The Community Helpers Project is a prevention program
designed to meet the unique needs of rural residents. Starting with the
recognition that the expansion of traditional service delivery models (i.e.,
professional services delivered by agency bound mental health agents) would
not be able to solve the needs of rural Americans for rehabilitative mental
health services, we endeavored to design an alternative model for the delivery
of proactive mental health education. We aimed at creating a low-cost system
for helping people provide each other with resources and support, a method
in which nonprofessionals in the community became trainers in life skills
for coping and adjustment. We wished to build on some of the unique strength
of rural communities - their solidarity, their sense of responsibility
to resolve their own problems, their commitment to one another, and their
acute sense of their own needs - to reinforce and extend a community ideology
that focused on social support and interdependence. Our ultimate hope was
to set in place a structure for prevention that local residents could own
and perpetuate with little help from formal mental health services and
without the involvement of university based psychologists. This report
will discuss the historical background of the project, its operations,
its effectiveness, and problems that were encountered.
Problems in Rural Mental Health
Despite the difficulties in generalizing about the 55 million Americans in rural areas and about their communities, several general problems have been identified in considering mental health needs in rural areas. The President's Commission's Task Panel on Rural Mental Health (Task Panel on Rural Mental Health, 1978) describes rural areas as leading to stress due to factors associated with geography such as isolation and transportation problems; as populated by a large number of undereducated, poor, and unhealthy people; as associated with a higher than average prevalence of psychiatric disorders, especially depression, and severe intergenerational conflict; and, as providing fewer role models for change and more effective coping. As far as service planning is concerned, the Task Panel notes that rural values are holistic, that functioning in the community is the "social yardstick" of mental health, that distinctions between physical and mental health are seen as artificial, and that helping in rural communities is very different from urban helping. Flax, Ivens, Wagenfeld, and Weiss (1978) list the following as broad sociocultural themes of rural areas: "man's subjugation to nature; fatalism; an orientation to concrete places and things; a view of human nature as basically evil; human activity as being, not doing; and human relationships as having their basis in personal kinship ties" (p. 3).
Just as the community mental health movement was fired by the observation that barriers to service delivery posed major obstacles to the underserved, so are there barriers specific to the underserved, rural population. The complexity of such barriers is well described by Berry and Davis (1978) and by Wagenfeld (Note 1). Wagenfeld argues that many rural residents have values that militate against seeking help for "problems of the mind," that the social structure of rural America may impede service delivery, and that the nature of typical mental health services (designed mainly for the needs of people who are urban, white, middle class in nature) may be irrelevant to rural needs. The double handicap of high prevalence of problems and limited service availability is worsened by the types of services available. In Halifax County, North Carolina, for example, Lee, Gianturco, and Eisdorfer (1974) found that few people would go to a mental health clinic for help. Despite nearly 4 years of full operation and 12 years of community involvement, the clinic was not seen as a major resource. This also was true in our project areas: only 3% of a sample of local residents had used local mental health services.
Lee et al. speculate that lack of knowledge about mental health problems plus the stigma attached to labeling are possible explanations for minimal clinic use. In other words, the residents do not accept the idea that mental health problems are illnesses and find other ways to deal with their "mental health." In such a dilemma, the mental health system can easily "blame the victim" for not seeking attention earlier and deal with only those "appropriate" for the traditional mental health technologies. In southeastern Kentucky, Levenberg (1976) was faced with exactly this dilemma. Fortunately, he did come to the conclusion that his psychological notions of mental health could coexist with the views of his rural fundamentalist "gatekeepers." Mazer's (1976) narrative of his resocialization as a rural mental health professional provides another good example of ideological changes mental health professionals must make in rural areas. One obvious solution to the entry problem lies with the indigenous helper. The Task Panel on Rural Mental Health (1978) is clear on this:
The importance of recruiting indigenous persons to work in rural mental health programs cannot be overemphasized. People familiar with local customs are needed as caregivers at all levels of specialization. Training of local indigenous mental health care extenders for rural programs is of special moment; it is necessary, practical, and feasible to involve in the service delivery system those persons who form a bridge between traditional folkways and current concepts in the delivery of services. (pp. 1183-1183)Clearly some mental health systems are using indigenous help, whether paraprofessional or nonprofessional (see Gertz, Meider, & Pluckhan, 1975; Huessy, Marshall, Lincoln, & Finan, 1969; Kahn, Williams, Galvez, Lejero, Conrad, & Goldstein, 1975; Ostendorf & Hammerschlag, 1977). These indigenous helpers are, however, generally used to provide treatment (Herbert, Chevalier, & Meyers, 1974; Hollingsworth & Hendrix, 1977). Thus rural residents who overcome their concern about stigmatization and seek mental health services may be treated by a counselor who resides in the area. This is clearly advantageous as an advance in treatment, but in no way deals with mental health problems in a preventive way, nor does it offer much hope for the mental health system to serve significantly more clientele. It also does not provide an avenue for mental health enrichment or promotion for most people, whose everyday lives involve ordinary life problems, both anticipated and unexpected, for which they have had little or no preparation. A service delivery model using local residents in ways consonant with local notions of psychosocial problems which emphasizes the acquisition of resources for living is more likely to increase the accessibility of mental health resources than is the mere use of local counselors.
