Appalachian Church Leaders: An IPA Study to Understand Their … · 2020. 3. 7. · healthcare...

Appalachian Church Leaders: An IPA Study to Understand Their

Experiences with Substance Misuse

Michael Evan Thomas

Dissertation submitted to the faculty of the Virginia Polytechnic Institute

and State University in partial fulfillment of the requirements for the degree

of

Doctor of Philosophy

In

Human Development

Erika L. Grafsky, Chair

Nancy Brossoie

April L. Few-Demo

Pamela Teaster

February 13th, 2020

Blacksburg, VA

Keywords: Appalachia, Substance misuse, opioid use, church leaders, IPA,

qualitative research

Copyright

Appalachian Church Leaders: An IPA Study to Understand Their Experiences with

Substance Misuse

Michael Evan Thomas

Abstract

The region of Appalachia in the United States is a diverse region that is full of beauty,

mountains, art, and culture. Due to a history of abuse from large corporations, the impact

of the decline in coal mining and generational poverty, the region is currently on a road

toward recovery. Substance misuse rates are disproportionality high, and there are limited

resources available to address the issue. Literature suggests that church leaders may be a

potential resource. The goal of the study was to provide a better understanding on the

substance misuse epidemic through the eyes of church leaders. Interpretative

Phenomenological Analysis guided this qualitative study. Church leaders (n = 10) were

interviewed and four significant themes emerged: narratives used to describe their

experiences with substance misuse, the stigma associated with substance misuse, the

community impact that substance misuse has on Appalachia, and the lack of

understanding and need for training on substance misuse for church leaders and

healthcare practitioners. The results of the study are discussed and connected to

discussions of the implications for clinical practice, recommendations for further

research, and limitations of the study.

Appalachian Church Leaders: An IPA Study to Understand Their Experiences with

Substance Misuse

Michael Evan Thomas

General Audience Abstract

Appalachia is a mountain range located in the eastern portion of the United States. It is a

diverse region that is full of beauty, mountains, art, and culture. Due to a history of abuse

from large corporations, the impact of the decline in coal mining and generational

poverty, the region is currently on a road toward recovery. Substance misuse rates are

disproportionality high, and there are limited healthcare resources available to address the

issue. The goal of the presented study was to provide a better understanding of the

substance misuse epidemic through the experiences of church leaders, which are

abundant in the region. Church leaders, a sample of 10, were interviewed and four

significant topics emerged from their stories shared: narratives used to describe their

experiences with substance misuse, the stigma associated with substance misuse, the

community impact that substance misuse has on Appalachia, and the lack of

understanding and need for training on substance misuse for church leaders and

healthcare practitioners. The results of this study suggest that church leaders may be used

as a resource to help lower the impact of substance misuse. The experiences of the church

leaders gained from this study can help provide training to church leaders and healthcare

providers on ways to work together and lower substance misuse in Appalachia.

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Dedication

I dedicate my dissertation to my parents who worked 12-hour shifts daily so that

my brothers and I could focus on our education and not have to work half as hard as

them. I am forever thankful. Additionally, I dedicate this work to all of my Appalachian

family members who paved the way for me. I know that y’all have continuously guided

me throughout this process. From start, to finish, to future. Thank you.

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Acknowledgements

This research would not be possible without the support and help of my family,

close friends, and colleagues. I am grateful to have found a phenomenal support system

professionally and personally. Additionally, without the support of my Appalachian

community, I would not have been able to complete data collection as quickly as I did.

First, I would like to thank my chair, Dr. Grafsky. Without your qualitative

knowledge and guidance, I would have been lost. Thank you for supporting me and

providing phenomenal mentorship. I knew that you were always a phone call or text

away for support. Dr. Brossoie, I cannot thank you enough. You were constantly my

research mentor and were always there to support me as I navigated the academic

systems. The knowledge that you have shared with me will continue to help move me

forward in my career. Dr. Few-Demo, thank you for teaching me how to debate a theory

and how to hold my head high as I am impacted by the academic system. Dr. Teaster,

thank you for your policy guidance and for allowing me to see that I can keep my accent

in academia.

Second, I would like to thank my cohort at VT and at Purdue. Each of you have

helped provide me with an amazing academic experience. Wonder Twin, thank you for

being there. We both know that we would not have survived without the other. We also

know that we probably would have gotten into a lot less trouble without the other. Emily,

thank you for being weird never ignoring my calls. Aaron, frenemy. Best frenemy.

Jameson, thanks for always grabbing a beer and not needing to talk about the program.

To my Purdue cohort, thank you for constantly hearing me talk about Appalachia for 7

years now.

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Third, I would like to thank my family. The support that y’all have given me has

provided me more than I could ever imagine. To my parents, I don’t know how I will

ever be able to pay you back. To my brothers, you two have helped me in more ways than

you know. To Robert, thank you for understanding what it meant to be Appalachian and

being proud of that.

Last, I have to acknowledge my Appalachian community. Thank you. I always

knew that I could find support in my mentors from Appalachia. I am forever grateful.

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Table of Contents

Abstract ..................................................................................................................... ii

General Audience Abstract ........................................................................................ iii

Dedication ................................................................................................................ iv

Acknowledgements .................................................................................................... v

Chapter 1: Introduction .............................................................................................. 1

Rationale for the Study .....................................................................................................2

Rationale for Qualitative Methods ....................................................................................3

Purpose .............................................................................................................................4

Research Questions ...........................................................................................................4

Definition of Terms ...........................................................................................................5

My Role and Background .................................................................................................6

Outline of Dissertation ......................................................................................................8

Chapter 2: Literature Review ...................................................................................... 9

Overview of the Appalachian Context ..............................................................................9

Appalachian Culture ........................................................................................................9 History. ................................................................................................................................................. 10 Cultural Identity ................................................................................................................................... 12

Four Dominant Themes .................................................................................................. 14 Mental health ........................................................................................................................................ 14 Substance Misuse ................................................................................................................................. 16 Barriers ................................................................................................................................................. 17 Use of church leaders ........................................................................................................................... 18

Substance Misuse Treatments ......................................................................................... 20 Celebrate Recovery .............................................................................................................................. 21

Policy Implications ......................................................................................................... 23

Gaps in Literature .......................................................................................................... 23

Current Study ................................................................................................................. 24 Theoretical Framework ........................................................................................................................ 25

Chapter 3: Methods.................................................................................................. 29

Overview ........................................................................................................................ 29

Research Methods........................................................................................................... 30 IPA........................................................................................................................................................ 30 Case selection ....................................................................................................................................... 31 Data Collection ..................................................................................................................................... 33 Reflective journal ................................................................................................................................. 33 Data storing .......................................................................................................................................... 34

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Analysis .......................................................................................................................... 35

Trustworthiness and Rigor ............................................................................................. 36

Ethical Considerations .................................................................................................... 39

Chapter 4: Results .................................................................................................... 40

Participant Demographics .............................................................................................. 40

Interview Process ............................................................................................................ 40

Results ............................................................................................................................ 41 Stories ................................................................................................................................................... 41 Stigma ................................................................................................................................................... 44 Community impact ............................................................................................................................... 47 Understanding and Training ................................................................................................................. 50

Chapter 5: Discussion ............................................................................................... 54

Theory ............................................................................................................................ 54 Microsystem ......................................................................................................................................... 55 Mesosystem .......................................................................................................................................... 56 Exosystem ............................................................................................................................................ 59 Macrosystem ........................................................................................................................................ 61 Chronosystem ....................................................................................................................................... 64

Future Directions and Limitations .................................................................................. 65 Limitations............................................................................................................................................ 66

Conclusion ...................................................................................................................... 66

References ............................................................................................................... 68

Appendix A: Email Protocol for Initial Contact ........................................................... 80

Appendix B: Email Protocol for Follow-up Contact..................................................... 81

Appendix C: Informed Consent .................................................................................. 82

Appendix D: Recruitment Flyer ................................................................................. 88

Appendix E: IRB Approval ......................................................................................... 90

Appendix F: Interview Script ..................................................................................... 91

Table 1: Participant Demographics ........................................................................... 98

Table 2: Emergent Theme Formation ...................................................................... 100

Table 3: Polarization Example ................................................................................ 104

Table 4: Ecological Model Examples ....................................................................... 105

Table 5: Denomination Doctrine Statements ........................................................... 106

Running head: IPA & APP CHURCH LEADERS

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Chapter 1: Introduction

The region of Appalachia in the United States is a diverse one that is full of beauty,

mountains, art, and culture. Due to a history of abuse from large corporations, the impact of the

decline in coal mining, and generational poverty, the region is also on a road toward recovery

(Keefe, 2005; Moody, Satterwhite, & Bickel, 2017; Williams, 2002). The region of Appalachia

in the United States is a diverse one full of beauty, mountains, art, and culture but one that also

has a history of abuse from large corporations, the impact of a decline in coal mining, and

generational poverty. A focus of recovery includes understanding and intervening in the high

rates of substance misuse that found in the Appalachian Region (Hirchak & Murphy, 2017;

Moody et al., 2017; Monnat & Rigg, 2016; Shannon, Perkins, & Neal, 2014). Substance misuse

across Appalachia has become part of a national conversation as awareness of the opioid

epidemic has grown (Dean & Kimmel, 2019; Macy, 2018).

Several common themes are evident in the literature exploring the high rates of substance

misuse across Appalachia. The first is the lack of healthcare resources (Goins et al., 2005;

Roberts et al., 2017). This includes barriers that residents face obtaining healthcare, such as

needing to travel longer distances to do what and high rates of residents who are uninsured

(Stamm, 2003). A second theme is the lack of trust that people from Appalachia tend to have

concerning outsiders and healthcare professionals (Keefe & Parsons, 2005; Stamm, 2003). The

history of outsiders coming into the community and taking advantage of them impacts residents’

willingness to seek out healthcare (Keefe et al., 2005). The last theme is a lack of mental health

service providers (Hendryx, 2008; Hill et al., 2016). A shortage of therapists in the region

impacts the residents who do try to seek mental health treatment (Talbot, Ziller, & Szlosek,

2017), though there have been recent efforts to increase the number of mental healthcare

IPA & APP CHURCH LEADERS

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providers in the region to provide support, relief, and resources to combat the problem (Moody et

al., 2017).

When identifying potential resources to help lower the impact of substance misuse in

Appalachia, church organizations have emerged as very important . The use of the church,

religion, and spirituality is often cited in the literature as an important aspect of rural healthcare,

especially mental health care (Keefe, 2005). Many rural communities have an abundance of

church organizations, and church leaders may be a vital source of decreasing barriers associated

with access to mental health care, specifically substance misuse. Although they are not mental

health providers, a number of religious leaders have responded to unmet mental health needs in

rural communities (Hall & Gjesfjed, 2013). The goal of this study is to understand the

experiences of Appalachian church leaders discussing substance misuse with their community

members.

Rationale for the Study

A number of gaps in the literature on Appalachia are present. First, theory is rarely used

to inform research. Most research focuses on differences between rural and urban populations

(Hirchak & Murphy, 2017; Moody et al., 2017; Monnat & Rigg, 2016; Shannon et al., 2014).

Second, the existing research does not evince an understanding of the culture of Appalachia.

Instead, current research focuses on documenting disparities, such as higher rates of substance

misuse. Third, these studies do not provide adequate insight into interventions to benefit these

communities. Connecting theory and capitalizing on cultural resources is needed to impel

research and intervention that recognizes the unique culture of Appalachia.

The lack of collaboration between researchers and community members is particularly

evident pertaining to substance misuse. Most of the literature focuses on the lack of resources,


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the higher rates of mental illness, and other factors that negatively impact the culture (Hirchak &

Murphy, 2017; Moody et al., 2017; Monnat & Rigg, 2016; Shannon et al., 2014). While this is

necessary for research to inform readers and funders about why the current research topics are

relevant, it also furthers stigma and stereotypes that plague the Appalachian community

(Williams, 2002). It is important that future research include the voices of community members

as partners and for community stakeholders to be more involved with the data collection. Last,

collaboration between researcher and participants could generate a conversation rooted in

positive aspects of Appalachia rather than focus onn disadvantages that the communities face

(Hirchak & Murphy, 2017; Moody et al., 2017; Monnat & Rigg, 2016; Shannon et al., 2014).

Rationale for Qualitative Methods

Qualitative methods are particularly useful for this project, given the limited empirical

literature surrounding the use of the church as a way to discuss and intervene in substance

misuse. For instance, there may be unknown factors that affect how church leaders discuss

substance misuse with their community members. Further, church leaders may be an untapped

resource in Appalachia communities. Using qualitative methods is appropriate because

qualitative approaches are often employed to understand a phenomenon and explore the meaning

individuals make of a social problem (Daly, 2007).

Interpretative Phenomenological Analysis (IPA) is a systematic qualitative approach that

seeks to understand how people make sense of major life experiences (Smith, Flowers, & Larkin,

2009). Since its development, IPA has been widely utilized in psychological studies related to

health. According to Smith et al. (2009), several benefits of the use of IPA align with the goals of

the proposed study. It is concerned with exploring experiences of participants, I am interested in

understanding in detail how participants make sense of cultural shifts (such as the opioid


4

epidemic), and I am working hard to place myself in the shoes of the participant through the use

of double hermeneutics (explained further in Chapter Three).

This methodology helps me retain a sense of cultural mindfulness when approaching my

questions and the answers that the participants provide. Given the lack of trust in researchers

that is part of the history of Appalachia (Stephens, 2005), the use of IPA will allow for the

participants to be as centered in the research process as possible. Semi-structured interviews will

allow participants to share their perspectives on discussing substance misuse in their

communities. As I share the results of this study, I am conscious of how I represent the

participants and their experiences.

Purpose

Given the current state of research on substance misuse in Appalachia, the goal of this

study is to provide a better understanding substance misuse through the eyes of church leaders.

This study explored how church leaders discuss substance misuse with their community

members and resources that they use to address substance misuse. The project was informed by

Bronfenbrenner’s (1979; 2005) Ecological Systems Theory. Framing an exploration of how

church leaders address the problem of substance misuse is a proximal process that is embedded

within various interrelated systems. The qualitative approach of IPA guided the research design

and methodology.

Research Questions

This study aimed to answer the following questions:

• What are the experiences of church leaders when working with community

members impacted by substance misuse? (RQ1)


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• How do church leaders connect with mental health service providers when

substances such as opioids impact a community member? (RQ2)

• What do church leaders see as the solution to the current substance misuse

problem? (RQ3)

Definition of Terms

Below is a list of commonly used terms throughout this dissertation.

Appalachia. The states included in the region are West Virginia, Mississippi, Alabama,

Georgia, South Carolina, North Carolina, Tennessee, Kentucky, Virginia, Maryland, Ohio,

Pennsylvania, and New York (ARC, 2019).

Culture. For this definition, Falicov (1995) will be used:

Culture contains shared world views, meanings, and adaptive behaviors derived from

simultaneous membership and participation in a multiplicity of contexts, such as rural,

urban or suburban setting; language, age, gender, cohort, family configuration, race,

ethnicity, religion, nationality, socioeconomic status, employment, education, occupation,

sexual orientation, political ideology; migration and stage of acculturation (p. 375).

