Journal of Rural Community Psychology, Vol. 12, No. 2,1993
Rural Review
Cutler, D.L., &  Madore, E.
Community-family network therapy in a rural setting.
Community Mental Health Journal, 1980, 16, 144-155
The psychologically impaired individual in rural areas, say the authors of this report, tends to isolate himself from family, friends, and the community in general. The greater the psychological impairment, the narrower is the individual's social involvement. As an alternative to most traditional direct service approaches, the authors utilize what they call "social network therapy."

Because this method is time consuming and requires the involvement of a number of professionals and lay people, certain criteria must be met before this therapeutic approach is utilized. A crisis state must exist and must be expanding; stress in the family must be growing, multiple agency contacts must not have resolved the problem; removal of the family member must be contraindicated- with out major changes, the family must see the problems as potentially disastrous; there must have been multiple agency contacts without 'continuity of care'; and agency personnel must have come to feel that the problem is nearly "hopeless."

A "network team" is organized, and the target of services is shifted from the individual alone to include anyone and everyone with potential for offering social support, such as family members, relatives, friends, neighbors, work associates, and personnel from other agencies.

 In a meeting at an agreed-upon time and place, the "network" is brought together. At this meeting an "advocate" clarifies and supports the thoughts and feelings of "team" members. The "conductor" functions as a group leader and facilitator. A "consultant," usually-a mental health professional, points out and clarifies issues the "conductor" may have overlooked. Seeing that the agreements made in the network meetings are carried out is the role of the "monitor."

Not only does "network therapy" increase the psychologically impaired individual's social and community involvement, but it is said by the authors to provide supportive services to all those involved. In addition, this therapeutic approach is seen as having the auxiliary function of providing a training ground for other mental health professional and lay people with an interest in community involvement. This method is said to be particularly useful in a rural setting where distances can work against attempts at social reintegration, and where isolation is often too easily obtained.

Summarized by James D. Medina

Field, G., Allness, D., & Knoedler, W.
Application of the training In community living program to rural areas.
Journal of Community Psychology, 1980, 8(1), 9-15

The Training in Community Living Program was instituted to maintain chronically impaired individuals in a community environment as opposed to repeatedly hospitalizing them. The program was deemed a success in an urban area (Madison, WI), yet questions arose as to its applicability and feasibility in a rural setting. Three rural counties were offered consultation to aid in the community treatment of chronic mental patients.

Program principles included: (a) teaching normal coping skills in context, (b) reality-oriented treatment of symptomatology, client advocate role by staff, and (c) assertiveness.

Initially, mental health staff from the respective counties trained briefly at the Community Living facility. Afterwards, Community Living staff helped the counties set up a program and accompanied county workers as they worked with patients. Community Living staff withdrew their support and frequency of contact as county workers demonstrated skills learned in the program. Consultations dropped to once every 2 weeks, and then to once per month. Length of consultation contacts lasted from 6 months to 1 year.

In order to aid the establishment of this program, county staff were advised to start small and adapt principles of the Community Living Program to their rural environment. By working alongside the county workers, Community Living staff could demonstrate in a direct fashion the various principles and techniques, and also could offer support and encouragement when workers encountered frustrations and obstacles.

A number of features were discussed pertinent to establishing this program in a rural area. These included personal relationships with other service providers, an orientation to outreach, the absence of inpatient facilities, and the attitudes of rural program directors.

 Two of the counties experienced no rehospitalization of the clients they served (five and seven chronically ill patients, respectively). Of the 13 clients treated by the third county, only three needed rehospitalization within 1 year after the initial Community Living consultation.

The authors felt that the obtained results offered support for the treatment of rural chronically impaired clients within a Community Living framework.
Summarized by Bruce Reed


Haley, M.W.
Developing a program of mental health services In a rural county jail
Hospital and Community Psychiatry, 1980, 31(9), 631-632

      The purpose of this program was to provide mental health services to the inmates of Marengo County jail in rural Alabama. A 1975 order by the U.S. District Court prohibiting the Alabama State prison system from accepting new prisoners had caused a backlog of state prisoners within the county jail. Additionally, there had been a request by the Marengo County sheriff, who was also the jail administrator, for mental health services to be included in the criminal justice system.

The sheriff s goals for the mental health provider were: (a) to provide inmates with mental health services, (b) to aid in reducing the negative impact of impending overcrowding, and (c) to improve administration of the jail. A psychologist, with a background in corrections, became the contracted mental health provider. Funds were obtained under a Law Enforcement Assistance Administration (LEAA) grant.