Two rural areas in central Pennsylvania were chosen for
the initial trial of our model. One was the town of Bloomsburg, a county
seat with a population of 12,000; the other was more rural, the western
part of Snyder County, which had a population of 3,200. The larger five-county
region has a population of 229,000, of which nearly half live in small
towns no larger than 13,500 in size. Although residential patterns are
twice as rural as the national average, employment is more industrial in
nature than the national average. Adults travel an average of 16 miles
a day to work and one fourth of the employed travel more than 40 miles
a day. One out of six families is below the poverty line. The area is mostly
white, and there are many cultural groups which maintain strong traditions.
The areas differ markedly in the availability of human services. Bloomsburg
is a town with many human service resources, including a major medical
center and its own mental health clinic. Western Snyder County residents
must travel, often considerable distances, to receive any human services,
a fact that local citizens resent. The small social service staffs in this
area are stretched quite thin in trying to serve the population of an entire
county. We chose these two areas for their similarities - they are both
"rural" in geography and in many views about human services - and their
differences - one is a small town with distinct human services and the
other is a more isolated, spread-out area that is underserved
Project Ideology: Human
The Community Helpers Project was developed as an alternative approach to expanding mental health resources in rural areas. We did not see ourselves as extenders of current mental health services since we suspected that many residents' views of themselves and their problems would not be best addressed this way. Rather, we proposed a prevention approach in which we sought to disseminate a life development model for human change (Danish & D'Augelli, 1980). This human development intervention model avoids some of the conceptual problems of the concept of prevention (see Kessler & Albee, 1975). Rather, it stresses the need for an understanding of normative individual and family development, not psychopathology; and analysis of expected and unexpected life events as points of intervention, not only extreme stress and crisis; and the development of an array of services that are as ecologically relevant as possible, instead of a standard technology that is assumed to be generalizable. This model is especially relevant to the rural ecology in that it does not revolve around psychiatric images of people and psychopathology, does not rely on professionals as direct service providers, and values informal and indigenous sources of help as central, not ancillary, to change. The image of individuals and families in context undergoing development over the lifespan through a series of life events of varying stress (see Hultsch & Plemons, 1979) is much more likely to generate support that the image of individuals developing mental illnesses for which diagnosis and treatment are needed. As Flax, Wagenfeld, Ivens, and Weiss (1979) state:
Those who argue that the problem of mental health services underutilization lies within the consumers of services would likely note that it is a function of certain of their attitudes, beliefs, values, or practices. They might reject the notion of mental illness as a category; they might be suspicious of professionals; the primacy of local or kinship ties might preclude or make difficult going to outsiders for help; there might be a preference for a naturalistic or folk healing, or some combination of these. Even if they do get into treatment, their values are often incompatible with the goals of psychotherapy (or at least, long-term psychotherapy) so that they are likely to derive less benefit from treatment and terminate earlier. (p. 32)Enhancing Natural Helping
Our approach to the dilemma of expanding services in ways that are locally relevant was to work with informal helpers already living in the community. Although it tong has been recognized that most people turn to neighbors, kith and kin, and friends when faced with life problems (e.g., Gurin, Veroff, & Feld, 1960), only recently has there been a concerted effort to study how people help each other. From the general conclusion that much mental health aid, whether information, advice, or empathic understanding, is provided informally between close associates, has resulted in the recognition that there are certain local individuals who are unusually helpful and who may be the central figures in the community's helping networks (Caplan, 1974; Collins & Pancoast, 1976). Much research remains to be done on the operation of these "natural neighbors" (Collins & Pancoast, 1976), and to date most empirical work on informal helping concerns help-seeking only with little information available on help-giving (Gourash, 1978). Nonetheless, we felt that a reasonable way to promote use of the preventive mental health service we were planning was through the use of individuals with particular interest and competence in helping others. For a detailed discussion of issues in the use of social networks for prevention activities, the reader is referred to Gottlieb and Hall (1980).