Appalachian Culture. Keefe (2005) defines Appalachian culture as having strong family

ties, a sense of community, an explicit and implicit appear to independence, self-reliance, and

empowerment. While media portrays Appalachia as “rednecks,” it is important for the audience

to understand the diversity that is contained in the mountains of the region (Fletcher &

Schumann, 2016; Keefe, 2005).

Substance Misuse. The term substance misuse is used throughout this dissertation instead

of addiction or substance abuse. Substance misuse is a less stigmatizing term and is not seen as

harmful to those impacted by substances as the other two terms can be (SAMHSA, 2014).


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Substance misuse refers to the intake of any substance that negatively impacts the person’s well-

being and everyday function (SAMHSA, 2014).

Healthcare providers. The term healthcare provider is used throughout this study and

refers to any healthcare provider, for example primary healthcare, OBGYN, mental healthcare,

and nurse practitioner. Due to a low rate of mental healthcare providers in Appalachia (Thomas

et al., 2019), I use healthcare provider more frequently than mental healthcare provider.

Stigma. The term stigma is defined as a socially determined concept referring to the

devaluation of individuals due to distinguishing characteristics (Rao et al.,2019). Stigma heavily

affects the helping services field and is especially prevalent when working with people suffering

from substance misuses (Cutler et al.,2008; Avery et al., 2013).

Ecological Systems Theory. This dissertation utilizes Bronfenbrenner’s (1979, 2005)

Ecological Systems Theory to guide the research questions and purpose of the study.

Fundamental to understanding Bronfenbrenner’s theory is the notion that a person’s behavior is

influenced and influences multiple contexts within which one is embedded.

My Role and Background

Growing up in rural Appalachia was a unique experience. My life in Appalachia included

the mountains always being close by, hiking trails being abundant, and gardens constantly full of

fresh vegetables. The outdoors was embedded within my culture but so was substance misuse.

Each of my family members slowly became affected by substance misuse, which was heightened

in the late 1990s when opioids became popular. Throughout the early 2000s, I began to see a

shift in my community and family. My parents fought to save their siblings who would became

affected by substance misuse, which included many deaths over the past ten years. My love for

Appalachia and for my family has led me to my research interest and dissertation topic.


7

My identity as an academic from Appalachia has influenced my work. This identity has

allowed for me to find my calling as a researcher. I have been able to understand the experiences

of families living in Appalachia on a personal level and use my passion for my community to

navigate the many new systems that I have encountered. Additionally, I have been fortunate

enough to leave Appalachia. I consider this fortunate not because it caused me to lose an

understanding of my identity, but because I now have a deeper understanding of my identity and

its influence on me. While growing up in Appalachia, I did not understand or notice its unique

culture. I simply understood my families’ values and the values of my community. Now that I

have lived outside the community, I can appreciate my family and Appalachia with a richer

understanding.

When I transitioned out of Appalachia to obtain my master’s degree, I was constantly

reminded that I was different. I was encouraged to lose my accent. I was told that my grammar

was not graduate level material. These were constant reminders that I was an outsider in

academia and that my Appalachian identity was the cause. During my time at Virginia Tech, a

university located in Appalachia, I was reminded of my Appalachian identity. My teaching

evaluations suggested that I used “y’all” too much. Ironically, I was praised for my research that

focused on Appalachia, and then told that I was no longer Appalachian. My identity became

important when it was relevant to the research, but then I was constantly asked to hide my

identity because it did not represent the identity that an academic at a research intensive

institution should have. I felt as though I was asked to let go of my Appalachian identity to blend

in with academia.

I am grateful for the opportunity to obtain my graduate degrees and the ability to work be

an Appalachian academic. I am more grateful than ever to return to Appalachia and my


8

community to provide support and train clinicians how to be sensitive and supportive of the

region and its uniqueness. This dissertation represents how I combine my multiple identities.

Outline of Dissertation

This dissertation is divided into five chapters. The first chapter is an introduction about

the Appalachian community and current problems that these communities are facing, the

rationale for the study, the rationale for using qualitative research methods and IPA, the purpose

of the study, the research questions, and my own role and background. Chapter Two presents a

review of the literature relevant to the purpose of this study. Chapter Three describes the research

methods, including choice of sample and sample size, participants selection, forms of data

collection, analyses of data, validation strategies used to increase validity and quality of the

study, and potential ethical issues. The fourth chapter presents the results. Each case is described

along with the themes, accompanied by exemplative quotes that emerged from analysis. Chapter

Five includes a discussion of the results and implications for clinical practice, policy

implications, limitations of the study, and recommendations for further research. An Appendix

includes copies of the Virginia Tech Internal Review Board approval, consent forms, and the

interview protocols. Last, four tables are provided: the participant demographics, how emergent

themes arose, an example of polarization, and an example of the role of stigma.


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Chapter 2: Literature Review

Overview of the Appalachian Context

The Appalachian community is a regional culture that may be unique or odd to those who

are not familiar with it (Keefe, 2005), and this may also contribute to stigma around the

population. Stigma exists within community members themselves, outsiders of the community,

and healthcare providers that serve the Appalachian communities (Keefe & Parsons, 2005;

Smalley & Warren, 2015; Stephens, 2005). In reviewing literature that discusses Appalachia,

four dominant themes are evident: mental health, substance misuse, barriers to healthcare, and

the use of church leaders as a potential resource. The most recent increase in publications around

Appalachia focus on the high rates of substance use, such as opioid addiction, and compare these

rates to urban and non-Appalachian populations (Hirchak & Murphy, 2017; Moody, Satterwhite,

& Bickel, 2017; Monnat & Rigg, 2016; Shannon, Perkins, & Neal, 2014). While substance

misuse rates are higher in Appalachia, there is a lack of research that focuses on efforts to

understand, identify, and leverage existing resources to reduce the impact of substance misuse.

Appalachian Culture

Defining the Appalachian territory is essential but not an easy task. Geographically, the

region is a vast, mountainous region along the eastern United States. The states included in the

region are West Virginia, Mississippi, Alabama, Georgia, South Carolina, North Carolina,

Tennessee, Kentucky, Virginia, Maryland, Ohio, Pennsylvania, and New York (ARC, 2019).

Each part of the region has its unique qualities. Williams (2002) focuses on a “core Appalachian

region” spread over six states: Georgia, North Carolina, Tennessee, Kentucky, Virginia, and

West Virginia. Importantly, understanding the diversity that exists across Appalachian regions is

essential and may be something that is unknown to people outside of the region. To describe the


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Appalachian region and this culture that exists within it, it is important to understand the history.

Additionally, it is important to understand the cultural identity of the Appalachian people: how

they may view themselves but also how outsiders stigmatize and stereotype the culture.

History. The culture of Appalachia is a product of the mountains and its extensive

history of poverty (Keefe, 2005; Williams, 2002). More precisely, mountain living, the history of

large corporations taking advantage of residents and forcing many into poverty, and the

continued exploitation of natural resources shape the lives of Appalachian residents (Keefe,

2005; Williams, 2002). Moreover, core values embedded in Appalachian communities have

evolved with its history and remain pervasive. Such values include familism, a shared religious

world view, neighborliness, love of the land, and the avoidance of conflict (Beaver, 1986; Keefe,

2005;1988; Williams, 2002). This history is unique to the setting and is highly connected to the

culture of the region.

The decline of several important industries in Appalachia that have impacted its current

economic state and culture. The first industry that helped the region prosper was the tobacco

industry (Williams, 2002). Due to increased health awareness and federal legislation, as well as

competition from growers outside of the United States, a steady decline in tobacco production

occurred through the late 1990s (ARC, 1998). Many of the largest tobacco-producing regions of

Appalachia were considered “distressed” regions by 1998 (ARC, 1998). After the tobacco

production companies left, the land that was used to grow the product was abandoned and

vacant. This dramatically impacted local farmers and their communities economically.

Further down the road, another resource in the area, coal, would have a similar outcome

(ARC, 2019). The coal industry was unique compared to the tobacco industry because the large

coal-corporations would create a “coal town”, and the corporation would operate the town’s


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grocery store, medical centers, and other vital resources in the community (Macy, 2018). Once

the corporation would abandon the town, the resources would leave with them. This left even

more Appalachian communities devastated by poverty and a lack of resources.

Another important event in history that has shaped the Appalachian culture was the

introduction of the North American Free Trade Agreement (NAFTA) (Dean & Kimmel, 2019).

NAFTA resulted in many factories in Appalachia shutting down, and this occurred as opioids

were being introduced into the medical field (Dean et al., 2019). More specifically, after the

formation of NAFTA, 70% - 80% of jobs in some rural Appalachian towns disappeared (Moore,

2012). Studies suggest that socioeconomic factors, specifically unemployment, low social

capital, economic or family distress, and high dependence on mining industries, suggest a higher

rate of opioid use compared to communities not impacted by these variables (Dean et al., 2019;

Hollingsworth, Ruhm, & Simon, 2017; Monnat, 2018; Rigg, Monnat, & Chavez, 2018).

Additionally, the region was a target for the opioid corporations (Macy, 2018). Doctors were

encouraged to overprescribe and were rewarded based off the amounts of opioids that they could

push into the region, creating the perfect storm. A region impacted by the decline in multiple

industries and a community in mental and physical pain was the perfect fit for the opioid industry

(Dean et al., 2019).

These three major waves of job loss in the region: tobacco, factory (mainly textiles), and

coal have had profound socioeconomic impacts on the area. Therefore it makes sense that the

shame and mental health difficulties that can result from job loss can be associated with an

increase of prescription drug use, particularly when they were so readily available as a result of

pharmaceutical company marketing tactics (Macy, 2018). While it is not the role of this research

to blame NAFTA or other legislation for the current opioid epidemic in Appalachia, it is


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important to understand how the connection between job loss and opioid use are connected to the

history and cultural identity of the region (Dean et al., 2019; Hollingsworth et al., 2017)

Cultural Identity. The cultural identity of Appalachia is complex and layered. There is

diversity found within the mountains and each community and region has its own unique

characteristics. Keefe (2005) defines Appalachian culture as one that has strong family ties, a

sense of community, an explicit and implicit desire for independence, self-reliance, and

empowerment. It important to note that while these characteristics are used to describe the region

as a whole, they may not represent all families or systems in Appalachia. Thomas and Brossoie

(2019) interviewed healthcare providers and asked them to identify what cultural characteristics

healthcare students should know about Appalachia. The results suggested that students need to

understand the Appalachian culture, which included a strong value of personal autonomy,

independence from individuals outside the family or region, and a basic understanding of unique

terminology that is included in the cultural dialect (i.e., Old Arthur, case of the nerves, sugar tit,

and in a delicate condition). The participants in this study suggested that the mountains have a

unique culture that is influenced by its history, and this culture cannot be replicated outside of

the region (Keefe, 2005; Thomas et al., 2019). Moreover, the discussion of generational poverty

and the region being disadvantaged is not lost within Appalachian studies research. These

disadvantages have the potential to spark a conversation concerning the region and its residents;

a conversation that that may suggest the culture to be a geographically disadvantaged culture

compared to other regions of the United States.

Examining the socio-cultural-political context unveils Appalachian communities as

members of a disadvantaged regional-minority group, despite the majority of the population

identifying racially as white (ARC, 2019). More specifically, the history of these communities


13

having their power taken from them by outsiders, high rates of poverty, the social isolation of

many community members, the low rates of higher education, the unique language that exists in

the region, and the stigma of being Appalachian are all factors that fuel the concept of

Appalachians being a disadvantaged population (Terman, 2016) and provide justification of a

narrative of marginalization about the Appalachian region.

It is critical to discuss how media and popular culture view the region. It is rare for other

cultural groups to be freely stereotyped more than Appalachia (Smith, 2004). The term hillbilly

can still be used in the media to describe the region’s residents, and TV networks are still able to

exploit the culture through the creation of “reality tv,” such as the pilot of a television show that

would film a family as they move away from the Appalachian Mountains to Beverly Hills

(Smith, 2004). This pilot was humorously entitled, The Beverly Hillbillies, which is a reality tv

spinoff from the old sitcom. Most recently, the opioid epidemic has inevitably raised stigma

around the Appalachian culture by exposing the ability of large corporations to take advantage of

the communities. The region was a target of pharmaceutical companies due to the high amount

of blue-collar jobs, specifically manufacturing plants and coal mines, found in the region (Macy,

2018).

While the above descriptions are merely a snapshot of the culture of Appalachia, it is no

mystery that the culture is unique. For example, there is an organization that solely focuses on

this culture, the Appalachian Studies Association. Furthermore, the Appalachian Regional

Commission has called for the need of substance misuse work to be done in the region to provide

support to the many communities impacted by the opioid epidemic (ARC, 2019). The need to be

mindful of the culture in the region when working in Appalachia is necessary. Current

evidenced-based models for substance misuse treatment do not include the cultural context as an


14

important focus, especially models that focus on the dominant themes that are found in current

literature discussing Appalachia. Lastly, it is important to discuss the growing amount of

diversity in the region. While popular culture would like to paint the region as all white, there is

still racial, ethnic, and sexual identity diversity found across the region (ARC, 2019). This tends

to be forgotten when the region is discussed.

Importance of church. The church community can be viewed as a significant cultural

organization in the Appalachian region (Keefe, 2005; Macy, 2018). The church can serve as a

place for the community to come together and celebrate holidays, major events, and create a

sense of fellowship for its church members. Two of the major denominations found in the region

include The Church of God (Pentecostal) and Southern Baptist (Williams, 2002; Zimmermann,

1990). For many residents, their church community may provide a place of belonging, but there

is a gap in the literature of how church communities support residents impacted by substance

misuse in Appalachia.

Four Dominant Themes

Mental health. The current state of mental health in rural communities and Appalachia

includes a higher prevalence of mental health symptoms than found in urban settings (Hendryx,

2008). Due to lower accessibility and availability, rural residents who finally seek out mental

health services tend to enter with more severe symptoms (Smalley, Warren, & Rainer, 2015).

These symptoms include higher levels of depression, domestic violence, anxiety, rates of suicide,

child abuse, and elder abuse (Stamm, 2003; Smalley & Warren, 2015). Furthermore, a

disproportionately high rate of substance misuse can be found in rural communities compared

with urban communities (Shannon, Perkins, & Neal, 2014).


15

In a qualitative study of service providers and clients, Hill, Cantrell, Edwards, and Dalton

(2016) explored rural women's experiences with mental health and barriers to treatment. They

found a number of barriers, including stigma centered on mental health, a lack of support, and a

lack of education about mental health. This study has helped to advance the understanding of

mental health in Appalachia due to the discussion of stigma still being present in the service

providers and the clients. Unfortunately, the researchers did not identify potential actions to

lower stigma, increase support, and increase education centered on mental health in Appalachia.

Hastings and Cohn (2013) performed a mixed-methods study to understand the benefits

and challenges associated with rural mental health practice. Mental health care providers were

asked to complete a 40-item questionnaire that measured the domains of job satisfaction, areas of

care and practice, competence in areas of care from schooling, and strengths and challenges in

providing services in a rural area. In addition, the participants were asked four open-ended

questions on work setting and rural life. The authors suggest that training programs should

discuss the uniqueness of practicing in a rural setting and that a discussion on practicing in rural

areas may be necessary throughout training programs to increase the number of therapists in

rural communities.

