Diane S. DeRue, MPA, LSW, Rob Schlegel, BA, LSW, & Jennifer Yoder, BA
Located in rural north-central Ohio, Wayne and Holmes counties are home to approximately 35,000 Amish -- the largest Amish population in the world. For more than a decade, The Counseling Center of Wayne and Holmes Counties -- a local community mental health agency --has developed specialized programs and services sensitive to the Amish way of life. With a grant from the Ohio Department of Mental Health’s Cultural Diversity Team and as part of the center’s ongoing consumer satisfaction and program evaluation process, Amish community members participated in an assessment of mental health care and treatment.
Surveys were conducted with three key informant groups, including a sample of Amish mental health consumers, members of the Amish Family Support Group and Amish community leaders (bishops and ministers). The goal of this project was to find out what works and what needs to improve in the mental health care of Amish consumers and family members.
In-home interviews of randomly selected case management consumers were conducted to help identify consumer perceptions of current services and consumer ideas about unmet needs or service enhancements. Family members were present during the consumer interviews, and additional information was gathered from them. A survey was also developed to gather opinions and information from the Amish Family Support Group members and the Amish bishops and ministers.
The Amish are a strong patriarchal society with community leaders being bishops and ministers. All bishops and ministers are male and come to serve the church, in these life long positions, through the drawing of lots. Approximately 8,700 Amish individuals, families and church leaders living in more than 50 of the 200 local parishes are represented in the survey results.
Part 1: Consumer Surveys
Fifteen consumers were randomly selected from the center's Amish Case Manager's case list.The consumers, all of whom have severe mental illness, were surveyed in their homes. Of those surveyed, 54% were male and 46% were female. The interviews included members of all levels of the Amish culture, with the most conservative Swartzentruber Amish comprising 23% of the group, 46% Old Order Amish, and 31% New Order Amish, the least conservative group.
The survey revealed that while a majority of consumers recognized that the mental health system is, and should be, the primary resource for services in mental health intervention, only 61% recognized the importance of psychotropic medication over the traditional remedies (herbs, vitamins, prayer and hard work) used for symptom control in the Amish culture.
When asked which services provided by the local mental health center have been helpful, 46% of the respondents mentioned case management, 32% identified the psychiatrist, and 7% identified emergency services. There was a 3% response in each of the following areas: counseling, employment, housing and partial hospitalization. Consumers also believed that the Amish Family Support Group meetings and educational presentations were helpful, with 67% indicating that both the meetings and the educational component were helpful and 33% indicating that they did not attend the support group meetings. One hundred percent of the consumers that do attend the Amish Family Support Group responded that the group meets their needs.
Sixty-one percent of the survey participants stated they have missed mental health appointments due to problems with transportation. Survey respondents were asked what they would like to see done differently in providing mental health services to the Amish. There were few responses: none, smaller groups, needs met through services, I don't have nerve problems. Participants were also asked what other programs or services could be developed or provided that would be helpful. The only response was “The Counseling Center really helped in our lives.”
Part 2: Survey of Amish Family Support Group Members
Forty-four Amish Family Support Group members participated in the survey. As usual, more women (79%) than men attended the support group, and in order to keep track of possible gender differences, color-coded surveys were used. The survey was developed to measure members’ attitudes in seven areas affecting mental health treatment: the cost of mental health treatment, the Amish Church belief system, the Amish community's belief system, the effects of transportation, fear of proselytization, family influences, and influences of employment.
Each of the male respondents answered all of the survey questions, but 8 (18%) of the questions were not answered by the female participants. The reason women did not answer all the survey questions can only be speculated upon: Perhaps some did not know how to answer the question, were not sure how others would answer the question, skipped it and forgot to return to it, etc.However, experience indicates that the most likely reason for the omissions is that respondents were uncomfortable with the question and/or their response and that rather than respond negatively, they would rather not answer the question at all.
Cost of Treatment and/or Services
A large majority of both males and females believe that cost of mental health services should not be the determiningfactor in seeking mental health services. This belief is so clearly predominant that potential debt would not restrict these members of the Amish community (males 100%, females 89%) from seeking mental health services.