An additional source of confidence in the nature of our intervention was provided by a community survey that assessed patterns of help-giving and help-receiving. Based on research by Wellman, Craven, Whitaker, Stevens, Shorter, DeToit, and Bakker (1973) and Warren (Note 2), the survey asked 213 residents in the two project areas (see D'Augelli, Vallance, Danish, Young & Gerdes, 1981 for a more complete description of the areas) about informal helping relating to 11 problems of living (tension; safety in neighborhood; feeling "blue"; 11 case of the nerves"; feeling hopeless; personal illness or injury; death of a spouse or close friend; personal problems with friends, neighbors, or people at work; personal problems with people at home; loss of job; and couple separation and divorce). Detailed information on the survey results is available elsewhere (Young, Giles, & Plantz, in press), but some relevant findings about how these residents help others are the following:
I . Eighty-seven percent of the sample reported that they were sought out for personal help of some kind.From our survey data we were able to differentiate active helpers people who reported being sought out for help at least weekly - from non-helpers - people who reported that no one sought their help (Vallance & D'Augelli, Note 3). Active helpers tended to be younger, better educated, employed, to live in larger households, and to have lived a shorter time in their community. They also scored higher on a set of measures of "community-mindedness."
2. Although 38% reported that they were sought out less than monthly, 35% were sought at least once a week.
3. Many problems are problems of living, not highly specialized concerns needing professional technology.
4. The following percentages of the residents reported that they often used the following helping behaviors:
"try to understand the situation and feelings" (67%); "just listen" (49%); "give advice" (39%); "talk about
my own experiences" (36%); "ask questions" (35%); "show them a new way to look at things" (34%);
"tell who else to see" (28%), and "took some other action on the matter" (87%).
5. When asked which behaviors were the most helpful, the same ordering as above was found.
6. When asked why others sought them out, respondents mentioned personal qualities such as being
willing and able to listen and their closeness to the "helpee".
In addition to documenting a substantial volume of informal helpgiving, the data show much help-seeking. For example, respondents averaged 2.1 life problems of their own in the last year and they talked to someone else about 73% of these concerns. As expected, the individuals they talked to, in order, were spouses, friends, relatives, neighbors, physicians, coworkers and religious leaders. Only 12 of the 447 (2.7%) problems reported by all respondents were discussed with professional helpers. In fact, when asked directly about the local mental health service, 57% of the respondents did not know its location and another 15 % gave an incorrect location. Only 36 % of the respondents could identify a kind of service provided by the mental health program. So, despite many life problems, these residents do not perceive local mental health services as essential to their own help-seeking.
The survey findings are stark evidence of two critical facts for program planning in the areas we worked in: (a) many problems of living are discussed informally with others and very few ever are presented to formal mental health agencies and (b) a tremendous amount of social support, listening, and advice occurs. These two findings suggested the potential value of collaborating with local helpers to enrich their ability to help others. The rationale for the model of collaboration is well stated by Collins (1973):
The most significant fact that has as yet emerged from
study and experiment with natural neighbors is that one consultant can
act in that capacity with fifteen natural neighbors at one time and can,
through their contacts, influence their natural systems toward increasing
the scope of the service and the numbers of people served. Simple arithmetic
then reveals the power of a method that may enable one mental health professional
to influence 750 families, even to a very small degree. (p. 48)
The project formally began in July 1977. Before that, extensive contacts were made to gather local support. The endorsement of the local mental health agency accompanied our grant proposal as did statements of need from various community leaders. After funding began, the mental health administrator and his advisory board created an advisory board for this project in each of the project's two activity sites and appointed members. These boards worked with project staff (several community psychologists and advanced graduate students) and a local project liaison person (considered a mental health staff member, though funded by project funds) to plan and implement all phases of the project - from recruiting participants to conducting training groups and recruiting local helpers to attend these groups to the more mundane tasks of locating rooms to conduct meetings. Much effort was spent in advertising the program. Stories were run in local papers and on radio and television; brochures were distributed throughout the communities; and ministers were persuaded to announce the program from their pulpits.
The primary focus of the training was the teaching of a set of verbal helping skills that can be used in any helping interaction, whether one conducted by a professional, a paraprofessional, or a nonprofessional. The program developed by Danish, D'Augelli, and Hauer (1980) was used. The goal of the training is to help trainees acquire a less directive style of helping (give less advice, be less self-disclosing, be less definitive) by practicing a more reflective way of communicating that allows their helpees to talk more freely and more openly. In particular, the program points out the problems with excessive advice and questioning and aims for the learning of "continuing responses" which deal with another person's thoughts and feelings. This program was chosen because the skills are very generic and are not conceptualized as "counseling" skills; because there is considerable research evidence that the procedures are effective in teaching the skills; and, because the project staff had had extensive prior experience with the skills and the training model.