These two articles provide examples of research published around the theme of

Appalachian mental health. The themes of high stigma, a lack of service providers, and a lack of

proper training for service providers to work in rural areas are dominant themes throughout the

literature (Hill, Cantrell, Edwards, & Dalton, 2016; McNichols, Witt, & Gatewood, 2016; Smith,

Peck, & McGovern, 2004; Talbot, Ziller, & Szlosek, 2017). The methods have included a

mixture of qualitative and quantitative measures, but there is a lack of theory guiding the

research. These articles have advanced the literature by providing a deeper understanding of the


16

uniqueness of the community, but there is still a lack of implementation on what evidenced-

based programs or treatment modalities are working in these communities. Closing this gap in

the literature is a crucial area for the next steps in improving the mental health of Appalachian

communities.

Substance Misuse. The burden of substance misuse is heavily documented in the

empirical literature of Appalachian communities (Broffman et al., 2017). The majority of

substance misuse research compares the higher prevalence of substance misuse in urban

communities compared to Appalachian communities (Monnat & Rigg, 2016), yet there is limited

research on what has been effective for reducing substance misuse.

For example, Shannon, Perkins, and Neal (2014) examined the differences in substance

misuse among rural Appalachian and urban non-Appalachian individuals participating in drug

court. A series of logistic regression analyses identified individuals in the rural Appalachian area

were significantly more likely to report lifetime use of cocaine, illicit opiates, and illicit

benzodiazepines, but they were less likely to report methamphetamine use when compared with

individuals in the urban non-Appalachian area. Regarding past 30-day use, individuals in the

rural Appalachian area were significantly more likely to use marijuana, illicit opiates, and illicit

benzodiazepines, but they were less likely to report crack cocaine use when compared with

individuals in the urban non-Appalachian area.

Monnat and Rigg (2016) examined differences in prescription opioid misuse among

adolescents in rural, small urban, and large urban areas. A social-ecological framework guided

the study, and secondary data analysis was utilized to test the research questions. The results

indicated that rural adolescents were more likely to be impacted by opioid misuse than their

urban counterparts. This was the first study examining rural-urban differences to utilize the


17

social-ecological framework to identify specific individual, social, and community

characteristics that influence opioid use.

It is evident that there are higher rates of substance misuse among rural and Appalachia

populations compared to others (Hirchak & Murphy, 2017; Moody et al., 2017; Monnat & Rigg,

2016; Shannon et al., 2014). In 2017, four states within the Appalachian Region (West Virginia,

Ohio, Pennsylvania, and Kentucky) had the highest rates of drug overdose deaths in the country,

and most Appalachian states experienced increases in drug overdose deaths between 2016 and

2017 (ARC, 2019).

Barriers. Related to mental health and substance misuse disparities, barriers to accessing

healthcare is another prevalent theme in the literature of Appalachian populations. These barriers

can include the ability to access healthcare, the amount of healthcare service providers available,

availability of insurance to help with the costs of healthcare, and cultural stigma on utilizing

services (Stamm, 2003).

Goins et al. (2005) examined barriers rural elders report when accessing healthcare,

including how they cope with the high costs of prescription medication. The research team held

90-minute focus groups in six rural West Virginia communities. The results concluded that five

categories of barriers to healthcare emerged: transportation difficulties, limited health care

supply, lack of quality healthcare, social isolation, and financial constraints. Furthermore, six

diverse coping strategies for dealing with the cost of prescription medication were identified.

They included: reducing dosage or doing without, limiting other expenses, relying on family

assistance, supplementing with alternative medicine, shopping around for lowest prices, and

using the Veteran's Administration. This study referenced the cultural importance of collecting

qualitative data rather than quantitative due to cultural characteristics of rural communities, for


18

example, the need for “front porch talk” (Thomas & Brossoie, 2019) to gain trust with rural

participants.

Brems, Johnson, Warner, and Roberts (2006) examined barriers to healthcare as reported

by rural and urban interprofessional providers. The analysis found significant barriers to optimal

care that are common across rural communities, with the smaller rural communities having

higher barriers to treatment. Barriers reported included resource limitations, confidentiality

limitations, dual relationships between clients and providers, increase in provider travel, and a

lack of access to services by clients. Brems and colleagues (2006) provided practice and policy

implications for each of the barriers listed; a significant contribution to the literature.

These articles highlight the barriers and overall lack of resources prevalent in rural

healthcare. These disparities are magnified when focusing solely on mental health care (Talbot,

Ziller, & Szlosek, 2017), and impacted by the current model of substance misuse treatment as

mental health care rather than an integrative healthcare system that combines traditional

healthcare and mental health care (Moody et al., 2017). This understanding helps guide research

in terms of understanding that special training may be needed to prepare healthcare providers to

work more effectively in rural communities. Furthermore, these studies provide support for more

research to be conducted that works at overcoming these barriers and to work with the resources

within Appalachian communities, such as church leaders.

Use of church leaders. The use of the church, religion, and spirituality is often cited in

the literature as an essential aspect of rural and Appalachian healthcare, especially mental health

(Keefe, 2005). Many rural, Appalachian communities contain an abundance of church

organizations, and church leaders may be a vital source for decreasing barriers associated with

access to mental health. Although they are not mental health providers, religious leaders such as


19

clergy have responded to unmet mental health needs in rural communities (Hall & Gjesfjed,

2013). Clergy have become increasingly popular and consistently identified as a more attractive

option when seeking out assistance for mental health-related issues: specifically, for individuals

wanting to incorporate religion and personal faith into the therapeutic process (McAuley,

Pecchioni, & Grant, 2000). Many clergy identify training and education on how to deliver

services such as various mental health therapies as minimal and often inadequate (Hall &

Gjesfjed, 2013). Church leaders consider mental health to be an area where their techniques and

ability are lacking in skill as well as confidence (Sullivan et al., 2014). Neither referrals nor

collaboration between church leaders and mental health professionals occurs at a consistent pace

despite the increased utilization of church leaders for mental health services (Hall et al., 2013;

McAuley et al., 2000).

McMinn et al. (2005) examined factors that affected referral patterns between church

leaders and mental health service providers. Two survey studies were conducted to explore the

characteristics that enhance or hinder collaboration. The first study used a sample that was solely

church leaders that were part of the Southern Baptist Convention. The results showed that church

leaders were more likely to refer to a therapist who was known to use prayer and identify as a

Christian. The second study focused on a sample of therapists, and the results showed that a

therapist is more likely to collaborate with a church leader if the client has spiritual questions, no

support network, and cannot afford a therapist. This study does an excellent job of creating a

deeper understanding of what may be affecting collaborations between church leaders and

therapists. The use of a mixed-methods research design proved beneficial in gaining a better

understanding of the lack of collaboration and suggestions on how to overcome this barrier, such

as encouraging more communication between church leaders and mental health service


20

providers, training church leaders and mental health service providers on the benefits of

connecting with mental health, and creating a support network between church leaders and

mental health service providers.

Smith, Riding-Malon, Aspelmeier, and Leake (2018) utilized a qualitative research

design to investigate how to bridge the gap between religious leaders and helping professionals

to improve rural mental health. The study used a grounded theory methodology. The results

indicated that church leaders were more likely to collaborate if they had a better understanding of

mental health and a history of past collaborations. Barriers to collaboration included a perceived

distrust between therapists and church leaders, a lack of mental health service providers

encouraging collaboration, and a preference to collaborate with other church leaders over

therapists. This article utilized a few models to help guide their research: Clergy outreach and

professional engagement (COPE) and Clergy, academic, and mental health partnership (CAMP).

These models provide relevant insight into future research that could occur with church leaders.

Substance Misuse Treatments

When connecting current substance misuse treatment models and the role of the church,

two programs are frequently used: Celebrate Recovery and Alcoholics Anonymous (Brown et

al., 2013). Through these programs, religious organizations can offer free community services

outside of the typical health care system, and many groups are moderated by church leaders

(Smith et al., 2018). Thus far, there is limited research examining these programs from an

opioid-specific, longitudinal, or cultural lens perspective (Brown et al., 2013; Smith et al., 2018).

Furthermore, there is little research that has gained an understanding of these types of programs

through the eyes of church leaders, especially those in Appalachia. Consequently, these

programs follow an abstinence-only model, and this style of group therapy could further the


21

stigma, pain, and impact of substance misuse at the individual, family, and community levels

(SBIRT, 2014; Smith et al., 2018).

Celebrate Recovery. The substance misuse treatment framework that is most commonly

followed in Appalachia is Celebrate Recovery (CR) (Brown et al., 2013; Smith et al., 2018). For

example, there are six celebrate recovery groups within 25 miles of Blacksburg, VA. There are

only two Alcoholics Anonymous (AA) groups within the same distance. According to the

program’s website, CR is a Christ-Centered 12-step program for community members impacted

by substance misuse. In addition to the 12-steps that closely follows the 12-steps of AA, CR has

eight guiding principles (CR, 2019).

The 12-steps are:

We admitted we are powerless over our addictions and compulsive behaviors, that our

lives had become unmanageable, we came to believe that a power higher than ourselves

could restore us to sanity, we made a decision to turn our lives and our wills over to the

care of God, we made a searching and fearless moral inventory of ourselves, we admitted

to God, to ourselves, and to another human being the exact nature of our wrongs, we

were entirely ready to have God remove all these defects of character, we humbly asked

Him to remove all our shortcomings, we made a list of all persons we had harmed and

became willing to make amends to them all, we made direct amends to such people

whenever possible, except when to do so would injure them or others, we continue to

take personal inventory and when we were wrong, promptly admitted it, we sought

through prayer and meditation to improve our conscious contact with God, praying only

for knowledge of His will for us, and power to carry that out, and Having had a spiritual


22

experience as the result of these steps, we try to carry this message to others and practice

these principles in all our affairs (CR, 2019).

Additionally, the eight principles of CR are:

Realize I’m not God; I admit that I am powerless to control my tendency to do the wrong

thing and that my life is unmanageable (Step 1), earnestly believe that God exists, that I

matter to Him and that He has the power to help me recover (Step 2), Consciously choose

to commit all my life and will to Christ’s care and control (Step 3), openly examine and

confess my faults to myself, to God, and to someone I trust (Steps 4 and 5), Voluntarily

submit to any changes God wants to make in my life and humbly ask Him to remove my

character defects. (Steps 6 and 7), Evaluate all my relationships. Offer forgiveness to

those who have hurt me and make amends for harm I have done to others when possible,

except when to do so would harm them or others. (Steps 8 and 9), Reserve a daily time

with God for self-examination, Bible reading, and prayer in order to know God and His

will for my life and to gain the power to follow His will (steps 10 and 11), yield myself to

God to be used to bring this Good News to others, both by my example and my words

(step 12) (CR, 2019).

The 12-steps and eight principles of CR follow an abstinence-only approach to substance

misuse, and this approach may create more stigma due to the shame that is created from an

abstinence-only approach (SBIRT, 2014). Furthermore, the groups are not guided by licensed

healthcare providers, and this allows for CR to not follow any mental health ethical guidelines

for treatment. The advantage of CR is the availability of the groups and the assumption that

Appalachia community members may prefer to connect with their church for substance misuse

guidance compared to a mental health service provider (Smith et al., 2018).


23

Policy Implications

Substance misuse is gaining national attention as the opioid epidemic has become part of

the American lexicon. Policy is being created to assist people impacted by the epidemic (Perez,

2018). Toward the end of 2018, a bill (HR6) was passed to transition the country towards

solutions that would lower the impact. This bill contained five main focuses: (a) the expansion of

recovery centers through government funding, (b) the requirement of the U.S. Postal Service and

other entities to track drug shipments, (c) the ability for clinical nurse specialists and others to

prescribe drugs (such as Buprenorphine) for five years that will help people lower their addiction

to opioids, (d) liberates the National Institutes of Health to more quickly pursue research projects

related to non-addictive drugs for pain, and (e) make changes to several Medicare and Medicaid

regulations, such as the expansion of Medicare to cover opioid treatment (Zezima and Kim,

2018). While this bill is a great start, there is more to be done concerning policy and the opioid

epidemic, such as providing better training and resources to practicing healthcare providers.

Gaps in Literature

As mentioned in chapter one, there are several gaps in the literature that guide the

development of the current study. With a few exceptions, there is a lack of application of theory,

a dearth of research on effective treatments for substance misuse in Appalachia, and an absence

of attention to how the culture of Appalachia can be leveraged to support the reduction of

substance misuse.

Of the research studies covered in this literature review, only two directly stated specific

theories that helped to guide the research and the research questions (Monnat & Rigg, 2016;

Smith et al., 2018). One reason for this gap could be that the majority of research documenting

health disparities of Appalachian populations is published in medical journals, and the use of


24

theories may not be as common as in research from other disciplines. Regardless, the use of

theory could significantly increase the rigor of the research being conducted and could have

implications for future research, prevention, and intervention efforts.

The lack of implementation science guiding prevention and intervention efforts around

substance misuse in Appalachia is startling, particularly given the clear need that has been

documented. Coupled with the lack of discussion evidenced in the literature about the potential

strengths and resiliency of Appalachia communities, it would be beneficial for future research to

include discussions around the strength and resiliency of the communities and work directly with

individuals within these communities to capitalize on resources.

Current Study

The goal of this study is to contribute to the gap in the literature by gaining a better

understanding of substance misuse in Appalachia through the eyes of church leaders. The

proposed research study responds to suggestions of existing literature (Hall & Gjesfjeld, 2013;

Smith et al., 2018) to utilize church leaders, yet no existing studies examine the experiences of

church leaders discussing substance use or how church leaders in the Appalachian area are

working to reduce substance misuse. To that end, this research study aims to answer the

following questions:

• What are the experiences of church leaders when working with community members

impacted by substance misuse? (RQ1)

• How do church leaders connect with mental health service providers when substances

such as opioids impact a community member? (RQ2)

• What do church see as the solution to the current substance misuse problem? (RQ3)


25

Theoretical Framework. This project was informed by Bronfenbrenner’s (1979, 2005)

ecological systems theory. This theory has been widely used across many disciplines, such as

family science, social work, psychology, and healthcare, but originates out of human

development. A fundamental understanding of Bronfenbrenner that has evolved over time is the

idea that a person's behavior is a function of the interaction of the person's traits and abilities

with their systems. Essentially, the core of this theory is an understanding that humans are

profoundly impacted by and impact the multiple systems within which they are embedded.

Bronfenbrenner’s framework has been to understand Appalachia and its healthcare crisis

(Stamm, 2003).

Bronfenbrenner's work is unique in that it challenged the idea that an individual's

behavior is solely explained by examining the individual's traits and abilities (White, Klein,

Martin, 2015). To understand this theory, it is essential to understand the key concepts of

microsystems, mesosystems, ecosystems, macrosystem, the chronosystem, and proximal

processes (Bronfenbrenner, 1979; 2005). Each key concept will be further discussed in the

context of the current study.

A microsystem is the smallest unit of relationships (Bronfenbrenner, 1979). It takes into

account the role that relationships have on the individual, the family, and the system. The

simplest example of a microsystem is the dyad between a child and parent (White, Klein, Martin,

2015). Furthermore, the microsystem includes any other forms of relationships, such as

friendships, work relationships, and community relationships. When connecting the microsystem

to the literature on Appalachia, it is essential to understand the importance of family within the

Appalachian culture (Keefe, 2005; Williams, 2002). The microsystem would take into

consideration the impact that family has on the individual and the impact that the individual has


26

on the family. It is understood within the Appalachian culture that the individual is representative

of their family and relationships, or what Bronfenbrenner (1979) would consider a microsystem.