The largest population in the jail was composed of young first or second offenders who were motivated to change their life style, yet had insufficient or inadequate vocational, educational, or personal resources to facilitate the change. A work release program was instituted in the county for this portion of the jail population. The psychologist pooled test and interview data with law enforcement officials. Inmates who were deemed good risks were referred to the sheriff, who recommended eligible inmates to a rehabilitation board for final approval before entering the work release program.

Participants lived in a part of the jail which was separate from the remaining jail population. They were transported to a wide variety of employment sites on a daily basis. Of those who were participants, only 10% have returned to the jail; rearrests were mainly due to misdemeanor offenses. Income from this program was distributed within the county jail system for various physical and programming improvements. When necessary, funds also were channeled to the county welfare department to aid inmates payments of child support.

Apparently this program achieved its stated purpose. In addition, it fosters community involvement via volunteer services, and assists families of inmates. Most importantly, it does not conflict with aspects of security in the jail system. Benefits to the jail administration, line staff, and staff-inmate relationships also were reported.

This innovative rural jail program was chosen in 1978 by the Western Interstate Commission for Higher Education as one of the seven model programs for mental health services in Jails. Summarized by Bruce Reed

Husaini, B.A., Neff, J.A., Harrington, J.B., Hughes, M.D., & Stone, R.H.
Depression In rural communities: Validating the CESD scale
Journal of Community Psychology, 1980, 8(1), 20-27.

The study was reported to be an effort to collect validity data on the Center for Epidemiologic Studies-Depression Scale (CES-D) using a rural population. The existing data has been based primarily on urban samples, thus leaving a need for data relevant to rural settings. Specifically, the authors chose to investigate the scale's ability to discriminate between client and nonclient groups, as well as among various diagnostic categories and levels of severity. The authors also sought to define new cutting points for the CES-D, to assist rural mental health workers in the identification of individuals reporting depressive symptomologies so disabling as to warrant psychological intervention.

The subjects were drawn from nine rural counties located in central Tennessee, with a total subject population of 913 persons. CES-D scores and other data for the 200 subjects comprising the experimental (client) group were obtained through area mental health centers and a local VA hospital, with the data for the 713 control nonclient subjects having obtained during an earlier survey. The ages for each group ranged from 18 to 60 years.

The results revealed that the CES-D effectively discriminated the client and nonclient groups, since the mean CES-D score for the client sample was nearly four times that of the latter. The scale significantly differentiated a sample of clients with diagnoses of depression (e.g., depressive neurosis) from a group holding other classifications (e.g., schizophrenia) and differentiated clients in both groups in terms of level of problem severity. it was only among the various subclassifications of depressions, such as between primary depression and mental maladjustment with a depressive component, that the scale was unable to discriminate at a significant level.

The authors concluded by reporting both possible and probable cutting points for the CES-D, regarding potential caseness. These new points which are different from those reported for urban samples, were based on the rural population used in the present investigation.

In all, the study appeared to provide considerable support for the validity of the Center for Epidemiological Studies-Depression Scale, as well as providing needed normative data specific to a rural setting.
Summarized by Marc Vargo

McConnell, S.C.
Psychology in the Raw
Voices, 1978,14(3), 51-53

The author offers a personal, vivid account of his experiences as a clinical psychologist at a community mental health center in the mountains of Western North Carolina. He relates first-hand encounters with the residents fear and misconceptions of mental health care. By learning about these rural peoples and enduring the hardships of their mountain life, the author feels he has grown personally and has both acceptance and affection for this culture.
Summarized by Mary Beth Kenkel

Taylor, L., & Brooks, G.W.
A screening program to reduce admissions to a state hospital.
Hospital and Community Psychiatry, 1980, 31(5), 9-60

The report concerned an experimental program designed to reduce the rate of admissions to the Vermont State Hospital a psychiatric facility with a stated commitment to deinstitutionalization. Specifically, the program sought to lower the admission rates of the three counties located nearest the hospital, to levels similar to those found in the more remote areas of the state. At the time of the study, the rates among these three counties were over twice those of the more rural counties.

