Invisible Outsiders: Developing a Working Alliance with Appalachian Clients

Jake J. Protivnak, Cassandra G. Pusateri, Matthew J. Paylo, Kyoung Mi Choi


Appalachian clients are often ‘invisible’ within the majority culture and possess characteristics unique to the region that must be considered within the counseling relationship (Tang & Russ, 2007).  Individuals in Appalachia have higher incidences of certain mental health disorders and substance use as compared to the national average (Appalachian Regional Commission [ARC], 2008).  Although the need for mental health services is evident, limited research exists to inform mental health professionals how to deliver culturally competent interventions to build a working alliance with Appalachian clients.  The authors will discuss a framework for mental health professionals to develop a strong working alliance through a review of the cultural distinctions of Appalachian individuals, culturally appropriate counseling interventions, and a case illustration.


Appalachia; cultural competence; working alliance; counselors; diversity

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