The microsystem is an important concept in the proposed research. As indicated in the

literature, it is evident that the church often plays an essential role in the individual's life, and it

can be a safe place for individuals to explore the meaning of their substance misuse. By focusing

on understanding church leaders’ experiences with the opioid epidemic rather than therapists,

this research demonstrates an understanding of the multiple microsystems for individuals in rural

Appalachia (Keefe, 2005; Williams, 2002).

The mesosystem is defined by the interactions of two or more microsystems

(Bronfenbrenner, 1979). An example of this could be the interaction between an individual's

family of origin and an individual's church family. The mesosystem is a crucial part of

researching in Appalachia because it positions the researcher to understand the relationship

between the different microsystems. For example, the relationship between family expectations

that the relationship the individual has with their substance misuse and their mental health.

Family expectations (a microsystem) impact the individual and the dyadic relationship with their

substance misuse (a microsystem) and their mental health (a microsystem). Under-utilized

avenues for prevention and intervention for substance misuse can be explored by examining the

interactions between various microsystems. Research questions two and three are guided by the

mesosystem.

The exosystem includes the interaction of systems that impact the individual that the

individual is not part of (Bronfenbrenner, 1979). As applied to this study, the opioid epidemic

represents an exosystem influence. The current rise in opioid use in Appalachia stems from over-

prescription by doctors who are the result of pharmaceutical companies dumping the medication


27

on the doctors with inadequate training and poor understanding of the in addictive properties

(Moody et al., 2017). This interaction of systems has directly impacted the community members

of Appalachia due to doctors overprescribing the medication because of their understanding that

it was fast pain relief (Monnat & Rigg, 2016).

The macrosystem includes the culture that impacts the individual (Bronfenbrenner,

1979). The location of living in the mountains, the history of generational poverty, and the

resiliency of the people (Keefe, 2005; Williams, 2002) are important aspects of the Appalachian

culture. This study recognizes the importance of culture and values understanding its influence

on how church leaders have made sense of the opioid epidemic. Research question three is

guided by the macrosystem and the proposed study working to gain a deeper understanding of

the culture of the epidemic through the experiences of church leaders.

The chronosystem includes the idea of time and change (Bronfenbrenner, 2005). The

chronosystem was a later supplement to the theory, and it gives understanding to how a shift in a

system can impact an individual. For example, a shift in family structure such as divorce can

significantly impact family members involved in the event. There are four major shifts in the

recent time of Appalachia that may provide an understanding of the barriers and culture of

Appalachia. These four barriers were discussed above under the history of Appalachia. For this

section, the last two events will be focused on: the decline in coal mining and the introduction of

opioids (Keefe, 2005; Williams, 2002). While people from Appalachia have a unique

relationship with coal mining (Keefe, 2005; Williams, 2002), it is essential to discuss how the

decline in this type of labor has impacted the communities. The decline has increased the barriers

to healthcare due to a decline in jobs, a decline in healthcare insurance, and an increase in rates

of poverty (Roberts, Banyard, Grych, & Hamby, 2017). The use of church leaders, a resource


28

that is relatively common in Appalachia (Smith et al., 2018) could help combat the impact of

healthcare by the decline in coal mining. It is essential to know the negative impact that coal

companies have also had on Appalachian communities (Williams, 2002), but the focus here is

how to move forward with substance misuse resources.

The second shift in the system was the introduction of opioids. This shift co-occurred

with the decline of coal mining and dramatically impacted the culture of Appalachia (Keefe,

2005). The most significant shift has been the increase in substance misuse connected with more

barriers to healthcare. This shift is helping to guide the proposed research study and its relevance

to the current time and change occurring in Appalachia instigated by the opioid epidemic.

Lastly, another important aspect to the bioecological theory includes the concept of

proximal process. As Bronfenbrenner developed his theory, he emphasized the aspects of

process, person, context, and time (Bronfenbrenner & Morris, 2006). Proximal processes can be

defined as enduring interactions between the person and people, objects, and symbols in their

immediate environments (Bronfenbrenner, 1999). These dynamic interactions are the mechanism

that facilitates development and understanding. Parenting behaviors between a parent and a child

can be considered a proximal process. Given that it is currently unclear how church leaders

discuss substance use with their community members and if these conversations influence

substance misuse, this study is exploring a potential proximal process between Appalachia

church leaders and individuals and families impacted by substance misuse.


29

Chapter 3: Methods

Overview

A qualitative research design guided the data collection for this study and relied on

participant interviews and the collection of demographic characteristics. Interpretative

Phenomenological Analysis (Pietkiewicz & Smith, 2012) guided the analysis of the data.

Utilizing a qualitative design enabled me to better understand the experiences of church leaders

addressing substance misuse in Appalachia.

In the present study, there were three guiding research questions:

• What are the experiences of church leaders when working with community members

impacted by substance misuse? (RQ1)

• How do church leaders connect with mental health service providers when substances

such as opioids impact a community member? (RQ2)

• What do church leaders see as the solution to the current substance misuse problem?

(RQ3)

As part of the semi-structured interview schedule, follow-up questions and probes incorporated

the use of ecological systems theory to explore each unique context that the church leaders are

involved with. For example, follow-up questions after RQ1 included:

• How has the opioid epidemic impacted your church community? (Macro System)

• How has the epidemic impacted your own family? (Micro System)

• How would you describe the epidemic, given your experiences with it? (Micro System)

For a full list of follow-up questions, please reference Appendix D.


30

Research Methods

IPA. The goal of a phenomenological study is to uncover the lived experiences of

individuals and to interpret how these individuals make sense of their experiences (Smith,

Flowers, & Larkin, 2009). More specifically, Interpretative Phenomenological Analysis (IPA) is

a form of phenomenology that draws upon the fundamental principles of phenomenology,

hermeneutics, and ideography (Pietkiewicz & Smith, 2012). It is concerned with an in-depth

exploration of lived experience and with how people are making sense of that experience. The

focal point of an IPA study is therefore guided by open and exploratory research questions. It is a

dynamic process with the researcher taking an active role, and the participants are regarded as

co-researchers. This creates a collaborative process between the participant and I, and methods

of IPA include interviews and written accounts of participants’ experiences (Daly, 2007).

As stated above, there are three important aspects to IPA: phenomenology, hermeneutics,

and ideography (Pietkiewicz & Smith, 2012; Smith et al., 2009). Phenomenology can be

described as the experiences of the participants. Hermeneutics can be described as the researcher

working to understand and interpret the participant’s experiences. Lastly, ideography can be

described as the emergent themes that arise from each of the participant’s experiences

(Pietkiewicz & Smith, 2012; Smith et al., 2009). My goal was to work with the participants to

uncover each of the three core philosophies of this type of analysis.

For this exploratory study, the use of IPA methodology (Pietkiewicz & Smith, 2012) was

ideal because it provided understanding, meaning, and truth to the lived experiences of church

leaders concerning any discussions that they may have on substance misuse with their

community members. The overall goal of this study, to gain an understanding of the lived

experiences of church members concerning discussing substance misuse with their church


31

congregations, is consistent with IPA methodology (Pietkiewicz & Smith, 2012). Given the

limited literature surrounding the use of the church as a way to discuss and intervene in

substance misuse, there may be unknown factors that prevent church leaders from discussing

substance misuse with their church congregants. The role of stigma around substance misuse

may be one factor, primarily due to some religious beliefs that look down on any form of

substance misuse (Keefe, 2005). The hypothesis that these discussions may be occurring is based

on existing literature and understanding of the gaps in the literature. For example, the literature

suggests that church leaders are being utilized as a partner in mental health (Smith et al., 2018),

but there is not any direct literature that discusses church leaders being a partner in discussions

around substance misuse in Appalachia.

Another justification for using IPA methodology involves the need to understand the

language of church leaders if they discuss substance misuse with church congregants.

Understanding the ways in which church leaders discuss substance misuse could inform

prevention and intervention efforts with church leaders and healthcare providers who are

working in Appalachia. I collected first-person accounts of the experiences and phenomena of

church leaders discussing substance misuse with their church congregants (Pietkiewicz & Smith,

2012). Furthermore, by gaining an understanding of substance misuse within church community,

any dominant themes that began to emerge helped guided future research around substance

misuse in Appalachian communities.

Case selection. For this research study, the sample included 10 church leaders who

served in Appalachian communities. Recruitment occurred around rural towns in the central

Southeastern portion of Appalachia. This portion of Appalachia included Southwest Virginia,

East Tennessee, West Virginia, and Northeast Georgia. Sampling was intentional in that the


32

church leaders recruited represented a variety of Christian church denominations, such as

Baptist, Pentecostal, Catholic, and Methodist. Not restricting the sample in terms of church

denomination allowed for variance in the experiences of church leaders and any differences that

emerged as a result of church policy, resources, and procedures could be accounted for as

needed. While IPA studies are typically homogenous due to the phenomenon under

investigation, there is a lack of existing information on the experiences of church leaders

discussing substance misuse in Appalachia that would suggest limiting the sample to a specific

denomination. The sample size of 10 church leaders is an appropriate sample size for an IPA

study (Pietkiewiez & Smith, 2012). There are a few reasons for a smaller sample size when

utilizing an IPA approach (Shinebourne & Smith, 2009). First, the detailed examination via a

case-by-case analysis involves a depth of analysis and is time consuming. Second is the need for

a fairly homogeneous sample in this study, Christian denominations in Southeastern Appalachia.

The sample size should provide a sample homogeneous enough to elicit detailed experiences

around a shared phenomenon. The goal is for these experiences to reach data saturation, which

occurs when the experiences of the participants begins to reflect similar experiences and themes

across the data (Pietkiewiez & Smith, 2012).

Recruitment was purposeful; in part for the need for a homogeneous sample, and also

guided by existing research experiences when working in Appalachia (Shinebourne & Smith,

2009; Thomas et al., 2019). Research has indicated that the best form of recruitment occurs via

word of mouth and snowball sampling (Shinebourne & Smith, 2009; Thomas et al., 2019). To

start the recruitment process, I contacted various leaders in Appalachia to see if they could

forward the research flyer to any possible church leaders that would be willing to participate in

the research. These leaders included Appalachian Studies professors, healthcare providers in


33

Appalachia, and members of the Appalachian Studies Association. This resulted in the

recruitment of the majority of participants. The participants contacted me via email expressing

interest in participating in the study. Once a few church leaders agreed to interview, the

interviews were scheduled. At the end of the interview, participants were asked if they knew of

other church leaders whom they thought would be willing to participate in the study. These

methods of recruitment yielded the target sample size. Once data saturation was reached, I halted

recruitment. Data saturation was considered obtained once no new themes were discussed by

participants.

Data Collection. Initial contact with the participants occurred via email. The email

exchanged between the participant and me (see Appendix A) included information about the

study and the informed consent. After the participant reviewed the information provided and

agreed to participate, scheduled an interview.

The collection of data included interviews conducted via the phone. This method was

preferred by the ability to audio-record and to facilitate participation for individuals unable to

meet in person. I used an audio recorder during each phone interview. The interviews lasted

between 35- 60 minutes. The interviews that included participants 5-10 were shorter than the

beginning interviews (average length was 35 minutes) due to saturation of the. Church leaders

were able to participate in the interview in a setting that they felt most comfortable. I followed a

semi-structured interview guide (see Appendix D) but allowed for a natural flow of conversation

between the participant and I to ensure that the participant felt comfortable sharing their

experiences.

Reflective journal. I kept a reflective journal that included field notes throughout the

data collection and analysis process. The journal provided me with a space to reflect on my


34

experience of emerging myself into the research and working to gain a deeper understanding of

the lived experiences of the church leaders. The use of a reflective journal adds rigor to

qualitative research through the process of recording my reactions, assumptions, biases, and

expectations about the research process (Rossman & Rallis, 2012). For example, I wrote down

my initial reactions at the end of each interview. These reactions included a sentence or simply a

word. For example, I have reflected that I wrote the word “stigma” after each interview. This

represented my feeling of the impact that stigma had on the church leaders and their work with

substance misuse.

Data storing. Data was kept in my secure office. All interviews were audio recorded, and

the audio files were stored on an encrypted external hard drive. Each interview was transcribed,

allowing thorough emersion into the data. During transcription, I kept notes through the

reflective journal.

Each transcription was located in a folder and each transcription was labeled in a way

that does not connect the transcript with the participant, for example “transcription 1.” A list of

participants and the label on their transcript was kept separate from the transcribed files,

increasing confidentiality. Additionally, per IRB guidance, consent forms were kept separately.

Thus, there are four separate electronic folders throughout the research process. The first folder

held the consent form. The second folder will hold the transcribed interviews which included

participant demographics. The third folder held the document that connects the transcribed

interview with the participant, and the fourth folder held the reflective journals that occurred

throughout the data and analysis process. All folders were kept in a secure location.


35

Analysis

The analysis process followed the guidance of Smith, Flowers, and Larkin (2009). I

analyzed the data by first transcribing and reviewing each interview. Transcription aided the next

level of coding and this process included the transcriber diving into the data and fully emerging

themselves into the interviews. Next, initial exploratory coding was used to identify meanings

and use of language conducted in three discrete coding processes: (a) descriptive, (b) linguistic,

and (c) conceptual. Descriptive comments focused on describing the content of what the

participant said, linguistic comments focused on exploring the specific use of language by the

participant, and conceptual comments focused on engaging at a more curious and theoretical

level. Following initial coding, I looked for emerging themes and categorized them into

dominant and subdominant themes. An emergent theme was considered a dominant theme only

if more than half of the participants provide a quote regarding the theme. An emergent theme

was considered a sub-dominant theme if there are more than two quotes, but less than half of the

participants providing a quote regarding the theme. For an example of how emergent themes

were formed, see Table 2.

Once themes were identified, the analysis procedures of abstraction, subsumption, and

polarization were used to finalize the themes and capture the essence of the experience of church

leaders discussing substance misuse with their community members in rural Appalachia.

Abstraction was used to identify any patterns between emergent themes. This involved

connecting pieces that are found within themes and developing a new understanding for the

cluster, known as super-ordinate (Smith et al., 2009). For example, a group of emergent themes

around the impact of substance misuse in Appalachia: “people are afraid of strangers due to the

impact of substance in the community”, “meth has changed everything ”, and “systemic impacts”


36

will be grouped together under the new theme “community impact.” Subsumption may also be

used if an emergent theme itself requires status of super-ordinate (Smith et al., 2009). For

example, “lack of community resources” became a super-ordinate theme that would bring

together closely related themes similar to “no therapist to refer to”, “providing substance misuse

counseling more than the church leader feels comfortable doing”, and “feeling overwhelmed

with discussing substance misuse with high numbers of community members.” Lastly,

polarization was used to examine transcripts for opposing relationships between emergent

themes by focusing on differences rather than similarities (Smith et al., 2009). For example, a

theme that was unique to only two participants included the understanding that the church may

not trust therapists who not have similar religious beliefs as the church leader. While this theme

is important to understand, it was not a theme expressed by all participants and it opposed other

participants’ understanding of therapy. Specifically, other participants conveyed that there did

not need to be a similar religious background between therapist, church leader, and community

members for therapy to be effective. These participants seemed to have an understanding that

therapists are trained to not use their personal, religious beliefs as therapeutic tools. For an

example of polarization, see Table 3.

