Invisible Outsiders: Developing a Working Alliance with Appalachian Clients


  • Jake J. Protivnak Youngstown State University
  • Cassandra G. Pusateri East Tennessee State University
  • Matthew J. Paylo Youngstown State University
  • Kyoung Mi Choi California State University, Fresno


Appalachia, cultural competence, working alliance, counselors, diversity


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.

Author Biographies

Jake J. Protivnak, Youngstown State University

Professor and Acting Chairperson, Department of Counseling, School Psychology and Educational Leadership

Cassandra G. Pusateri, East Tennessee State University

Assistant Professor, Department of Counseling and Human Services

Matthew J. Paylo, Youngstown State University

Associate Professor, Department of Counseling, School Psychology and Educational Leadership

Kyoung Mi Choi, California State University, Fresno

Assistant Professor,  Department of Counselor Education and Rehabilitation