, it must have the funds and the personnel to establish small treatment units and clinics, operating in different locations at specific times, or as circuit-riding teams. A few such clinics are now in operation, but the basic tenet of the national mental health pro- gram—to provide treatment for those who need it where they live— is here a problem so difficult that mental health professionals must have help from others. First, someone must find the people who need help and are hidden in isolated areas. When a psychiatric social worker actually has to climb to the top of a slate dump to find a small community in need of assistance, the time involved makes it impossible for her to help very many other people that day. Once the people who need help are found, and if they agree to come for treatment, there must be a way to let them know when and where a traveling clinic is available. When a patient goes to a mental hos- pital and is discharged following treatment, there are additional problems. How is he to receive followup care if he needs it? Who will provide the psychoactive drugs he may need? Where is the money coming from to buy those drugs? The simple mechanics of transportation and the dissemination of information are not simple in rural Appalachia, and conference participants discussed at length 787-714 O—65——2 3 ''the need to find additional purveyors of information so that the people can be educated to seek help when they need it and to be told where they can find it. Everyone concerned agreed that the school system provides the largest number of trained personnel potentially available to help provide this sort of education, even though some teachers have received only a minimum of training, but it is extremely difficult to change the status quo in many rural counties. Difficult or no, the fact remains that schools are the biggest industry in much of Appalachia. (State aid for education is literally the largest single source of income in several counties.) In some areas school teachers outnumber all other professionals by a ratio of 200 to 1. They know, or should know, the pupils whom they teach and the families of those pupils. It is, there- fore, imperative that mental health professionals secure the coopera- tion of county school superintendents if they are to establish effective mental health programs. The Frontier Nursing Service which operates in Leslie and Clay Counties, Ky., has proved that basic education and basic care can be provided effectively to people of even the most remote areas, when the nurses and nurse-midwives go to the people and into their homes. Twenty-five or 30 years ago there were no paved roads in Leslie County; now there are two main highways through the area. In the beginning, this pioneering, privately financed and dedicated serv- ice sent its nurses out on horseback or on foot. Now, they can travel most of the area by jeep, and more of their people can get over the mountain to the doctor. But the frontier nurses still have their hands full, and they cover only parts of two counties in all of Appalachia. They, too, need more helpers. Another potential source of help could be available through an increased liaison between mental health professionals and public wel- fare and child welfare workers. Conferees, however, said that pres- ent day practice, based on traditions of many years’ standing, must be radically changed if this sort of liaison is to be effective in more than a few instances. In comparison with welfare personnel in other parts of the Nation, many of those in Appalachia need additional training through which they can broaden and humanize their approach to these families. Throughout the region, professionals are few and overworked. In many a county, one physician constitutes the entire County Medical Society. Interested though he may be in diagnosing and referring patients with mental illnesses to specialists, he has little time to spare beyond his overwhelming task of trying to meet the physical needs of the people in his area. In some parts of North Carolina and West 4 ''Virginia, however, where depressed rural areas lie adjacent. to more prosperous resort or urban communities, there are more general prac- titioners. Some of these are responding to the American Medical Association’s recent emphasis on the physician’s role in mental health by joining in seminars and classes for physicians in general practice. In some areas, public health nurses provide whatever mental health services there are. They help disturbed people before they go to the hospital and they help them when they come home. Conference par- ticipants agreed that their compassion and concern is great and that they need more help from more mental health professionals. In this land of paucity—of job opportunities, of education and of many other things which most other Americans take for granted—there is also a paucity of professional and community leadership. It is at best difficult to establish and maintain a working organization among pro- fessionals of varying disciplines, but this must be achieved in rural Appalachia if the inadequate resources now available are to be used with maximum effectiveness. The People and Their Problems When the conference on mental health in Appalachia opened, every- one in attendance agreed that it would be difficult indeed to define the limits of responsibility for the mental health professional in estab- lishing a comprehensive mental health program. This is true even in a sophisticated urban community, and it is mére dramatically the case in the hills and hollows of West Virginia and eastern Kentucky. Conferees searched for some sort of practical means of solving the more pressing mental and emotional problems of the people, since the task of remaking an entire society was too vast and not within their province. America has never established a nationwide, integrated plan to provide comprehensive health services for all the people and it is only because of the desperate economic and social plight of Appa- lachians in the