Trustworthiness and Rigor

An essential piece of qualitative research is the use of trustworthiness and rigor (Barbour,

2001). Yardley (2000) presented four broad principles that offered a variety of ways to establish

a thorough qualitative study. These principles can be applied to multiple qualitative research

methodologies, and each principle has been implemented throughout this research design. The

four principles are sensitivity to context, commitment to rigor, transparency, and coherence, and

impact and importance.


37

The first principle, sensitivity to context, was executed throughout the study. It began in

the structuring of the interview session, and this structure included time for me to join and build

rapport with the participants. This was done through what I refer to as "front-porch" talk, and it

included conversations that introduce me to the participant. During the interview, sensitivity to

context was shown through the appreciation of the experiences that the participant shared

through empathy and creating a relaxed interview experience. Lastly, sensitivity to context was

demonstrated through the findings and the discussion of the findings. This was done with the

goal of ensuring that the findings and discussion do not increase any stigma on Appalachia,

particularly from a reader who does not identify as Appalachian.

The use of reflexivity throughout the research process was essential to ensure trustworthy

and rigor. Reflexivity serves as a means for monitoring a researcher’s own subjectivity

throughout the research process (Daly, 2007). Specifically, my own social position as an

Appalachian community member may impact the degree to which aspects of my own identity are

included in the final products of the proposed research project. My identity had the potential to

create bias and shape how I interpret the data. For instance, it may influence the analysis process

and generate themes that may represent my own experiences rather than the experiences of the

participants.

To ensure that my own experiences did not impact the results of the proposed study, I

implemented a number of strategies. First, the use of a reflective journal provided me with the

ability to track my own experiences and themes that manifested from data collection. It became a

tool that could be referenced if I felt as though my own identity was impacting the proposed

study. Another measure included the honesty of my identity as both an “insider” and “outsider”

to the culture. This required me to fully reflect on my own Appalachian identity and to track the


38

occasions where my identity created vulnerability, power, awkwardness, affirmation, conflict, or

an experience of clear self-awareness (Daly, 2007). Again, this honesty was present in the

reflective journals kept throughout the data process. Reflexivity was demonstrated with me

disclosing my Appalachian identity to participants. I did this to increase trustworthiness and it

helped to facilitate a welcoming environment for the participants when they became aware of my

personal ties to Appalachia.

The second principle, commitment and rigor, is demonstrated through the methodology

and methods of this study. The thoroughness of the study defines rigor, the appropriateness of

the sample used, the quality of the interview, and the completion of the analysis (Smith et al.,

2009; Yardley, 2000). Interviews were thorough and reflected a personal commitment to the

comfort and safety of the participants. Lastly, the data analysis was conducted in a systematic

manner that works to inform the reader of the importance of the participant's lived experiences.

The third principle, transparency and coherence, was evidenced in this description of the

research methods by documenting how participants were selected, how the interview was

planned to be structured and conducted, and the steps that were used in the analysis. To ensure

coherence, I read the drafts and write-up carefully and intentionally attempted to review the

write-up as an outsider to the Appalachian region (Smith et al., 2009). To create coherence, the

use of reflective journals created an opportunity for the me to separate from the experiences of

the church leaders. I drafted the write-up multiple times, with feedback from my advisor, who

was less connected to the data, to allow for the analysis to become more coherent, and the goal is

that the final write-up represented the process of IPA (Smith et al., 2009; Yardley, 2000).

The final principle of impact and importance was evident in the final write-up of the

qualitative research. The goal is that by following the above principles (Yardley, 2000), the


39

research creates a valuable contribution to the literature and benefits the Appalachian population

through the understanding of the experiences of church leaders discussing substance misuse

within their communities.

Ethical Considerations

All of the participants were treated under the ethical guidelines of the Virginia Tech

Institutional Review Boards (IRB). There is minimal risk associated with this study. This was an

exploratory study that attempted to understand the experiences of the participants. All efforts to

maintain confidentiality were made. All data collection procedures focused on exploring the

research questions.

I maintained participant confidentiality. All data (informed consent, contact information,

interviewer notes, audio files, and transcripts) was collected and stored in a secure setting (my

locked office). Data remained in the same secure setting in which it is collected. Additionally,

the interview protocol included limited request of sensitive, personal information about the

participants. An example of sensitive information that was asked includes questions that focus on

the participant’s personal history with substance misuse. All questions asked were delivered in a

way that was safe, and the participants were given the option to not answer any questions that

they were not comfortable with answering.


40

Chapter 4: Results

The purpose of this study was to understand the experiences of church leaders when

working with community members impacted by substance misuse. The results presented in this

chapter are organized in a way that represented the systemic impact that substance misuse has on

Appalachian communities and the church leaders working in the region.

Participant Demographics

The demographics for the participants (n = 10) was diverse in experience, denomination,

and Appalachian identity. The length of time practicing as a church leader ranged from 5 – 40

years, with the average length of time of 19.6 years. All participants identified as Caucasian.

Three of the participants identified as women and seven identified as men. The denominations

represented by the church leaders included Baptist (n = 2), Methodist (n = 2), Presbyterian (n =

1), Episcopal (n = 1), Pentecostal (n = 1), Mormon (n = 1), Catholic (n = 1), and

nondenominational (n = 1). All participants practiced in southcentral Appalachia. Half of the

participants (n = 5) reported the Appalachian identity as extremely important to them personally

and professionally. For more demographic information, see Table 1.

Interview Process

Interviews were conducted over the phone. The average length of each interview was 45

minutes. The church leaders were eager to participate in the interview, and the questions flowed

at a natural pace and represented that of conversational dialogue. I would consistently ask for

clarifying information and would occasionally ask the participant to provide insight into a theme

that a previous participant discussed. For example, the first participant interview addressed the

need for more community engagement from church leaders. In the interviews that followed,


41

participants were asked to describe how they participate in community engagement and how they

believe the church should do so.

Results

Four themes were representative across participant interviews:

• The use of stories to describe their experiences working in their communities with

substance misuse

• The stigma associated with substance misuse

• The community impact that substance misuse has on Appalachia

• A lack of understanding and the need for training on substance misuse for church

leaders and healthcare practitioners

In this chapter, each theme will be further broken down and discussed in detail. Quotes will be

presented to represent the church leaders’ experiences and capture the essence of how they work

with their community members impacted by substance misuse.

Stories. An overarching theme that emerged across participant interviews included the

way church leaders would use stories or narrative accounts to describe how they interacted with

their members of their church community around substance misuse. The narratives could include

a story of someone in the community that was impacted by substance misuse or to describe their

personal and professional experiences with how substance misuse comes up in their work. These

stories provide powerful examples of how the church leaders were affected by substance misuse.

There are three avenues in which substance use is brought up to me. The first is when the

family or individual is in crisis and they are in the hospital. The second is when an

individual comes to me and talks about their relative’s substance use. The last is when

people turn to the church for help. This happens when they realize that substance use is a


42

dependency that can’t always be overcome by itself. Sometimes the sermons on Sunday

may cause someone to come to the church to discuss their substance use. This probably

happens about twenty-percent of the time.

This participant described how they learned about the impact of substance misuse on their

community:

Within the main body of my church, there has not been very much substance misuse with

the immediate church members. There was one family who had a son who hurt their

back, became addicted, and then ended up back home. It ruined his marriage, career, etc.

My dad is also a pastor. He doesn’t talk about substance use. My mom works in a

retirement community and she has discussed medication abuse. I do remember my

parents talking about a doctor who lost his license because he became addicted to

prescription drugs.

Another church leader shared a powerful story of how an important family in their church

was impacted by substance misuse and that the community noticed the compassionate response

of the church leader:

Each church has a matriarch and a patriarch. The matriarch had a nephew with movie star

good looks. They had been in the church for at least 30 years. His picture from his high

school days showed that he could have been on the big screen. After two years of being at

the church as a pastor, I was asked to meet him in the hospital. When I saw his body, he

looked 70 years old before he was barely 40. He was hugely impacted by meth. I buried

him a few months after I met him. I was asked to do that, and I assume it was because I

was the only pastor that had a college degree in the area, and I did not follow the standard

objectives of a funeral. When I would lead funerals, my objectives at the funeral included


43

these in this specific order: comfort the family, honor the dead, share the gospel.

Typically, in Appalachia, sharing the gospel tends to be the first thing that happens at a

funeral. This usually means the preacher would say something similar to ‘Don’t end up

like this guy.’ I wouldn’t do that. People noticed that, and they wanted me to bury their

family members.

Participant’s also shared stories of how they discussed the problem of substance misuse

with other local leaders in their denomination:

One of our clergy members said, ‘If people would find Jesus and be saved, then things

would turn around.’ Most of us are saying it’s a little more difficult than that. We know

there is a spiritual component to recovery, but it takes more. It’s a brain and body disease.

You can’t pray away your chronic disease. Other members said they didn’t have that

problem, and we asked him to ask his church community. He did, and he reported that

half the congregation has been impacted by substance use. I’m not sure if its stigma, not

knowing, or not being aware.

As you will see through the participant voices throughout the results, recognition of the impact of

stigma is a salient theme of the church leaders’ experiences with substance misuse in their

communities. Several of the church leaders were making efforts lower the stigma of substance

misuse within their church communities by simply discussing it.

Church leaders also described how stigma around substance misuse is shaped in some

ways by the particular drug:

In our church, opioids don’t have the illegal stigma that other drugs do. People have their

guard down because the drugs are prescribed by their doctors and then they become

addicted. We see a lot of that in our church community and it is hard to convince a person


44

that a legal drug can become addictive. Then it transitions to a bigger problem with the

use of illegal drugs once their prescription runs out or they share their opioids with family

members who may become hurt. That is an issue in our community too. Since prescribed

opioids are legal, people are more likely to share with others.

While the above descriptions are a snapshot of how church leaders used stories and narrative

descriptions to are also used throughout the following three themes.

Stigma. All participants, directly and indirectly, discussed the understanding of stigma

connected to substance misuse. “Lepers” was a term used to describe community members

impacted by substance misuse. In the bible, this term represents someone who is impacted by sin.

One participant stated,

Someone asked me my thoughts on substance misuse, and I compared it to modern-day

leprosy. People were afraid of it. They didn't understand it. Jesus walked right in the

middle of it. Thousands of people are dying, but people are ignoring it. I think we are

called to act on this topic.

Additionally, another participant made the statement,

We basically turned our backs on the gay community when HIV hit. We treated them like

a bunch of lepers. Jesus loves everyone. You have to come to him still, but he expects us

to love everyone. We didn’t do a good job there. We can’t make that same mistake with

people impacted by substance misuse.

This powerful quote occurred with one of the first three interviews. This allowed the me to share

this quote in subsequent interviews and allow for the participants to reflect on it. All participants

agreed that the quote reflected the stigma that church leaders, community leaders, healthcare

providers, and community members may have of those impacted by substance misuse. For


45

example, one participant stated, “Always air on the side of compassion. If you turned your back

on sinners, then you wouldn't help any, and we wouldn't get help ourselves."

Stigma impacted how church leaders learned of people who were impacted by substance

misuse. The majority of the participants stated that community members who were impacted by

substances did not come to talk to them directly. As one participant stated,

I usually hear about someone who is impacted by substances second hand. A parent

comes to me to discuss their child. Unfortunately, I may only learn about a church

member’s substance misuse when I visit them in the emergency room or when I am

called to prepare the eulogy.

Additionally, another participant made the statement, “They don’t start the conversation about

substance misuse, but then it might lead to it.” Another participant described how they noticed a

difference in how often church members would discuss substance misuse with them once they

became senior pastor,

Not so much as a senior pastor. That has been the change from a youth pastor to a senior

pastor. Young people have a more openness to talk about their brokenness, but not as

adults.

This understanding that church members were not comfortable directly discussing their

substance misuse seemed to be understood and acknowledged by all participants.

Each church leader involved in the study discussed how each of them have worked to

overcome their own feelings of stigma associated with substance misuse. Several participants

discussed working through their stigma related to their personal or familial experiences with

substance misuse. One participant stated, “I grew up with a father addicted to opioids. I

understand what it is like to be in that environment. I use this experience to gain a deeper


46

understanding of what my church members are going through.” Another participant stated that

their understanding came from their sibling,

It is a huge problem in the church and my family. I deal with it in the church and then

also my brother. Time after time, I have dealt with people and tried to help them with

their addiction issues.

Additionally, many participants utilized substance misuse training to help them overcome their

stigma of substance misuse. Half of the participants had a background in mental health, and this

training has allowed them to work toward understanding the stigma that is associated with

substance misuse. For example,

I did an internship for my master's back in 2006 with a treatment center, and ever since

that time, I have been very interested in substance misuse. I have continued to worry

about it. I have encouraged my church to open up to recovery groups.

Another participant reflected, “Most helpful for me has been learning about the neurobiology of

addiction. For the community, it has been talking about substance misuse like you would any

other healthcare problem, such as diabetes.” Several participants understood how beneficial

trainings on substance misuse were for their own feelings of stigma and believed it would be

helpful for other church leaders and community members. Additionally, participants discussed

how they utilize their own experiences with mental health concerns to lower stigma,

I have my own anxiety and OCD, and once a month I will admit to my church about my

mental health, and this really connects with my church members. I let them know that

there are more people out there struggling with mental health.

Church leaders conveyed a clear understanding of the impact stigma surrounding

substance misuse had on their communities. One participant stated,


47

Honestly, the thing that I have seen that is the biggest help is lowering the stigma is being

honest about it and talking about our own mental health problems. Once I see people be

open with others about their mental health and substance misuse, then others seek the

help that they need. It is a good start for the church to discuss it as not being a weakness,

and we need to talk about it.

This example provides insight into how impactful substance misuse has been at the community

level in Appalachia. It shows how powerful it can be for church leaders to lower the stigma by

merely being more honest about the impact that substance misuse has on themselves and their

community. This theme of community was discussed more throughout each interview.

Community impact. Throughout the interviews, the understanding of how much the

community is impacted by substance misuse was evident. One participant shared their perception

of the macrosystemic influences of substance misuse in the Appalachian community:

We work in the coal fields a lot. I think that because coal has shut down and people are

now in poverty that a lot of people are leaving these areas. The people that stay are

impacted by depression and they turn to drugs to lower the pain. In my opinion, if the

economy was better than that would lower the impact of substance use.

Another participant reflected on how the use of substances in the community is connected

to the need for financial resources, "It's not that they want to do drugs, it's that their friend sells

drugs and they know that their friend needs the money." It was common for participants to

understand the systemic impact that the introduction of certain drugs had on their community,

“Meth changed everything about 15 years ago. It made drugs so affordable. People couldn’t

afford cocaine. Now people are making it [meth] at home.” This statement highlights how the

introduction of meth into the community caused a tremendous shift in the community’s system.


48

Further, one of the participants reflected on the financial impact of substance misuse on their

local Appalachian community:

[Town of participant} is such a fascinating place. I was surprised that it was part of

Appalachia, but then I wasn’t surprised due to the high level of poverty. The town has

five payday loan places. The community couldn’t keep Applebee’s in business, but we

can keep those five loan places busy. I think that speaks to the drug population.