The program, termed the Rural Community Screening Program, was an effort to screen, in nonhospital settings, those persons considered candidates for admission. Mental health workers were placed in community mental health clinics within the tricounty area, where clients were screened for possible hospitalization. In addition to screening, however, the workers also were trained to apply crisis intervention techniques when appropriate, and to refer clients to facilities other than the state hospital when possible. The program staff consisted of five screeners, an admission coordinator, program evaluator, and a secretary, with the program being initiated in 1974 and concluding 3 years later.
The results revealed that while only 2% of all potential admissions were screened in community clinics prior to the program, 50% of such clients were screened in these clinics by its conclusion. The increased use of community settings was due largely to an increased willingness on the part of community agents to refer clients to such settings. By the termination of the screening program, hospital admissions had dropped from an initial total of 1,122 to 632 in the tricounty area. The goal of the program had been attained, since admissions among the three immediate counties reduced to the same level as found in the more remote areas of the state.

The authors concluded by stressing the need for additional housing alternatives for patients in Vermont. It was stated that admissions could have been reduced even further, had other residential facilities been available for patient use.

In all, the report illustrated the ways in which a rural, Northeastern state appeared to resolve partially a problem often encountered in more urban settings.
Summarized by Marc Vargo

On November 15, 1980, the First Annual Rural Symposium entitled Helping Networks in Rural America: A System of Linkages Among People was held at the California School of Professional Psychology—Fresno. Summaries of some of the presentations follow, other presentations are being revised for articles for future issues of the Journal of Rural Community Psychology.

Forming a Partnership with the Community
Carole Parrott                  Joe Sebastian
Central Valley Regional Center     Merced County Mental Health       1920 Princeton Drive              480 East 13th Street
Visalia, California 93277           Merced, California 95340
The presentation focused on the presenters experiences in the development of two rural mental health programs in Central California. Social, political and economic factors were reviewed, with emphasis placed on the importance of proper entry of mental health personnel into the rural community.

In order to gain successful entry, including the acquisition of both needed information and local support, the mental health worker should adopt a tell us what you need stance when approaching members of the community. Such a stance allows the worker an opportunity to learn about needs as perceived by the community, while also receiving a general impression of the way in which mental health services are regarded in the local area. Also, such a receptive stance was claimed to place the worker in the relatively non-threatening role of a concerned helper, thus reducing community resistance and enhancing acceptance and cooperation.

Similarly, the presenters maintained that informal participation in community activities may help the mental health worker gain access to important information about the community and its structure, while also serving to increase his or her visibility and eventual acceptance in the local area. Examples of such participation included the volunteering of time for community causes and the involvement of mental health personnel in local organizations.

Essentially, Parrott and Sebastian reported that the mental health worker must first become a partner to the rural community, if he or she later is to be come a functional part of the community.
Summarized by Marc Vargo

Social Networks In the Mexican-American Community
Margarita Prado-Borrego
Dinuba Counseling Center
1327 East El Monte
Dinuba, California 93618

In her presentation, Ms. Prado-Borrego stressed the importance of utilizing community support systems in the treatment of emotional disorders. Special attention was given to the identification of the support networks found in many rural Mexican-American communities, such as those located in California's San Joaquin Valley, and to the ways in which these resources may best be approached by the mental health practitioner.

Concerning the types of social supports available, three major sources were identified, including the curandero or spiritual healer, the compadre or the client s godfather, and the local religious leader. These sources are highly regarded by many Mexican-Americans, being most important to those who retain their traditional cultural beliefs concerning a supernatural causation of physical and emotional disorders. Thus, the inclusion of such influential sources may help to ensure that a client remains in treatment, while also serving as resources for the client, afterwards.

In order to select and utilize the appropriate supports, the practitioner should work through the client's family. Each family has its own preferences and, if asked, usually will share this information with the mental health worker. Beneficial results frequently are obtained when support sources are contacted by the family, rather than by the practitioner, since such sources often are more cooperative when requests come from those with whom they are familiar. Overall, the family was viewed as an especially important link to the major support networks within the Mexican-American community.

The presenter concluded with the recommendation that practitioners functioning in other cultural and sub-cultural, rural settings should be aware of the particular social supports available to their clients, and utilize these resources when appropriate.
Summarized by Marc Vargo

Community Education in a Rural Setting
Al Vital
Tranquillity Union High School District
P.O. Box 457, Tranquillity, California 93663

In his presentation, Mr. Vital outlined guidelines for establishing a comprehensive community education program in a rural multi-cultured setting. Currently, Mr. Vital is the project director of the Community Education Program operated by the Tranquillity Union School District. This program, begun in 1976, and funded by the Community Schools Act, provides extensive community services for children and adults in an isolated and rural area covering some 650 miles in the western part of Fresno County. One of the concepts of the program is to use the facilities and other resources of the School District after normal school hours for educational and service programs.