contemporary world of industry and automation that a concerted effort to improve the entire economy and health of the area is underway. It became quickly obvious during the discussion that only by looking at each of the varying and common problems of the residents of this depressed land could mental health professionals decide where and 5 ''how they could be helpful if additional funds and other resources were to become available to the Appalachian region. As a sociologist said, “When you work as a professional in Appa- lachia, it makes you permanently mad. So many of the people have nothing. Just nothing. And they have no hope. Until the entire situation is changed so they have something to hope for, you will continue to have a whole population with emotional and psychological problems and illness.” Take, for example, the men who have been miners and for one reason or another have been forced out of the mines. Many actually lose their respect for themselves as physical beings. If a man has a first or second grade education and a strong back and his back gives out, his education is of no support and he has little to sustain his image of himself as a self-sufficient man. The same thing happens if his job gives out. Since he thinks that no man can be down and out and unable to support his family without some good reason, he fabricates reasons to defend himself psychologically and soon has a fine assort- ment of psychosomatic or neurotic symptoms. This represents an attempt to achieve psychological security in addition to the minimum financial security of welfare. For, while some form of public assist- ance may take care of his problems of work and take care of his family, he himself will not be able to go back to work unless he has confidence in himself and confidence that he can handle his job. He must have some assets to protect that confidence. If he has no hope and passes this feeling on to his children, he adds to the generation that has given up the struggle of living and clings to the one thing it has—the welfare check. For many men today in eastern Kentucky and parts of West Vir- ginia, the only means of survival is to be classified as disabled under one of the welfare programs. It is understandable that these men develop illnesses that are not always physically based. It is also understandable that their children drop out of school, when they see nothing to hope for. This situation is so widespread that it presents a motivation and a mental health problem of major proportions. There are other men who still live in a hunting and fishing culture, where the woman tends the garden and becomes the subsistence base. This makes it difficult for a man to know who he is. When industrial work is available, it tends to pull the women into the plants rather than the men. So the man is disenfranchised in his home. When the woman goes into town for wage work, the subsistence garden goes by the board and people don’t “neighbor” any more. Families split up and some of the farms have become so eroded that a man can only subsist as a hired hand, and this is a real departure from the old ways. 6 ''They now say there is a price on the man; you can buy his labor; that he is “job scared”; and this goes against all his traditions of independence. This condition tends to perpetuate itself because, insofar as the woman is the stable figure in the family, the sons tend to mirror the anxieties and inadequacies of their fathers. However, in spite of all this there are still many men who want jobs but who cannot find jobs for which they have been trained. When the unemployment work programs became available, men came to work even though this might jeopardize what other meager income the family received from outside sources. But the salient problem is that there are two, four, and six people, depending on the county involved, for every available job. This also puts the man in a dilemma. If he goes off welfare and tries to get a job, he will not be paid as much as he received before and, too, the job might not last. So he has the choice of being totally “disabled” or not “disabled” at all. He has one other choice; he can move out. Out-migration brings more problems to Appalachia, since most of those who leave the area are young people and potential leaders, who will not return. The population of much of the area is now composed of a higher proportion of older people. There is a noticeable increase in the number of people over 65, even though the total population has dropped 15 or 20 percent. At the age of 17, 18 or 19 the people go out to join their kinfolks in South Lebanon or Cincinnati, Colum- bus or Cleveland, or Middletown where their kin can help them get jobs. Young families move out with their children, and those who are left behind are those less able to care for themselves. Any mental health program for Appalachia, therefore, must be based on the assumption that the out-migration of the younger population will continue. The rate of migration, however, will change in relation to events occurring in other parts of the Nation. If automation comes to the factories of Ohio, Michigan, and Illinois, job opportunities will de- crease in those locations and migration out of Appalachia will be slowed as the people will be forced to stay on at home. In eastern Kentucky, for example, there is little industrialization. Tourism does not present many job opportunities, nor does commer- cial agriculture. Thus, the human resources of the area need to be developed and the skills of the persons who continue to live there must be improved. Following this discussion of the dilemmas of men in Appalachia, the conference turned to a discussion of the women: what is happening to them, and how are their roles changing? Although some women who live near towns or mills are now working for wages, the majority 7 ''do not have this opportunity. In most cases, the women who seek help do so because there is no man in the family. Some men who want a job and cannot find one desert their families so that at least the children