Lastly, another participant described the cultural shift in the community that occurred,

The biggest issue and how it influences my work are that the breakdown in the

community that it creates, specifically the fear that someone who is on drugs is going to

break into the church. It creates a heightened fear and strangers of mistrust. It destroys

the community. I remember growing up in Appalachia, and people were still friendly to

strangers, as long as they looked like you. The epidemic has caused this cultural

breakdown.

Participants seemed to understand the systemic impact of substance misuse within their

communities and how a systemic approach to a solution would be the best fit. For instance one of

the church leaders recognized, “We did okay treating symptoms, but the root causes are too

systemic.” Furthermore, they consistently described how a community approach to healing

would be the most significant method. One participant described this through the means of

biblical scripture, “A key verse to me: “I was with you.” – Paul. We have got to minister in such

a way that people know we love them.” This scripture was used to capture the need for church

members to open their churches to the families impacted by substances and to not run people out

of their congregation. Additionally, “hope” and “compassion” were wording that participants

frequently used to describe solutions to the high rates of substance misuse in their community.


49

These words reflected participants’ recognition of the need for community care and church

leaders to exemplify hope and compassion rather than condemnation. One participant stated, “It

is important for the church to understand and create a community of care.” It was consistent for

participants to discuss the need to break away from discussions on how the church can “save”

community members and shift toward the church creating a community of care. This idea was

emphasized with the comment, “Truth is truth, love is love, kindness is kindness. You don’t have

to stretch too far to find commonality among people.”

One participant described how their church fell into an outreach program around

substance misuse:

We have a substance misuse ministry in our church. We accidently became involved in it,

and our church community has really embraced the ministry. It is our primary outreach

program. It accidentally started because we are Appalachian and have poverty, our

church is typically middle class. We started doing meals for free, and the people who

would primarily come were children and adolescents. We found out that these were kids

that had parents impacted by substance use. We knew we needed to do something after

this.

Creating a community of care included connecting mental health service providers and

other healthcare providers in the region, if available. Unfortunately, several participants

discussed a lack of medical providers in their local communities, and more specifically a medical

provider who was willing to work with community members impacted by substance misuse. For

example,


50

I work with a doctor, and they are the only doctor who will deal with those addicted.

Other doctors throw away patients once they become addicted to their prescription

medicine. The doctor that I use was able to get trained on addiction medicine.

When the church leaders were asked about how they collaborated with healthcare

providers, it became evident that church leaders recognized the need for collaboration:

For the most part, the church is open to helping people with substance misuse, but they

are not prepared and equipped with the longevity that is required to help. The church isn't

obtaining the proper picture of what that type of commitment requires. Prayer isn't going

to provide a quick fix.

However, a few participants raised a concern that healthcare providers may not be a good fit for

the church leader's community members: “There is a huge gap between therapist reaching out

too. We are Christians, and we want a therapist who isn't going to change our church member's

beliefs and values.” While this concern was not shared by all participants, it is an important point

to discuss, as it has implications for education and training for healthcare providers and church

leaders to build positive collaborations to tackle substance misuse. At the same time, some

participants also reflected a concern about the lack of substance misuse training that mental

healthcare providers in their communities may have: “We have very few [providers], especially

therapists. Often, clients will say that the therapist doesn't understand addiction." This expresses

the need for more training provided overall, not just for church leaders in these communities.

Understanding and Training. Participants reflected about how underprepared the

church is to work with community members impacted by substance misuse. Statements included,

“The church doesn’t know how to handle relapse, and this creates stigma. The church doesn’t

understand the long-term commitment that is needed” and “there aren’t any best practices for


51

substance misuse. Unless a church buys a halfway house. Some really bold things– but small

things, I haven’t been able to find much.” One participant discussed their lack of knowledge on

medicated treatment for substance misuse and how it can be helpful:

We want to normalize discussion around substance use. I’ve been working with this one

family for a few years. Their son is off and on suboxone and I’m interested in medicated

treatment. I don’t understand why they will be on suboxone for the rest of their life. I just

don’t have enough information.

These statements signify how church leaders can be overwhelmed with the impact that

substance misuse has on their community. Furthermore, it shows a gap that healthcare providers

can fill by merely reaching out to church leaders in rural communities to collaborate and provide

relief.

When asked if the participants believed that church leaders could benefit from training

that focused on substance misuse, they all stated yes. One participant shared,

The complexity in the world that we live in is overwhelming to the local church leader.

There is no way that the church leader can be an expert in anything. There is no way I'm

qualified to be an expert in substance misuse, but we are expected to be. It can be

overwhelming. We are doing the best we know to do. We could use some tools and

resources so that we could outsource some of these things.

Participants reflected on the differences in the resources and training that church leaders

had. Some church leaders recognized that their church denomination contained more resources.

For example, "Baptist churches and catholic churches tend to have more resources."

Additionally, the participant interviews illuminated some differences between how different

church organizations viewed substance misuse. For example, “Southern Baptist tends to be the


52

most conservative of faith groups. We tend to frown on all substance misuse, and that

condescending attitude is not helpful. Drug addicts do not want to be drug addicts.” Another

participant stated, “Our church expects members to seek out substance misuse services. In our

bigger cities, we provide support groups for those dealing with addition. “Not only does this

suggest a difference in church denominations, but it also reflects a difference in resources

between urban and rural.

Alcoholics Anonymous and Celebrate Recovery. Each of the participants was familiar

with Alcoholics Anonymous (AA), and several participants were aware of Celebrate Recovery,

but seemed to have a more limited understanding of the latter program. Overall, the church

leaders shared that the community aspect of AA was the best support that a community member

impacted by substance misuse could receive during their recovery path. One participant stated,

The best benefit of support groups is that people begin to socialize again. They begin to

relate and find connections. The only relationship they had before was with the drug and

they became lost. Alcoholics Anonymous allows for them to re-enter society. Eventually,

you can see the social relationships begin to grow. Texting is a good way to hide, so I

don’t allow for them to hide. Cell phones allow for people to hide more and socially

isolate themselves. We had one woman who has grown so much socially and it’s such a

beautiful thing to see. They begin to recover.

Another church leader spoke about the use of a higher power in AA and how it can be

beneficial, but that the program still lacked other vital aspects of recovery,

My experience with Alcoholics Anonymous has mostly occurred through the local drug

court in my county. I have a number of individuals involved with the drug court and have

had general conversations about Alcoholics Anonymous, but I do not have any direct


53

involvement. The higher power part seems to be beneficial, but the long-term recovery

seems to be missing. Having someone in your corner provides the best support.

Substance use is the caving to the will of a desire. What I have found is that most addicts

tend to have obsessive personality and they need a structured regiment. The 12-step

programs provide that structure.

The data gathered on how church leaders discussed their awareness of and potential impact of

these two programs demonstrations the need for more research and understanding centered on

the benefits of these programs for their communities.


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Chapter 5: Discussion

The results of this study are discussed in detail throughout this chapter. It includes a

discussion on the findings of the study and the connection with existing literature through the

lens of Bronfenbrenner’s ecological systems theory (1979, 2005). Additionally, this chapter

includes a discussion of the implications for clinical practice, recommendations for further

research, and a discussion of the limitations of the study.

Theory

The results of the study will be discussed through the lens of ecological systems theory

by Bronfenbrenner (1979, 2005), the theoretical framework that informed this study.

Specifically, each level can be connected to the experiences and narratives of the church leaders.

Furthermore, the influence of stigma will be centered throughout the discussion as it was

reflected in all of the church leaders experiences. Table 4 further illustrates how the concept of

stigma is influenced by each level of the system.

The narratives shared by the church leaders provided a rich understanding of their

experiences with substance misuse in their church communities. These narratives exemplified the

systemic impact of substance misuse in rural Appalachia and how community leaders are part of

the experience. The researcher could hear the passion in the voice of each participant as they

shared stories about their community and its members. Through the use of stories, it was evident

that substance misuse has infiltrated the church system and the church leaders are working to

find solutions, even if it was not part of their mission at the start of their career. Below, the

narratives and themes shared in the results will be woven throughout a discussion that is

influenced by Ecological Systems Theory.


55

Microsystem. A microsystem is the smallest unit that takes into account the role that

relationships have on the individual, the family, and the system (Bronfenbrenner, 1979). The

microsystem views the impact that family, community, and the church have on the individual

and the impact that stigma has on the individual, family, community, and the church. The

influence of stigma was a salient theme across the stories and narratives shared by the church

leaders. This included both the stigma of substance misuse and the stigma of mental health

services. A common way this manifested was how community members would not directly

discuss their own substance misuse with church leaders, but instead would prefer to discuss the

substance misuse second-hand, such as how substances impact others. These narratives

exemplified the impact that substance misuse has on individuals, families, and the community.

The participants discussed how substance misuse was condemned within the families of

their community. The condemnation from family and community influences the stigma of

substance misuse because it creates a negative understanding of substance misuse and how it

impacts individuals. The feedback that individuals impacted by substance misuse receive from

others can further isolate them from family and their community and potentially contributes to

negative interactions within their microsystem. Similarly, church leaders recognized how they

may potentially further stigma of substance misuse through their ministry, such as their sermons

that have focused on prayer rather than seeking out mental health services.

Church leaders described how they learned of members in their community who were

impacted by substance misuse. While these narratives were not typically shared to the

participants by the person who was using substances their stories described how they began to

see the impact of substance misuse in their communities. While this high prevalence of substance

misuse is evidenced in previous studies (e.g. Hirchak et al., 2017; Moody et al., 2017), this study


56

provides a unique insight into how church leaders are hearing about substance misuse affecting

their congregants. The narratives shared throughout the interview process were impactful and

provided examples of the experiences of church leaders. These stories are not represented in

current research that focuses on substance misuse in Appalachia. The addition of these stories to

the narratives of substance misuse in Appalachia could help to lower the stigma of substance

misuse through the normalization of the epidemic.

The role of community was a salient context discussed by participants. Church leaders in

this study understood that multiple microsystems were impacted by substance misuse, that it was

not just an individual problem. One of the major implications of the findings of this study

suggests that church leaders are aware of substance misuse as a community level problem, are

willing to intervene, but do not feel adequately equipped to do so. In order to intervene to lower

the impact of substance misuse at the community level, church leaders could be a valuable

community partner with healthcare providers to provide support and combat stigma.

Mesosystem. The mesosystemic level understands how different microsystems interact

around substance misuse (Bronfenbrenner, 1979). This study has implications that are

particularly relevant for mesosystem interactions. For example, if a church leader is increasing

the stigma of substance misuse through their sermons (the church community is a microsystem),

then it may impact the church members and their family (the family unit is a microsystem)

understanding of substance misuse and willingness to seek treatment. Similarly, church leaders

described the lack of training they had on substance misuse. This lack of training that focuses on

substance misuse received by church leaders impacts the congregants and communities they

work with once they are leaders in their church community. Exploring the findings at the

mesosystemic level can also provide an understanding of why church leaders were not told


57

directly about personal substance misuse issues of community members, but rather told by a

person once or twice removed from the individual impacted by substances. The messages that

the church system provides to the individual system creates a stigma around substance misuse,

and this inhibits a community member’s willingness to discuss their personal substance misuse

with church leaders.

The role of stigma, as reflected by the church leaders in this study, emphasizes the

importance for healthcare providers to work with church leaders to lower the impact that stigma

has on their communities in Appalachia via a systemic level. For example, participants

frequently requested suggestions from the researcher on how to lower stigma associated with

substance misuse. Healthcare providers could provide trainings that targets ways that church

leaders could craft sermons that focus on lowering the stigma of substance misuse. Additionally,

stigma was discussed as a barrier to accessing healthcare treatment in Appalachia.

Appalachia has many healthcare barriers, and this study is unique in that the participants

understood stigma as a barrier for substance misuse treatment (Browne et al., 2016). Not only did

barriers to healthcare services impact community members, but it also impacted the resources

and training available for the church leaders. All of the church leaders were particularly

interested in receiving additional treatment on substance misuse, mental health, and the opioid

epidemic. Many discussed how they have tried to access training but were not able to find

sufficient trainings that provided the information that they required. The lack of training and a

desire for additional training follows closely with previous literature (Hall & Gjesfjed, 2013;

Sullivan et al., 2014).

Unfortunately, many church leaders discussed how they were not trained on substance

misuse during their training to become a church leader. If they have had any training on


58

substance misuse, it was typically sought on their own or through their experiences with working

with community members. Healthcare providers should work with church leaders to provide

trainings that focus on substance misuse. Additionally, it is important for all parties involved in

Appalachian communities to come together to learn and understand how substance misuse

impacts individuals, families, and communities. Participants discussed how they believed that

even healthcare providers had stigma connected with substance misuse.

Results indicated that the unique resources in the church leader’s community, the

church’s denomination, and the background of the participant impacted their ability and

willingness to connect with mental health service providers. More specifically, it was not as

common for church leaders to discuss having a direct contact with a local therapist. Most would

have to connect with therapists in towns nearby. For example, a few church leaders have

connected with therapists that live over 90 miles from their town, which is consistent with the

lack of services documented in the literature (Hendryx, 2008).

There are a number of potential entry points in the mesosystem to reduce substance

misuse in Appalachia suggested by the findings of this study. For instance, trainings that

encourage church leaders to lead sermons that discuss substance misuse in a manner that is not

stigmatizing could be created and implemented. Using biblical scripture to describe how

community members could reach out and provide support to those impacted by substances would

work to normalize the impact that substance misuse has on all community members. Healthcare

providers could support church leaders in this task by guest lecturing at their local churches. By

connecting with church leaders, the healthcare providers could work to create trainings that

would increase the knowledge that church leaders in Appalachia have about substance misuse.


59

These training could potentially provide relief to church leaders who may feel overwhelmed and

underprepared to discuss substance misuse with their community members.

Exosystem. Regarding the exosystem, which includes the interaction of systems that

impact the individual that the individual is not part of (Bronfenbrenner, 1979), the findings

relevant to this specific system include the lack of training and understanding that church leaders

have on substance misuse. As discussed in the findings, most church leaders do not have much

training connected to substance misuse. Those who do include church leaders who were also

trained as a mental health provider, but even those participants reported feeling overwhelmed by

the current state of substance misuse in their communities. The lack of support that church

leaders have in feeling competent to assist their congregants who are impacted by substance

misuse is crucial for mental healthcare providers to understand. Understanding the need for

collaboration between church leaders and healthcare providers is fundamental because this is not

currently discussed in training program (Hall & Gjesfjed, 2013). If this is changed at the

exosystem through updating training program curriculums, then church leaders could potentially

feel some relief regarding the systemic issues impacting their communities. Training programs

could include discussions of the impact of substance misuse in Appalachia and how mental

health service providers could connect with community stakeholders, such as church leaders.

Updating training program curriculums for healthcare providers is vital to shifting the exosystem

towards a more systemic understanding of substance misuse and a more positive understanding

of how to lower the impact of substance misuse.

The background of the church leader influenced their willingness to connect with mental

health service providers. Some church leaders had a mental health background themselves. Their

prior training in mental health increased their willingness to seek help from mental health service


60

providers. Additionally, the church leaders who had family or close friends that were impacted

by substances were more willing to seek out services in their community and to share these

resources with their community members. Further understanding the background and training of

church leaders in Appalachia could influence the creation of additional substance misuse

training.