Four senior citizen centers, operated by the program, provide information and referral services, transportation, recreational activities, tax assistance and other related community services. Additionally, as program director, Mr. Vital attempts to provide district-wide coordination of other community services, e.g., by contacting the County Economic Opportunities Commission to provide hot meals for seniors, and also to bring in State and Federal grant monies, e.g., from the State Department of Aging.

To organize such a program, Mr. Vital stated that one must first determine the relevant factors of the community: the geography, the influential members, the boards and commissions, potential bases of power, agencies providing services, the funding sources for these agencies. Then an effective base of operation must be selected which offers flexibility. Ten to fifteen people highly committed to the project should be selected for a committee which will conduct a needs assessment. Findings from the needs assessment should be distributed to the entire community through all available media services. A Community Council, representing a broad cross-section of the community, should then be formed to determine specific goals and objectives developed from the needs assessment. Once the Community Council has determined the needed services, they must decide on how, when, and where, these services will be offered and financed. The previous data collected in the community will consist of various funding sources and volunteer help, all working together to provide a wide range of program services.
Summarized by  Mary Beth Kenkel

Network Theory A Case Example
Investigation at a Network of Services for the Elderly
Santo Bentivegna
California School of Professional Psychology—Fresno
1350 M Street, Fresno, California 93721

This paper presented a brief highlighting of Network Theory for the human services based in large part upon the work of Seymour Sarason. For the human services, networking describes a process of communication and/or exchange of resources between individuals who are members of agencies providing services to a community.

Using Sarason's theoretical framework, a survey was conducted in southern Connecticut to:

1. Define the mental health needs of the elderly in a particular target area.

2. Determine if a network exists to meet those needs.

3. Formulate recommendations to promote network development.

During the initial phase of the survey it became apparent that the task of defining the mental health needs of the elderly required a far more comprehensive investigation than the design of the survey allowed. To the elderly there is a far greater stigma attached to the label of mental illness or even that of obtaining social services, (welfare, food stamps), than there is to middle age or young adults in society. This same message was repeated to the investigators at every agency where they inquired. However, through private interviews it was found that many of the mental health needs of the elderly were complexly interwoven about the topics of death, isolation, loneliness life changes, and survival.

 An informal network among social agencies serving the elderly was found to exist in the area. There were no official meetings, no elected officials, and no fixed agenda schedule. They met primarily on the basis of reviewing municipal budget issues. When local government began to review city expenditures the net work rallied to show community solidarity and support in an effort to fend off any potential budget cuts. The network was beginning to change shape by the conclusion of the study. Members began meeting between the city review meetings and initiated the arrangement of parties and other social gatherings between residential and day patients from different facilities. Each agency shared equally in the cost of time, money, and equipment. There was one member identified as a potential director as he had become the constant, man in charge, referred to by all other network members. The individual acknowledged that he felt comfortable not only in portraying but also in accepting the role.

Four recommendations were put forward. The first was that a casually arranged yet formally structured meeting take place in which a statement of rationale, values, and goals be determined among network members. A formal statement of this nature would facilitate the network's focus on developing a more stable existence. They would, in effect, lay the foundation from which a stronger network could root and branch out. With a well-developed philosophical base, a more effective application of services is possible. As the network grows in strength and stability so will grow the potential for trust to develop between members. Trust must be present between members prior to any substantial sharing of resources. The bonding of resources in turn fosters each agency s potential for economic survival due to the increase in the flow of information and to the political clout which organized groups may wield.

Secondly, general meetings must be established to promote the flow of ideas and information, and to facilitate growth and expansion of the network.

This leads to the third recommendation, that of developing a means for greater community input and participation. Successful networks exhibit the ability to adapt to new social demands. Allowing community input and participation provides an avenue through which new information from outside the network may enter. This avenue completes the feedback cycle whereby the network may learn how it has met community needs, where it fell short, and what it could do in the future.

The fourth and final recommendation was that more resource exchange must be attempted between agencies. While an open forum for discussion is important, many of the network members felt that in some ultimate sense, talk is cheap . The actual sharing of resources extends the boundaries of the network and strengthens its linkages. Through the mutual sharing process, each agency enhances its own influence and success in the community.