can be fed by becoming eligible for a Public Assistance grant. Economically, a family without a man is better off than a family with a man who is unable to work or cannot get a job. Psy- chologically, however, the widespread absence of men in many fami- lies causes many problems. Some women are receiving Social Security benefits. Some are on welfare. Some receive veterans’ benefits or allotments supplemented by aid to dependent children. But they are barely making a go of it. In families where the man is at home, the conference participants agreed that, generally speaking, the woman provided stability in the family. Many mountain women have learned to care for their own children without negligence or abuse. Mothers who have brought their younger children to health centers have learned to trust the workers and then ask to bring their older children to see the doctor. Basically, the role of the Appalachian woman has changed less than that of the man. She still carries her traditional role, has a little more education than the man, takes care of any money in the family, and seems to be the stronger individual, better able to handle situa- tions resulting from poverty. There are many women who evidence a classical type of depression, brought on by a kind of social depriva- tion. They cannot secure for their children the things they once had or want to have. They cannot buy school books, and shoes, and enough clothes. They see no way out and they become depressed. They will, presumably, remain depressed until their situation is made more hopeful. Given even a small opportunity, however, Appa- lachian women have strengths with which they can begin to rehabili- tate themselves and their families. They must also have more opportunities, the conference agreed, for retarded children. One conferee said there is a higher percentage of “childhood disability” cases—mentally retarded children or seriously handicapped children—in the Appalachian area than in any other sec- tion of the country in relation to population. The complexities of providing care for these children are many. There are inadequate services for checking a child’s hearing and eyesight, for instance, so that some children are being classified as mentally retarded who may not be. There are also those who are so socially deprived that they are far more retarded than they would be if opportunities for educa- tion and contact with other children were available. Retarded chil- dren in Appalachia need a great deal more educational, emotional and rehabilitative support. 8 ''For older people in almost every part of rural Appalachia, living has become a state of waiting to die. When families stayed at home they cared for their elders, but as the economic picture worsened younger members of the family could not afford to care for the old folks. When thousands of families migrated, they left the old people behind. There are almost. no community resources such as nursing homes, foster homes, or homes for the aged in Appalachia. Their world can offer no way out for them except to put them in State hospitals. Close to 25 percent of the hospital population is aged 65 or over. The hospitals are caught. They do not have the staff personnel to provide an active treatment program for these old people, so the “patients” just sit and wait. The region needs nursing homes and foster homes. Individuals who are willing to start such homes need help in meeting licensing requirements. Families who keep their old people at home need help in learning how to live with old people who are senile. In the homes for the aged that do exist, professionals could enlist the interest of volunteers from church groups and others to provide activity pro- grams. The situation can be improved if volunteer leadership within the communities is developed. Meanwhile, throughout the hills there are old people living alone in almost total isolation. What of them? Similarly isolated are psychotic children, disturbed children, epi- leptic children, neurotic children, and every other kind of handi- capped child one can think of. They are rarely brought down from the hills. Appalachia simply does not meet the needs of sick and unfortunate children. There are neither inpatient nor outpatient facilities for them. It is almost impossible to arrange for a neuro- logical evaluation of children who may be epileptic or have other types of brain damage, because of inadequate transportation and long waiting lists. One mother, when told to bring her child to the hospi- tal for testing, said, “All right, I'll go out and start hitchhiking tomorrow and we ought to be there in a few days.” She was abso- lutely sincere about this. She had no other way than just to take the child out to the highway and start out. The social agencies do not have funds to meet such situations. For other children who go to consolidated schools, there are psy- chological deprivations and rejections which their parents did not know. These hill children now attend the same school with children from the more prosperous coves and valleys. To some degree, they are given more education than their parents, and more of them are entering high school. But more than half the eighth grade drops out, 9 ''and these are the hill children who leave school at 16. For the first time at school these children learn about class stratification in Appa- lachia, and most of them are rejected by the more prosperous children and by some of the teachers. The other kids call them “grimes.” So additional schooling, while it does provide for more education, in many cases increases the hill child’s sense of insecurity in meeting the demands of the modern world. He absorbs the insecurity of his par- ents at home and continues to grow up untrained and unsure of himself. Appalachian Behavior Patterns From its consideration of economic factors and their psychological effects on the people of Appalachia, the conference turned to a dis- cussion of the incidence and significance of certain behavioral dis- orders that are considered as specific