The major method of implementation was the human services pyramid (Seidman & Rappaport, 1974). Training of local trainers was the primary staff activity. In the first phase, staff trained local residents who would soon become trainers. These trainers underwent a brief program to learn how to train after the completion of their skills training. The second phase involved locating local helpers who were interested in increasing their skills and placing them in small groups conducted by two newly-trained trainers. Thus, at the critical level of work with the local helpers, professional staff were not directly involved. The only involvement at this level was through supervision of the trainers and through the continuous evaluation of the training, which is described later. The training program lasted about 10 weeks (it started out longer, but was shortened in response to advisory board suggestions) and each session was about 21/2 hours long. All community residents - trainers and helpers - were volunteers and received no remuneration for involvement.
Data collected on the helpers who chose to become involved
show that they are indeed engaged in many diverse helping activities. On
a sample of 37 of these helpers, we (D'Augelli & Ehrlich, Note 4) queried
their weekly helping activities and generated a descriptive profile of
their "natural" helping. These helpers were involved in 4-5 helping interactions
per week, spending on the average 126 minutes helping. Friends and relatives
were helped most frequently, followed in descending order by coworkers,
neighbors, spouses, clients, and others. Interestingly enough, half of
all the helping contacts took place at the helpers' homes or work places
and 20% were telephone contacts. Nearly all problems were personal relationship
problems or problems in living; few crises were reported. And, consistent
with the survey data, two nondirective helping behaviors, "just listened"
and "tried to understand feelings," were used the most frequently in helping
others with problems. Few problems were dealt with by referral (11%). Both
the context in which helping occurred and the kinds of behaviors used were
consistent with the available data on informal helping (e.g., Gurin et
al., 1960; Wellman et al., 1973; Warren, Note 2; Colten & Kulka, Note
5). Our participants indeed were actively involved in the delivery of what
Gottlieb (1976) dubbed "lay treatment" or of what Gartner and Riessman
(1977) labeled "a professional" help.
Several ways to gauge the impact of the project exist. Participation of community members is the simplest and most direct. We found that our initial goal of training 100 trainers in each area in 3 years was extremely overambitious. At the end of June 1980, the date that marked the end of grant funds, a total of approximately 35 trainers and 60 helpers had completed the basic helping skills training. (This is a conservative figure reflecting only those for whom complete evaluation data exist, so it does not include many residents who attended segments of the training.) As of the fall of 1980, at which point the project continued with the local mental health agency providing support to the advisory boards, an additional 30 helpers were becoming involved. Despite the smaller than expected numbers, the mental health impact of these 90 or so helpers may be considerable. Extrapolating from their data on helping activities (D'Augelli & Ehrlich, Note 4), these 90 helpers may be estimated to help about 363 people each week (4.03 x 90)1 Were the project successful in enhancing these contacts making them more "helpful" - much benefit could ensue.
Evaluation of changes in helpers' verbal helping skills suggests that their helping may indeed be more effective after training (Ehrlich, D'Augelli, & Conter, in press). Surprisingly enough, we found much room for improvement in helpers' pretraining behavior in helping situations. When asked to help someone else in a short role-played situation, the helpers used far fewer nondirective responses than their self-reports would imply. Only about one-fourth of their responses are of this kind whereas most are either directive or focus on themselves (self-disclosing, for example). After training, significant change was found, especially after the training materials were revised to strengthen their focus (see Erhlich et al., in press). Helpers more than doubled their use of nondirective (or continuing) responses and their focus on others' feelings while simultaneously more than halving their responses concerned with themselves and their own circumstances. Although we could not independently judge the outcome on helping of these changes, other research suggests that such modifications of verbal responses are indeed constructive (D'Augelli, Handis, Brumbaugh, Searer, Turner, & D'Augelli, 1978; Ehrlich, D'Augelli, & Danish, 1979; Ginsburg, Danish, & D'Augelli, Note 6). The people these helpers talk with assumedly should be able to feel more completely understood; their helpers will give fewer personal examples as prods for change; and their helpers should be able to respond more accurately to their feelings. It is worth noting that the increase in the quality of help provided did not alter the pattern of weekly helping in significant ways, although helpers did report more confidence in their helping others after training (D'Augelli & Ehrlich, Note 4). It is unfortunate that we were unable to obtain information directly from those helped by these helpers. We could not develop a method of data collection that would not interfere with the informal helping process. Any labeling of the informal help had the clear potential to change the relationship and we felt ethically bound to avoid any disruption of the helping process.