There is a lack of understanding on how substance misuse systemically impacts families

and communities (Brakenhoff and Slesnick, 2015). The findings of this study suggest that church

leaders in Appalachia were willing to serve as an important resource to combat substance misuse

in their communities. However, the participants in this study did not have specific answers when

asked what they view as a possible solution to the current issues in Appalachia. The participants

would constantly redirect the question back to me. I could sense a feeling of hopelessness

regarding possible solutions for the epidemic and that the church leaders I interviewed were open

to suggestions for addressing the issue. This sense of being overwhelmed by the impact of

substance misuse on their communities is shared by others in the community and is reflected in

the current discourse centered around the opioid epidemic (Hirchak et al., 2017).

Despite not knowing what should specifically be done to intervene in substance misuse in

Appalachia almost all participants believed that lowering the stigma would help provide hope

and positive change. They also reflected that more healthcare services available and education

around substance misuse would work to create a solution. Utilizing trainings to help lower the

stigma of substance misuse could be a beneficial solution for Appalachian communities

(Pescosolido et al., 2008; Rao et al., 2019).

The lack of training that church leaders described an important finding for the

implications of this study. Currently, there is no research on how mental health providers are


61

trained to connect and work with church leaders in their community (Smith et al., 2018). The

results of this study suggest that this should be addressed. Some solutions include training

programs for mental health and healthcare providers to describe how the church can be a

community resource and providing training for their students that provides an understanding of

how to best work alongside church leaders. Specifically focusing on the need for service

providers in Appalachia to understand the role of church leaders as a potential resource to lower

the impact of substance misuse. While it is likely that not all mental health providers have a

positive relationship with the church, this study provides a deeper understanding to the need for

collaboration between church leaders and service providers. Furthermore, this study provides

evidence that that church leaders are willing to collaborate. They are willing to receive help,

support, and to work collaboratively with mental healthcare providers to help overcome the

epidemic that is ravaging Appalachia.

Additionally, the exosystem reflects the concern of the scarcity of mental health service

providers in Appalachia (Hendryx, 2008; Thomas et al., 2019). It is evident through the findings

of this study of the need to increase training and recruitment of mental health service providers in

Appalachia.

Macrosystem. The culture that impacts the individual is considered to be the

macrosystem (Bronfenbrenner, 1979), and the location of living in the mountains, the history of

generational poverty, and the resiliency of the people (Keefe, 2005; Williams, 2002) are

important aspects of the Appalachian culture. These aspects were discussed in the narratives of

the participants and it was evident that these cultural factors are impacting the church leaders and

their work to lower the impact substance misuse.


62

Stigma can be directly connected to the culture of Appalachia and the resources available

in the region. As a whole, Appalachian residents tend to have a higher stigma of mental health

and seeking healthcare services (Thomas et al., 2019). Participants were well aware of the

Appalachian culture and discussed how the it impacted their community members stigma of

substance misuse. The findings of this study found that there were many cultural factors that

impacted stigma associated with substance misuse. These factors included limited healthcare

resources found in the region, limited trainings that focus on substance misuse for church

leaders, messages from the community that participants should “pray away” the impact of

substance misuse rather than obtain healthcare services, and stigma that church leaders may have

regarding substance misuse. Each of these factors affect the unique culture in Appalachia and

reflect a need for a systemic approach to substance misuse treatment. Understanding how stigma

has permeated the macrosystem suggests that in order to effectively lower the impact of

substance misuse we must address stigma at the macro level. Participant voices suggested the

need for the creation of a community of care and believed that this could be one positive solution

at lowering the impact of stigma and substance misuse in Appalachia.

How to create a community of care is important for the implications of this study. The

lack of hope that can be found in community members and the negative stereotypes that plague

the cultural identity of Appalachia (Smith, 2004; Thomas et al., 2019) were reflected in the

themes found in the narratives of the church leaders. When thinking about a community of care

model that already exists, Trauma Informed Care (TIC) is one such opportunity. Trauma

informed care is an approach to the delivery of care that transcends therapeutic models and

permeates every facet of care delivery from staff, to therapeutic models, to the environment of

care (SAMHSA, 2014). It is a way of being, responding, interacting, and approaching others that


63

honors the complex experiences of trauma and avoids re-traumatization. It is a stance that

challenges pathologizing, deficit-based language, treatment, and environments and instead

promotes growth, hope, understanding, empowerment, safety, and healing. This evidenced-based

model could provide support and training to better prepare church leaders and mental healthcare

providers to produce work that lowers the impact of substance misuse. Additionally, working to

produce research on Appalachia that follows the guiding principles of TIC would help to lower

any negative stigma that the research may connect with Appalachia.

The culture and training of each church denomination can be connected to the

macrosystem. The denomination of the church that the leader represented seemed to have its own

culture, and this culture would impact the process that the church leader would take to connect

with other services, as well as the degree to which the denomination had its own resources to

assist its congregants. Some denominations were more open than others towards utilizing mental

health service providers in their work. Participants explained that some of the church’s larger

organizations had more resources, such as ministries that focused on substance misuse, to

facilitate such connections. For example, the Mormon faith had an expectation of its members to

seek healthcare services, including for mental health. One participant explained that larger cities

actually had their own services that members could access. The participant added that this

expectation was more difficult to uphold in rural Appalachia. As mentioned in the results, it is

important to note that some church leaders were skeptical of mental health service providers. As

McMinn and colleagues (2005) reported as well, participants in this study shared the concern

that the provider may not have values that align well with the faith community. This concern

generates the need for service providers to understand the importance of connecting with church


64

leaders. This step in their clinical practice would allow for mental health service providers to

address any concerns church leaders may have regarding their services.

The church leaders experiences addressing substance misuse were influenced in both

implicit and explicit ways by the denomination they were affiliated with. In an effort to further

contextualize the participant’s contexts, I created a table (see Table 5) that shows a direct

statement from each church on their stance with substance misuse. All church denominations had

a strong stance against substance misuse on their national websites. Each church fully

condemned the use of drugs and alcohol. Additionally, the Mormon church frowns upon

drinking any substance with caffeine in it (coffee or tea). Uniquely, the catholic church has a

national rehab website with an available 24/7 hotline for anyone who would like to seek help. A

rehab center specifically funded by the Catholic church is resources that is unique to the

denomination. Understanding how the larger church system influences how church leaders

address substance misuse in their communities is an important area for future research.

Chronosystem. The chronosystem includes the idea of time and change

(Bronfenbrenner, 2005). Four major shifts in the recent history of Appalachia may provide an

understanding of the barriers and culture of Appalachia; the decline of tobacco farming, the

introduction of NAFTE, the decline in coal mining and the introduction of opioids (Keefe, 2005;

Williams, 2002). Hopelessness about the introduction of substance misuse in Appalachian

communities was often mentioned by the participants through the eyes of community member’s

experiences. Participants openly discussed the burden that hopelessness played on their

communities and the understanding that the church leaders were working to build hope amid the

sense of loss of loss of many who are impacted by substances (Hirchak & Murphy, 2017).

Interestingly, the participants did not seem hopeless or helpless themselves. While they were not


65

able to fully respond to the question, “What do you see as a possible solution to the substance

misuse epidemic,” the church leaders shared narratives that reflected how they would try to

create a sense of hope within their community. Furthermore, scripture was used to convey this

sense of hope and understanding. Appropriately, substance misuse research shows that people

who have a sense of hopelessness may rely on substances to help lower the burden they may feel

(Broffman, et al., 2017). This study suggests that a sense of hopelessness is an important factor

to understand in communities impacted by substance misuse. Future research should explore in

more depth how hopelessness permeates communities and shapes both the stigma and response

to substance misuse in Appalachia.

Understanding how major events in the history of Appalachia have impacted community

members and their substance misuse is unique to this study and can provide guidance for future

research and inform the creation of interventions that assist church leaders who work with

community members to lower substance misuse. For instance, participants discussed how

opioids are a unique drug because they are considered legal. Opioid use was not accompanied

with the same level of stigma as illicit drugs.

Future Directions and Limitations

The findings of this study suggest that future directions should include implementing

evidenced-based programs and training in Appalachia for church leaders that focuses on a basic

understanding of substance misuse and how it can impact individuals and their families. For

example, training church leaders on how to implement Screening Brief Intervention Referral to

Treatment could be a simple program to pilot and track the effectiveness of it. Additionally, a

pilot program that trains healthcare providers on the benefits of connecting with church leaders

would be extremely beneficial. There has been limited research on how healthcare providers are


66

collaborating with church leaders in rural communities, and this pilot study could provide insight

on the current state of this style of collaboration. Furthermore, a pilot program could allow for

future healthcare providers to create and build a community of care system in Appalachia. Future

research could integrate Trauma Informed Care into the trainings that are piloted, and this

integration could potentially benefit the results of the training programs. Lastly, this research did

not limit the sample to a specific church denomination, but the results suggest that there are

differences in denominations. Future research could focus on these differences and examine each

denomination separately.

Limitations. There are a few limitations to this study. First, the current study is limited

by the racial and ethnic diversity of the participants. Appalachia does not simply consist of

Caucasian church leaders, and the current study was only able to recruit participants that identify

as Caucasian. Additionally, the current study focused recruitment in southcentral Appalachia, so

the results do not represent church leaders across the Appalachian region. Finally, the sample

was not limited to church leaders of a specific denomination. Research that focuses on specific

church denominations may help provide insight on any differences and similarities with how

substance misuse is addressed between various groups of church leaders.

Conclusion

The purpose of this study was to understand the experiences of church leaders when

working with community members impacted by substance misuse. The findings of this study

provide an understanding of these experiences and suggest the need for more collaboration

between church leaders and mental health service provides in rural Appalachia. I hope that this

study will prompt further research, as well as prevention and intervention efforts, that includes

how church leaders can be an important resource in addressing substance misuse in Appalachian


67

communities. All church leaders involved in this study were extremely hopeful about the

potential for healthcare providers to collaborate with them. I too, am hopeful about the potential

for more systemic, community-based, and evidenced-based efforts to address substance misuse

in Appalachia that reflects the voices of the community and utilizes the resiliency and resources

of Appalachian culture.


68

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Appendix A: Email Protocol for Initial Contact

SUBJECT LINE: Appalachian Church Leader’s Participation Requested

Hello (Insert Name),

I am a doctoral candidate at Virginia Tech working with Erika Grafsky, Ph.D., Associate

Professor, on a research project to understand Appalachian church leaders’ experiences

addressing substance use in their communities. We anticipate the findings will be used to inform

programming to reduce substance use and help train healthcare providers to be better prepared to

work in Appalachia.

Would you be interested in helping us by participating in a 45-60-minute interview? The

interview can be done in a place of your convenience (such as your church or a coffee shop) or

via the phone.

I have attached to this email a copy of the project consent form for your review. It provides more

detailed information about the study.

If you are interested in participating in this study, please send me an email message

([email protected]) or telephone me (706-244-5010) at your earliest convenience to set up a date

and time to talk. I am also happy to answer any questions you might have about the study before

you make a commitment.

Thank you for considering this request. I look forward to hearing from you.

M. Evan Thomas, MS

Doctoral Candidate

Virginia Tech

mailto:[email protected]


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Appendix B: Email Protocol for Follow-up Contact

RE: Appalachian Church Leader’s Participation Requested

Hello (Insert Name),

Thank you for your response. We appreciate your interest in the study.

Below are times that I am available for an in-person meeting (you can pick the place most

comfortable for you for us to meet):

(Insert Times)

Below are times that I am available for a phone meeting:

(Insert Times)

Which of these times may work best for you?

Best,

M. Evan Thomas, MS

Doctoral Candidate

Virginia Tech


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Appendix C: Informed Consent

Appalachian Church Leaders: An IPA Study to Understand Their Experiences with Substance

Misuse

Principal Investigator: Dr. Erika L. Grafsky

Family Therapy Center of Virginia Tech (0515)

840 University City Blvd., Suite 1

Blacksburg, VA 24060 USA

Other study contact(s): M. Evan Thomas, MS

[email protected]

706-244-5010 –

Key Information: The following is a short summary of this study to help you decide whether or

not to be a part of this study. More detailed information is listed later on in this form.

The goal of this research is to gain a better understanding of substance misuse in Appalachia

through the eyes of church leaders. It is our understanding that Appalachian community

members lack mental health services and thus may need to rely on their church leader for

substance use support. We hope that your participation in this study will allow us to connect

mental health services providers and church leaders to combat the high rates of substance misuse

in Appalachia. Your perspective can train healthcare providers to be better prepared to provide

services in Appalachia.



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You are being asked for your consent to take part in a research study. This document describes

the key information that we believe most people need to decide whether to take part in this

research.

Detailed Information: The following is more detailed information about this study in addition

to the information listed above.

Who can I talk to?

If you have questions, concerns, or complaints, or think the research has hurt you, talk to the

research team at M. Evan Thomas at [email protected] or 706-244-5010.

This research has been reviewed and approved by the Virginia Tech Institutional Review Board

(IRB). You may communicate with them at 540-231-3732 or [email protected] if:

● You have questions about your rights as a research subject

● Your questions, concerns, or complaints are not being answered by the research team

● You cannot reach the research team

● You want to talk to someone besides the research team to provide feedback about this

research

How many people will be studied?

We plan to include about 10-12 people in this research study.

What happens if I say yes, I want to be in this research?

If you decide to take part in this research, the general procedures include coordinating with

the research team a time and place of your choosing to complete the audio recorded

interview.



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• The whole study will take 1 hour to complete the consent process and participate in the

interview. You are not required to answer all of the researcher’s questions. If you

choose not to answer a specific question, it won’t be held against you.

What happens if I say yes, but I change my mind later?

You can leave the research at any time, for any reason, and it will not be held against you.

• If you decide to leave the research, contact the investigator so that the investigator

can note your termination. After you decide to terminate your participation in this

research, you will no longer be contacted by the researcher. If you have already

participated in the interview, any information you have previously provided may still

be used by the researchers in this study. If you have not participated in the interview,

the interview will not be scheduled.

Is there any way being in this study could be bad for me? (Detailed Risks)

• This study involves minimum risks to the participants. There could be a risk in

psychological stress from discussing substance misuse, and any participant who needs

further assistance will be referred to the appropriate resources in their community.

• Measures taken to lower the impact of psychological stress include encouraging

participants to not use any identifiable information regarding community members.

• Furthermore, resources will be provided to participants if psychological distress occurs.

What happens to the information collected for the research?

We will make every effort to limit the use and disclosure of your personal information, including

research study and medical records, only to people who have a need to review this information.

We cannot promise complete confidentiality. Organizations that may inspect and copy your

information include the IRB, Human Research Protection Program, and other authorized


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representatives of Virginia Tech.

All information for this study will be collected and stored securely in the researcher’s office.

The audio recording of the interview will be transcribed. When this is completed, we will

remove your name and other identifying information and give your interview a code number.

Therefore, it will not be possible to link your responses to the interview questions to your name.

The results of this research study may be presented in summary form at conferences, in

presentations, reports to the sponsor, academic papers, and as part of a thesis/dissertation.