Sixty percent of men agreed that they could secure financial assistance from their church, if necessary, to pay for treatment, while only 47% of the females believed they could get church support for this purpose. Finally, it was also evident that a clear majority, 100% of the men and 89% of the women, believe that natural remedies do not work as well as mental health services for emotional problems, although they are less expensive. This response is the reverse of the consumer survey responses. The potential cost of mental health treatment, even in the absence of insurance resources, did not seem to be a deterrent to obtaining treatment for mental health problems.
Amish Church Belief System
The survey results indicated a gender bias regarding the feeling of support from the Amish church to seek mental health services and the influence of the church religious leaders on the actual determination to seek treatment. The majority of women (79%) agreed that the church is supportive and would encourage their church members to seek mental health assistance, while the majority of men (60%) disagreed. Four percent of the female participants did not answer this question. Overall though, a majority of both males (60%) and females (68%) agreed that they would likely seek treatment for emotional problems without consulting with their bishop. Additionally, 60% of men and 95% of women agreed that adhering to a good Christian lifestyle does not prevent mental health problems among the Amish.
The survey results seem to indicate that 60% of males and 63% of females feel comfortable seeking services from a counselor or doctor who does not specifically adhere to their Amish Christian values. It is important to note that 16% of the women failed to answer this question. If the hypothesis is correct that the women do not respond at all rather than respond negatively, the female response would be almost evenly split between agreeing and disagreeing with the question.
Amish Community Belief System
Seventy-nine percent of the women and 40% of the men surveyed indicated that they feel the Amish community would consider it appropriate to seek counseling if necessary. Both males and females think that their Amish neighbors believe that seeing a counselor is the best way to get help for emotional problems. All of the men and 84% of the women would encourage their friends to seek treatment for depression. While the majority of females (74%) feel that they would be criticized if the counseling were not Christian oriented, the majority of males (60%) did not view this as a concern.
Effects of Transportation
The survey does not point to transportation as a barrier to receiving treatment for mental illness. The majority of respondents feel that transportation problems should not prevent service, and 80% of men and 74% of women feel that the cost of transportation for mental health services is easily met by the Amish who need such services. Sixty percent of men and 63% of women stated that they would use the team (horse and buggy) to seek and obtain mental health services if necessary. Eighty percent (80%) of men and 95% of women believe that more should be done to help the Amish with transportation to psychiatric appointments.
Fear of Proselytization
A majority of both males (100%) and females (76%) do not believe that mental health counselors and their interventions are directed toward encouraging the Amish to leave their community or change their belief system. Most Amish are supportive of Amish-specific mental health services, and 79% of females and 60% of males feel that special Amish-only treatment services would be beneficial. A clear majority of both males (80%) and females (79%) do not fear they will turn or be turned “English” because of treatment for mental health and/or emotional problems. They did not feel intimidated or unduly influenced to change their Amish lifestyle through counseling or the treatment process. Amish men, it appears, are much more likely to entrust the care of their children to mental health professionals than are Amish women. Eighty percent (80%) of the males did not see a reason to be present during treatment with children, while the majority of females (58%) believe that they would need to be present and monitor treatment interventions.The latter percentage may in reality be higher as 16% of the women did not respond to this question.
A very clear majority of both males (100%) and females (95%) feel that one of the most important factors in seeking mental health services is support from family members. Also, a majority of respondents, males (80%) and females (95%), indicated that most of their family members believe mental health professionals and psychiatrists are helpful, knowledgeable and skilled in their intervention techniques. Men and women both indicated that family members would not necessarily have to go to the church for advice before taking a family member for mental health treatment. Also, the survey indicated that there is a majority belief among both sexes (men, 60%, and women, 84%) that family members are supportive of mental health intervention regardless of cost.
Influences of Employment
Almost all of the survey respondents, 100% of men and 95% of women, do not believe that their work schedules interfere with securing necessary mental health services. Surprisingly, considering the extremely powerful work ethic of the Amish, 100% of men and 74% of women believe that mentally ill individuals should not be encouraged to work if it is against a doctor's advice. Ten percent (10%) of the females participants did not respond to this question.
The majority of male respondents (80%) reported that Amish employers are understanding of the need for mental health intervention, compared with only 42% of female respondents. It is important to note that 11% of the female participants did not answer the question. However, 58% of Amish females did think most Amish employers would help pay for mental health benefits, and only 40% of the men believed workers would receive this type of benefit.