Since long-term data are not available on the maintenance
of the changes in helping skills promoted by the project, only short-term
effectiveness can be judged. Certainly it would appear that the model has
demonstrated itself to be an inexpensive way to bolster and enrich the
quality of informal helping. Professional staff, in a fairly short time,
were able to train rural residents to be mental health trainers in helping
skills. Since the project can continue with little outside help under the
aegis of its own advisory boards, this strategy over time can have powerful
consequences. Also, since particular care was taken to avoid disrupting
naturally occurring helping patterns and to avoid transforming the helpers
into counselors," the deleterious effects of training natural caregivers
and thereby formalizing their functioning has been avoided.
The evolution of this training intervention approximated the steps in a service development model we have described elsewhere (Vallance & D'Augelli, 1981). Nonetheless, many problems were encountered during the course of this project. A major set of problems was typical of any new effort: administrative confusions, clarification of goals and objectives, the creation of working relationships with others' the need to discover effective ways of engaging others in a collaborative venture. Other problems may have been more specific to the rural nature of the two project sites. That we were outsiders from a far away (2-3 hours), impersonal university was a constant problem; much energy was directed toward clarifying our purposes and persuading local board members that we had no concealed motives. Unfortunately, this mistrust seldom was directly expressed and often was delivered via intermediaries. Public meetings were not often contexts for airing these concerns whereas informal conversations at a local coffee shop were. Open and direct expression of suspicion was not normative. This also was seen in disorganized advisory board meetings in which several factions were in conflict but were unable to address the troubling issues.
Community participation was a major problem. Despite much
volunteer time spent on advisory boards, the configuration of boards changed
often, with the interest of members ebbing and flowing. More troublesome
was the problem of gaining widespread local interest and involvement. In
the middle of the 3rd year of the project, since recruitment problems were
demoralizing all involved, the staff decided that a telephone survey needed
to be done. The purpose of this was to disentangle two rival hypotheses
about the low community involvement: (a) that the project had little to
offer and would never "catch on" or (b) that few people knew about the
project, but, once made aware, would find it valuable and might choose
to become involved. The resulting random survey of 200 households (Vemon
& D'Augelli, Note 7) confirmed the second supposition. When asked if
they had heard of the project, 91/z% of the respondents assented. When
told about the intent of the effort, however, 82 % felt that a need existed
for the project, and 75 % could see some direct personal value. When asked
what would facilitate their active participation (options like babysitters,
fewer sessions, sponsorship by a local group, transportation, and so on),
the most powerful facilitator was talking directly to a group member, a
factor supported by 80% of the respondents. It is of course not paradoxical
that a program stressing social linkages and informal helping would find
a direct personal message to be so powerful We once again reaffirmed our
goals and suggested that marketing strategies be changed to encourage more
interest. Our marketing was changed to emphasize the benefits that participants
received, and in one area the program was presented as communication/listening
skills to appeal to a wider audience. In the future, it might be useful
to ask local helpers to "spread the word" to their friends and neighbors.
This occurred informally but also could be pursued more systematically.
The Community Helpers Project was designed to enrich informal
helping in rural communities. By building on the considerable base of local
helping, we intended to enhance the quality of the helping interactions
that was occurring. Despite the many problems, some a function of rurality,
some a function of the difficulty of "selling" mental health even when
framed in positive, proactive terms, and some a function of the delicate
nature of collaboration with indigenous helpers, the project remains in
the two communities and appears to be continuing without outside professionals.
The training model and materials have been shown to work, and change in
verbal helping has been documented. We have begun to encourage development
of a "helping community," but have gone as far as we can go. From this
point on, the local communities, through the advisory boards, will have
the task of making the resources we provided increasingly accessible to
even larger numbers of residents. Only local people can truly create their
own helping community.
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The reported research was supported by grant MH 14883
from the National Institute of Mental Health, whose support is gratefully
acknowledged. The authors also wish to acknowledge the cooperation of the
two citizens' advisory boards of the Community Helpers Project as well
as the constant support of Charles R. Evans, Administrator of the Columbia-Snyder-Montour-Union
Mental Health/Mental Retardation Program.
The Community Helpers Project is a prevention program designed to foster informal helping activities in rural communities. Staff personnel train local residents in basic helping skills and these residents in turn train others from the community who are involved in informal helping. Problems of rural service delivery and the need for prevention programming are presented. In addition, data on the effectiveness of the project and problems encountered in its implementation are discussed.
(Originial journal pages 3-16)