We protect your information from disclosure to others to the extent required by law. We cannot

promise complete secrecy, particularly if you share information about child or elder

abuse/neglect or possible to yourself or others.

If identifiers are removed from your private information or samples that are collected during this

research, that information or those samples could be used for future research studies or

distributed to another investigator for future research studies without your additional informed

consent.

The results of this research study may be presented in summary form at conferences, in

presentations, reports to the sponsor, academic papers, and as part of a thesis/dissertation.

Can I be removed from the research without my OK?

The person in charge of this research can remove you from this research without your approval.

Possible reasons for removal include not following researcher instructions or showing signs of

physical or emotional distress.

What else do I need to know?

If you are injured or experience emotional distress because of being in this research, contact the

researcher immediately. The researcher will refer you to appropriate medical services or


86

community supports. Any expenses accrued for seeking or receiving medical or mental health

treatment will be your responsibility and not that of the research project, research team, or

Virginia Tech.

Participant Verbal Consent (via telephone or in-person):

Do you agree to participate in this study? By agreeing, you acknowledge that you understand

the consent form and conditions of the project and that all of your current questions have

been answered.

_________ Yes _________ No

Do you agree to have this conversation audio-recorded?

_________ Yes _________ No

_________I certify that I have explained the study to this participant, answered any questions,

and obtained permission to proceed with the interview.

_________I certify that I have explained the study to this person, answered any questions, and

politely terminated the telephone call when the person declined to participate.


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Date: _______________

Interviewer’s Signature: _______________________________


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Appendix D: Recruitment Flyer

Appalachian Church Leaders Research

The goal of this research is to gain a better understanding of substance misuse in

Appalachia through the eyes of church leaders. It is our understanding that Appalachian

community members lack mental health services and thus may need to rely on their church

leader for substance use support. We hope that your participation in this study will allow us to

connect mental health services providers and church leaders to combat the high rates of

substance misuse in Appalachia. Your perspective can inform healthcare providers to be better

prepared to provide services in Appalachia.

What church leaders in Appalachia can do to help:

• Participate in a 45-60-minute interview.

• The interview should take approximately 45-60 minutes; covering 3 open-ended questions.

Questions will focus on your experience with discussing substance misuse with your

community members, your experiences helping community members overcome substance

misuse, and your ideas about solutions to help lower the impact of substance misuse.

• The interview (either in-person or via phone) will be audio-recorded, and all information

provided by you will be held in confidence.

• There is minimal risk and discomfort associated with this project, and there are no direct

benefits to you for being in this study.


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• You are free to withdraw from the study at any time without penalty, and if you decide to

stop participating in the interview, any information you have already provided may still be

used by the researchers.

• You will not receive compensation for participating in the interview process.

Confidentiality:

• The information that you provide will be held in strictest confidence and will not be shared

with anyone outside of the project team.

• Your name or place of employment will not be linked with the information you provide, and

we will replace all proper names and locations with pseudonyms prior to dissemination of

information.

• All data collected will be stored in a secure location in the project team’s locked offices.

Although interviews will be audio-recorded and transcribed, the audio recordings will be

destroyed after transcripts have been verified. The audio files will be stored separately from

the de-identified data in a secure location in her locked office.

Approval of Research:

This research project has been approved as required, in its entirety, by the Institutional Review

Board for Research Involving Human Subjects at Virginia Tech (IRB # 19-331).

CONTACT INFORMATION:

If you are interested in participating in this study, please contact:

M. Evan Thomas – Doctoral Candidate

[email protected] and 706-244-5010



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Appendix E: IRB Approval


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Appendix F: Interview Script

Appalachian Church Leaders Research

Participant Name ____________________________

Participant Telephone Consent

Do you agree to participate in this study? By agreeing, you acknowledge that you understand the

consent form and conditions of the project and that all of your current questions have been

answered.

_________ Yes _________ No

Do you agree to have this conversation audio-recorded?

_________ Yes _________ No

_________I certify that I have explained the study to this participant, answered any questions,

and obtained permission to proceed with the interview.


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_________I certify that I have explained the study to this person, answered any questions, and

politely terminated the telephone call when the person declined to participate.

Interviewer’s Signature: _______________________________ Date: _______________


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Thank you for talking with me today. Before I begin, do you have any initial questions for me?

If not, these first few questions will focus on your experiences as a church leader.

1. How long have you been practicing as a church leader? __________________________

2. Is your professional faith work done primarily in

Appalachia? _________________________

3. What county or counties do you primarily serve?

_______________________________________________________

4. How important is the Appalachian community to your personal identity?

a. Extremely important

b. Very important

c. Moderately important

d. Slightly important

e. Not at all important

5. How important is the Appalachian community to your professional identity?


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a. Extremely important

b. Very important

c. Moderately important

d. Slightly important

e. Not at all important

6. What is your race?

7. What is your ethnicity?


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Now, we are going to transition to questions that focus on your experiences discussing substance

misuse with community members. WHEN ANSWERING THESE QUESTIONS, PLEASE DO

NOT USE NAMES OF COMMUNITY MEMBERS OR ANY IDENTIFYING INFORMATION.

THIS IS TO ENSURE THEIR CONFIDENTIALITY AND SAFETY.

• Describe your experiences discussing substance misuse with your community members.

o How has substance misuse come up in your role as a church leader?

o How has substance misuse impacted your community?

Tell me about a time when you realized that opioids have impacted your

community.

o With what substances do folks in your community struggle?

o What do people outside of your community need to know about the impact of substance

misuse on your community?

• How do you help people who come to you about their substance misuse?

o What barriers do you think prevent people from seeking help?

• Describe a time that you were able to help a community member with their substance misuse.


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o How do you know when to intervene with a community member’s substance misuse?

Probe to explore gender, age, substance of use differences.

• How would you describe the TYPICAL AGE, GENDER, OR

SOCIOECONMIC CLASS OF THE people who do come to you for help?

• e.g. How would you have responded differently if they were abusing

alcohol versus pain killers?

o What resources have you used in the community to help you discuss substance misuse

with community members?

Probe: What has been most helpful? What has been least helpful?

o What resources do you think your community needs?

Probe: Do you connect with other churches in the community?

o Have you ever been involved with any formal recovery programs for substance misuse?

Probe: What have been your experiences with Celebrate Recovery (CR)?

Probe: What benefits or harms have you seen with group members attending CR?


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• Given your experiences, what do you see as possible solutions to high rates of substance

misuse in Appalachian communities?

o What do healthcare providers need to know about working with people in your

community about substance misuse?

Thank you for taking time to share our experiences with me.

Before we end the call, do you have any final questions or comments?

Is there anyone that you may think would be willing to participate in the study as well?

Thank you for your participation.


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Table 1: Participant Demographics

Participant Demographics

ID Location Length of

Time

Practicing

Appalachian

Identity

Professional

Identity

Church

Denomination

Gender

1 Rutledge, TN 14 years Not important Not

important

Baptist Male

2 Kingsport, TN 11 years Extremely

Important

Extremely

Important

Presbyterian Male

3 Ironto, OH 11 years Extremely

Important

Very

Important

Episcopal Female

4 Charleston,

WV

31 years Extremely

Important

Extremely

Important

Methodist Male

5 Winchester,

KY

28 years Extremely

Important

Extremely

Important

Non-

denominational

Male

6 Toccoa, GA 16 years Slightly

important

Very

Important

Pentecostal Male

7 Blacksburg,

VA/West

Virginia

30 years Very

important

Extremely

Important

Mormon Male


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8 Lee County,

VA

40 years Not important Extremely

Important

Catholic Female

9 Toccoa, GA 10 years Not important Important Baptist Male

10 Ashland, KY 5 years Extremely

Important

Extremely

Important

Methodist Female


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Table 2: Emergent Theme Formation

Emergent Theme Formation

Emergent

Themes

Original Interview Exploratory Commenting

Stigma

Someone asked me my thoughts on

substance misuse, and I compared it to

modern-day leprosy. People were afraid of

it. They didn't understand it. Jesus walked

right in the middle of it. Thousands of people

are dying, but people are ignoring it. I think

we are called to act on this topic.

There is an extreme form of

stigma here. Stigma directly

connected to the Bible.

We basically turned our backs on the gay

community when HIV hit. We treated them

like a bunch of lepers. Jesus loves everyone.

You have to come to him still, but he expects

us to love everyone. We didn’t do a good job

there. We can’t make that same mistake with

people impacted by substance misuse.

There is an understanding of

the stigma and the ability to

compare it to previous

stigmatized events in our

history. To compare the opioid

epidemic to the HIV epidemic

is huge in terms of stigma.

I usually hear about someone who is

impacted by substances second hand. A

parent comes to me to discuss their child.

Unfortunately, I may only learn about a

The insight here on how stigma

impacts the openness of

community members and the

way they communicate with


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church member’s substance misuse when I

visit them in the emergency room or when I

am called to prepare the eulogy.

their church leaders.

Community

In our church, opioids don't have the illegal

stigma that other drugs do. People have

their guard down, and then they become

addicted. We see a lot of that, and it is hard

to convince a person that a legal drug can

become addictive. Then, it transitions to a

bigger problem with the use of illegal drugs.

This seems to be tied to the

culture of the region and the

community impact that doctors

can have on people. The belief

that since it is legal, it won't

hurt me is powerful here.

Meth changed everything about 15 years

ago. It made drugs so affordable. People

couldn’t afford cocaine. Now people are

making it (meth) at home.

The impact that the

introduction of a drug into a

community is evident here.

Personally, I remember this

happening about 15 years ago.

The biggest issue and how it influences my

work are that the breakdown in the

community that it creates, specifically the

fear that someone who is on drugs is going

to break into the church. It creates a

heightened fear and strangers of mistrust. It

destroys the community. I remember

Wow. A community shift. A

cultural shift. This seems very

important to the understanding

of their experiences.


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growing up in Appalachia, and people were

still friendly to strangers, as long as they

looked like you. The epidemic has caused

this cultural breakdown.

Understanding

and Training

I've been working with this one family for a

few years. Their son is off and on suboxone,

and I'm interested in medicated treatment. I

don't understand why they will be on

suboxone for the rest of their life. I just don't

have enough information.

This participant is asking for

help with training and

understanding around

medicated treatment.

The church doesn’t know how to handle

relapse, and this creates stigma. The church

doesn’t understand the long-term

commitment that is needed” and “there

aren’t any best practices for substance

misuse. Unless a church buys a halfway

house. Some really bold things, but small

things, I haven’t been able to find much.

This participant understands

the lack of education and

training on substance misuse.

The complexity in the world that we live in is

overwhelming to the local church leader.

There is no way that the church leader can

This statement shows the need

for therapists to reach out and

provide relief. They are


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be an expert in anything. There is no way

I'm qualified to be an expert in substance

misuse, but we are expected to be. It can be

overwhelming. We are doing the best we

know to do. We could use some tools and

resources so that we could outsource some

of these things.

correct, they can't be expected

to know how to be a church

leader and a mental health

provider.

I've been working with this one family for a

few years. Their son is off and on suboxone,

and I'm interested in medicated treatment. I

don't understand why they will be on

suboxone for the rest of their life. I just don't

have enough information.

This participant is asking for

help with training and

understanding around

medicated treatment.


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Table 3: Polarization Example

Polarization Example

Original Interview Exploratory

Commenting

Polarized Quote Exploratory

Commenting

We are Christians,

and we want a

therapist who isn't

going to change our

church member's

beliefs and values.

This seems to be an

isolated comment.

Most other participants

do not inquire about

the religious

background of the

therapist.

The church isn't

obtaining the proper

picture of what that

type of commitment

requires. Prayer isn't

going to provide a

quick fix.

This participant

seems to understand

the importance of not

relying on religion to

lower the impact of

substance misuse.


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Table 4: Ecological Model Examples

Ecological Model Examples

System

Concept

Concept Definition

(Bronfenbrenner, 1979)

Example of How Stigma is Connected

Microsystem The smallest unit of

relationships.

Each unit (family, church, community) within an

individual's microsystem condemns substance

misuse.

Mesosystem The mesosystemic level

understands how different

microsystems are impacted by

substance misuse.

Microsystem of church leaders does not include

adequate training on substance misuse. This directly

impacts the stigma that community members

microsystems have of substance misuse.

Exosystem Includes the interaction of

systems that impact the

individual that the individual is

not part of.

Church leaders do not have adequate training on

substance misuse, and this impacts community

members and the stigma that church may have

regarding substance misuse.

Macrosystem The culture that impacts the

individual.

Appalachia contains a culture that contains a stigma

around substance misuse and mental health.

Chronosystem The idea of time and change The introduction of opioids into the culture of

Appalachia.


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Table 5: Denomination Doctrine Statements

Denomination Doctrine Statements on Substance Misuse

Denomination Statement Found on Organization Website (.org)

Baptist “That the messengers to the Southern Baptist Convention meeting in

Greensboro, North Carolina, June 13-14, 2006, express our total

opposition to the manufacturing, advertising, distributing, and consuming

of alcoholic beverages; and be it further

RESOLVED, that we urge that no one be elected to serve as a trustee or

member of any entity or committee of the Southern Baptist Convention

that is a user of alcoholic beverages. RESOLVED, that we urge Southern

Baptists to take an active role in supporting legislation that is intended to

curb alcohol use in our communities and nation; and be it further.

RESOLVED, that we urge Southern Baptists to be actively involved in

educating students and adults concerning the destructive nature of

alcoholic beverages; and be it finally. RESOLVED, that we commend

organizations and ministries that treat alcohol-related problems from a

biblical perspective and promote abstinence and encourage local churches

to begin and/or support such biblically-based ministries.”

Presbyterian “Abstention in all situations should be supported and encouraged.

Moderate drinking in low-risk situations should not be opposed.

Heavy drinking in any situation should be vigorously discouraged.

Any drinking in high-risk situations (e.g., during pregnancy or before

driving an automobile) should be vigorously discouraged, as should all


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illegal drinking.”

Episcopal “Confront and repent of the Episcopal Church’s complicity in a culture of

alcohol, denial, and enabling, speak to cultural norms that promote

addiction,

promote spiritual practices as a means of prevention and healing,

advocate for public funding and health insurance coverage for prevention,

intervention, treatment and recovery, and collaborate with qualified

community resources offering these services, and to respond with pastoral

care and accountability.; and be it further”

Methodist “Alcohol is a drug, which presents special problems because of its

widespread social acceptance. We affirm our long-standing conviction

and recommendation that abstinence from alcoholic beverages is a

faithful witness to God’s liberating and redeeming love. The United

Methodist Church grieves the widespread misuse of drugs and other

commonly used products that alter mood, perception, consciousness, and

behavior of persons among all ages, classes, and segments of our society.”

Pentecostal “Knowing that Satan will do all he can to hinder us, we will keep

ourselves free from all forms of gambling, tobacco, alcoholic beverages

and drugs that are physically and mentally harmful”

Mormon “Members should not use any substance that contains illegal drugs. Nor

should members use harmful or habit-forming substances except under

the care of a competent physician.”

Catholic “The Catholic Church has taken a firm stance against substance abuse, in


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all forms, for centuries. However, the Church also understands that people

make mistakes and knows addiction is a disease that can’t simply be

prayed away. If a parish member falls victim to addiction, the Catholic

Church provides resources to aid the way back to sobriety, including

directly providing drug and alcohol rehab.”

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