Part 3: Survey of Amish Bishops and Ministers
Twenty-five Amish bishops and ministers completed the survey, either in person or by mail. A majority of the religious leaders (75.50%) surveyed believe that members of their church should begin the path to mental health treatment by contacting and discussing their problems with the minister or bishop. Two comments were also included on the survey form stating that the parishioners and bishops or ministers need to work together and that the bishop or minister should be consulted only if he has been trained to handle emotional problems. Ninety-two percent believe that it is important for the church to help pay for mental health treatment and services. One respondent commented that the church should pay only if necessary.
A slight majority of religious leaders (52%) felt that their support for mental health services for members of their community depended upon the specific condition or situation. Ninety-two percent indicated that they do not encourage their parishioners to use “natural remedies” such as herbs, special diets, or chiropractic before seeking mental health services, but one respondent mentioned that he thought "this could vary a lot!" and another stated it "depends." Most of the religious leaders (64.50%) did not feel that giving up and/or accepting God's will is a preventative method for avoiding mental health disturbances, but 16.50% did not answer this survey question.One respondent stated that the "hardest part is to admit a person needs help, second hardest is to find someone to trust and understand problems."
Approximately one-half (49.50%) of the respondents feel that a mental health professional or counselor should be a Christian in order to serve the Amish community. Forty-three and one-half percent (43.50%) of the religious leaders believe that the Amish should avoid counseling if possible, with several stressing "if possible." Yet, a large majority (83.50%) of these respondents feel that the bishops should do more to support the people under them who have mental health problems.
A clear majority (80%) of religious leaders feel that a local inpatient organization similar to that operated by the Mennonite Central Committee (Oaklawn) should be available to serve the Amish community in our area. One participant was "not acquainted with Oaklawn," one would "prefer” a place like Oaklawn, and one would just like a hospital closer to the area.
A majority (67.50%) of the Amish religious leaders would like to work with the English community at large to increase mental health services for their people, and 64.5% believe that most counselors and doctors understand the Amish belief system and are supportive of it.
Sixty-eight percent (68%) believe mental health services must or should follow the Ordnung, or rules, of the Amish church. A slight majority of religious leaders (52.50%) would also seem to support a benefit auction to help people burdened by the cost of mental health services "if it is really needed.”
Interestingly, a large majority (72.50%) of the religious leaders believe that more Amish parents should seek help for their children with mental health problems, with 12% agreeing with the premise and 15.50% not answering the question. One respondent commented that parents should seek mental health services for their children "if needed or recommended by the doctor."
Only 44% of Amish religious leaders believe that more mental health services need to be developed directly in the community, with 40.50% disagreeing and 15.50% not answering the question. Overall, the majority (64.50%) of religious leaders report having received positive feedback about the mental health services provided to the Amish members of their community, while 3.50% had received negative feedback and 32% had no response.
The consumer survey suggests that the leading service desired and appreciated by consumers is case management.Second to this is the psychiatric care provided by the mental health center’s psychiatrists. All of the consumers, family members and community leaders view transportation as an area of need that would benefit from increased resources. The data collected suggests that the mental health center is recognized as doing a quality job providing services to the Amish and that continued visibility within the Amish community is important in order to maintain and expand this perspective as well as to provide access to those who need treatment for mental illness and emotional problems.
In terms of treatment provision, the survey results suggest a need for mental health professionals to be more accepting of the non-harmful traditional Amish remedies such as prayer and herbs in conjunction with the more universally accepted "English” medical/psychiatric treatments such as chemotherapy and psychosocial intervention strategies. It is also apparent that there is a great need to focus on education about psychotropic medications and the relief they provide from the symptoms of severe mental illnesses.
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Note: Diane S. DeRue, Rob Schlegel, and Jennifer Yoder are employees of The Counseling Center of Wayne and Holmes Counties in Wooster, Ohio and have worked with the Amish during their employment with the Center. Ms. DeRue has been the director of services for persons with severe and persistent mental illnesses since 1988. Mr. Schlegel was the case manager for the Amish from 1987-1993 and rejoined the agency staff in 1999. Ms. Yoder has been the case manager for the Amish from 1994 to present. Both Ms. Yoder and Mr. Schlegel have strong ties to the Amish community and speak the local Dutch dialects.
Contact: The Counseling Center of Wayne and Holmes Counties 2285 Benden Drive Wooster, Ohio 44691 Telephone: (330) 264-9029 Fax: (330) 263-7251 Web Page: www.ccwhc.org E-mail: firstname.lastname@example.org