entities of mental health concern. Aleoholism, in the pathological sense, is not a major problem in Appalachia, although the mountain people are heavy drinkers and spree drinkers. The alcoholic patterns of city dwellers do not exist among the hill people to any great extent. People have always made moonshine and stills are currently in operation. Many fathers of families on public assistance use drink as a sort of support or tran- quilizer, as an escape from the impossible situations they and their families face. But, at the same time, there is a strong moral feeling against the use of alcohol in their culture. As a result there is a tremendous amount of guilt associated with drinking. Drinking is a definite part of the culture of young men, and fights on Saturday nights are a big problem. The Appalachian hill people, conferees agreed, get the maximum nuisance value out of alcohol, but among alcoholic admissions to hospitals, for instance, they are not diagnosed as chronic alcoholics. Drinking sprees as such figure in a good deal of crime. Also, to a poor family, a drinking spree every 2 weeks or so can use up any free income. In terms of mental health in Appalachia, the drinking problem is of concern more because of the other problems it creates than because of alcoholism itself. The same problems exist in determining the incidence of juvenile delinquency, and the semantics involved in defining just what delin- 10 ''quency is in Appalachia. The systematic defiance of the law that is evidenced in urban gang warfare does not exist in the Appalachian hills. For the most. part, delinquency consists of violence, fights, drinking, beatings or sexual problems. One judge expressed it when he said there was nothing wrong with the people except that they weren’t working hard enough and just didn’t have enough to do. Another behavioral paradox is that, even though Appalachians inveigh against sin, including sex, they have a high rate of illegiti- macy. For the most part, however, girls who bear children out of wedlock are not ostracized. Sex education is almost nonexistent in the mountain areas. Where some is available, in Kentucky for exam- ple, frontier nurses go into the schools to provide sex education only with the consent of the parents. Inbreeding remains a problem. Although the culture, even among the most backward people, frowns on marriage between first cousins, there are still many such marriages. Such customs bring with them problems of children put up for adoption, and possibly additional problems of retarded children, but the customs themselves can be changed only through education. As Appalachian behavior has its weaknesses, it also has its strengths. One of the greatest isthe family system. Though families are breaking up, and even though their strong and fierce feelings of kinship breeds suspicion of anyone else, the families of Appalachia have held things together for longer periods, and in situations of greater adversity, than in most other American sub- cultures. Appalachian families will take their kinfolks in for weeks, months, and years, to share whatever they have. When families move out of the area, they send for their kin back home, help them find jobs and support them until they can support themselves. With any improvement of the economic situation in Appalachia, the family system can be one of the strongest factors in improving living con- ditions and attitudes in the area. Another source of strength may lie in the fact that Appalachia has a culture emphasizing work and thrift. Its attitudes and values are definite. A situation is black or white, good or bad, moral or immoral, with nothing in between. Such attitudes cause a variety of feelings about guilts and punishments, but provide a strong cultural base from which to work. The fact that some children are staying in school longer can have positive results in the future. Many parents are proud that their children can read and write, and parental attitudes toward education are changing. So, as education becomes more widely accepted, the possibility of training the human resources in the area will improve. 11 ''After 2 days of discussion, however, no matter how conference par- ticipants searched for resources within the area itself which might be used to provide a better life for the people, it was obvious that Appalachia is in deep trouble, economically, socially, and psycholog- ically. In recommending ways in which the National Institute of Mental Health and others concerned with developing a national com- munity mental health program can help to improve this specific situ- ation, conferees based their conclusions on the hard facts they have learned to recognize and accept during the years they have worked in the region with its people. Conclusions Two conclusions emerged with particular clarity from this confer- ence. Each was a recurring theme threading in and out of the entire discussion. One was recognition of the strength and resourcefulness of the people living in the hills and hollows of Appalachia when compared with the pervasive apathy and dependency of many urban slum dwellers and poor country folk. True, the Appalachian poor are un- likely of themselves to strike out along new pathways which might improve their circumstances, but this seems to be a realistic adapta- tion to economic depression, geographic isolation, and a culture at odds with the ways of the outside world. However, when oppor- tunity strikes, even though it may be modest, these people are ready to grasp it, provided they have or can acquire the necessary skills. When disaster strikes, they do not go to pieces. The strength of the Appalachian personality is a strength that commands respect. It also commands attention for the opportunity it offers to build programs through which the people can acquire the skills necessary to support themselves and to develop the self-respect that comes from standing on one’s own feet. The second conclusion is that any planning for Appalachia must include programs that will help the people psychologically and socially as well as economically. Most of these needs are related to the mental health of the people. All of them can be relieved and some can be eliminated with intelli- gent, supportive help, using the skills developed through mental health and those other programs whereby man undertakes to help his fellow 12 ''man. Traditionally this help has been provided by persons trained as professionals in one of the several disciplines identified with mental health. In the past few years awareness has increased nationally of how effective other local people can be if they are trained to perform specific parts of the full array of things a qualified professional might do, and to do well what they have been trained to do. Combining the insights derived from fairly brief training with their indigenous knowledge and understanding of the people they are trying to help, persons recruited and trained to serve in their own communities can simultaneously improve services to the handicapped, needy and vulnerable, while they are themselves gaining in the self- respect and security afforded by responsible employment. Although the opportunities for employing people in the Appa- lachian area were not analyzed in detail during this conference, the needs assuredly became evident—among others, the need of older peo- ple for companionship and care, the need of families for help with their home chores in times of trouble, and for help in getting people with problems to agencies that can meet those problems. The resource- fulness and sense of responsibility of the Appalachian people could qualify them uniquely as helpers to their less fortunate neighbors. Not merely the mental health needs but many economic and social needs of the Appalachian area can best be served through a large-scale program of mutual assistance and the development of human re- sources. Such a program of expanded social and humanitarian serv- ices would necessarily require governmental support, yet it might well prove to require a surprisingly small increase in total public expendi- tures, if major revisions were made in the way these funds are expended. In arriving at a conclusion of this sort, the assumption can be made that Appalachia differs from other areas of the country primarily in the degree and perhaps also in the time at which its distress has become acute. If technological unemployment is on the increase, the labor force in ever growing numbers will shift from manufacturing and extractive industries to those concerned with service. Among the service occupations those concerned with health, mental health and welfare are growing rapidly. Employment is increasing signif- icantly across the country, both in professional and in subprofessional positions, in precisely those kinds of services which are most urgently needed in Appalachia. Perhaps, then, Appalachia is illustrative of a problem which is not unique, but has already become more acute in this region. Appalachia may thus provide a prototype and a proving ground for the solution of problems which may lie just around the corner for the rest of the country. 18 ''Recommendations for Action It is obviously not the sole responsibility of mental health profes- sionals, either in public or private agencies, to remake a whole way of life in a whole region, but they can and must share in this development. That share must be founded on an effective adaptation of the con- cept of a community-based national mental health program to regional reality. Like some other parts of the country, Appalachia will benefit less from Federal support of the construction of community mental health centers than it would from Federal support of extended mental health services. Where centers of population are small, scattered, isolated and rela- tively inaccessible, a choice must be made. Will it be more effective and less costly to send the “helping people” to those who need their help than it would be to build mental health centers and then launch a program to attract people to them? Appalachia is made up of a large number of small counties. The States involved see no way to increase their current budgets for mental health services in any sig- nificant amount, and many county officials are traditionally suspicious of financing services in conjunction with other counties. Who, then, in Appalachia will provide the necessary finances to match a Federal grant-in-aid to construct a community mental health center? There are State mental hospitals in the region, but they may be located 150 or more miles away from many persons who need hospi- talization. In these circumstances, can they become the focal point of a community mental health service program? One State hospital, through a NIMH demonstration project grant, is operating a branch facility to extend treatment services to a wider geographic area. Conferees recommended that this type of service extension be accel- rated. If it were, they felt, the population could be provided with help before its disturbed people needed to go to the hospital, and for those who came home from the hospital, follow-up care and rehabili- tation would be more readily available and therefore more effective. There are other professionals, however, who feel that the State mental hospital system is not the most effective focal point for a community mental health program. They fear that extensions of State hospital services will only result in the creation of more “little 14 ''State mental hospitals” providing little more than the care and treat- ment available today. While working to resolve the controversy, everyone concerned agrees that the size and immediacy of the problem is such that experi- mentation is in order, and that traditional procedures must be changed to permit expansion of preventive services for mental health as well as treatment services for mental illness. The specific kinds of effective intervention in either treatment or in preventive work will, without exception, depend upon personal con- tact between the helping people—no matter who they may be—and the residents of the hills and hollows. Persons who come in from the outside can and do become accepted by the hill folk if they work with empathy and imagination in fitting the service to the person who needs it rather than trying to remake the person to fit the service. To this end, workers trained in mental health concepts should be made available as consultants to teachers, public health nurses, physicians, the clergy, and others whose primary tasks are not centered specifically in mental health work. For pro- fessionals such as psychiatrists, psychiatric social workers, psychiatric nurses, and public health nurses, provision of semiskilled helping aides would enable them to accomplish their work more quickly and in aid of more persons. Everyone in attendance said emphatically: (1) that he or she could use such aides and train them on the job; (2) that such aides could also be used by public welfare and child welfare workers; (3) that with funds available for salaries and training, the semiskilled manpower force in the area could be enlarged and upgraded in a relatively short period of time. Since there are few persons now living in Appa- lachia who have received such training, and since current salary levels are too low to attract and hold people from the outside, the conference also recommended that workers such as those envisaged in creation of the Volunteers in Service to America (VISTA) would be effective as an initial addition to the service program. Information on mental health as it pertains to their own jobs should be made immediately available to sheriffs and other law enforcement personnel in Appalachia and to the civic, church, and other com- munity groups that do exist. In enumerating the persons who have influence and day-to-day contact with people in isolated communities, conferees agreed that the proprietor of the store at the foot of the hollow, the school teacher, and the welfare worker are undoubtedly those who have the closest personal contact with families in need of mental health services. They should be given information on spe- cific things: The time and place of clinics, the availability of profes- 15 ''sional workers in the area and the ways in which people who need help can find it. There are already people in many such communities who are trying to provide this help. The next step is to find these people and to support them so that their help can be more effective. There are also some new resources in Appalachia. These must be expanded. The new medical center of the University of Kentucky is a significant new resource to which the people of eastern Kentucky are already turning. Students in the University’s Department of Community Medicine are going into the hill country to work with the doctors there. The Department of Psychiatry is also working with physicians of the area to improve resources and treatment methods. The resources in the area include private as well as public agencies providing services, but at present a large gap in cooperation, both in planning and in the provision of services, exists among them. This should be remedied by developing new attitudes toward cooperation. The already existing county associations, made up of agency repre- sentatives who meet to coordinate their work, could increase the cir- culation of information to professionals about resources that are currently available to them. The conference reiterated its hope that training will be established immediately to provide “aides” to professionals and to give the aides a workable knowledge of human behavior in the Appalachian com- munities—a knowledge of family structure, of child development, and of the developmental implications of the new consolidated school situation, for example. Some of this knowledge can be acquired through “apprentice” experience in various agencies. The group made these recommendations in the realization that experimental programs must be based on’ political and cultural tradi- tions which have resisted change for generations. If this point of view is accepted and put into action, conferees said as they adjourned, a community mental health program in Appalachia can do its share to provide hope and a productive life for the people of this depressed area. 16 ''PARTICIPANTS IN THE CONFERENCE Mrs. ANNE BLariR ALDERSON, Community Mental Health Consultant, Greenbrier Mental WHealth Project, Lewisburg, W. Va. Miss Bess Baty, Mental Health Nurse Consultant, Berea, Ky. Dr. JAMES S. Brown, Department of Rural Sociology, University of Kentucky. Miss HELEN Browne, Assistant Director, Frontier Nursing Service, Wendover, Ky. Mr. Reep T. Ewine, Director of Social Work, Saint Albans Outpatient Clinic and Bluefield Mental Health Center, Bluefield, W. Va. Dr. Date Faraser, Regional Psychiatrist, Lexington Mental Health Center, Lex- ington, Ky. Dr. Logan Graae, Superintendent, Eastern State Hospital, Lexington, Ky. Dr. Rosert Kerns, Director of Community Services, Department of Mental Health, Charleston, W. Va. Dr. Harvey Situ, Director of Compre- hensive Mental Health Planning, De- partment of Mental Health, Raleigh, N.C. Miss Wanpa Y. Wuirtr, Wastern Area Supervisor, Department of Child Wel- fare, Lexington, Ky. DHEW REGION III Mr. EpMuND Baxter, Regional Director. Mr. JULIAN HANLON, Mental Health Pro- gram Director (planning committee). Mrs. Kate B. HeLMs, Regional Foster Care Consultant, Children’s Bureau. NATIONAL INSTITUTE OF MENTAL HEALTH Dr. JouHNn J. Aparr, Anthropologist, plan- ning staff. Mr. Rosert H. ATWELL, Deputy Chief, Community Mental Health Facilities Branch. Dr. THOMAS GLADWIN, Social Science Con- sultant, Community Research and Serv- ices Branch (conference chairman). Mrs. RutH I. Kneg, Assistant Chief, Clini- cal Facilities Section, Community Re- search and Services Branch (planning committee). Miss Hazet Hotty, Editorial Consultant. Prepared by Public Information Section, National Institute of Mental Health 17 U.S, GOVERNMENT PRINTING OFFICE: 1965 O—787-714 '''' ''Public Health Service Publication No. 1375 ''CO292 79445 ''