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Complicated Grief in Rural Appalachia: Using Feminist Theory to Reconcile Grief.

Complicated grief (CG) is an enduring and impairing grief response to the loss of a loved one (Harris & Winokuer, 2016). CG can be mislabeled or misunderstood when expectations for grieving are situated within a specified amount of time or specified manners of grieving. As a result, CG develops when grieving individuals are unable to reconcile grief within cultural expectations and norms of grieving (Shear, Boelen, & Neimeyer, 2011). Clinicians often lack knowledge of CG despite its prevalence and impact, which indicates an urgent need to help counselors identify and treat this issue (Dodd, Guerin, Delaney, & Dodd, 2017). Furthermore, as the manifestation of CG is culturally rooted, cultural groups at potentially higher risk of developing CG require increased attention and refined focus for treatment.

Rural Appalachians are a cultural group distinguished by their geographic-location in rural areas across a 205,000-square-mile landscape covering the Appalachian Mountain region from northern Mississippi to southern New York (Appalachian Regional Commission, 2017). Rural Appalachian culture is characterized by values of community, egalitarianism, and self-reliance (Keefe, 2005), which, if not nurtured during the grieving process, could create feelings of isolation that lead to CG. Additionally, rural clients tend to base the need for mental health services on externalized behaviors, so they may neglect difficulties that stem from internal experiences of the grieving process (Gore, Sheppard, Waters, Jackson, & Brubaker, 2016). Thus, rural Appalachians may be at risk for CG if their grief experiences conflict with common Appalachian cultural values or behaviors. The nature of such conflict elicits the need for a treatment approach that supports the importance of cultural influences.

There is limited attention to rural Appalachians' grieving shies, patterns, and experiences in existing literature, despite knowledge of the significant role cultural identity plays in experiences of grief (Shear et al., 2011). Current understandings of cultural norms and values provide context for the ways rural Appalachians deal with other types of distress and life transitions (Keefe & Greene, 2005). As a result, bridging existing knowledge of rural Appalachian cultural values to an under-researched topic area within the population, through new applications of counseling theory, is warranted. We review CG and rural Appalachian culture to provide context for culturally rooted manifestations of CG within this population. Then we describe feminist theory as a fitting treatment modality that centralizes the role of culture. Finally, we demonstrate the use of feminist theory with rural Appalachians via a case illustration.

COMPLICATED GRIEF

CG is described interchangeably with prolonged grief disorder (PGD), persistent complex bereavement disorder, and traumatic grief (Harris & Winokuer, 2016). These terms, used interchangeably, refer to what Harris and Winokuer (2016) described as "difficult grief...[that] involves prolonged acute grief symptoms and situations in which the bereaved are unable to rebuild a meaningful life without the deceased person" (p. 114). This type of grief may emerge from any loss experience that is personally devastating to the individual. In this paper, we use the term CG to describe this phenomenon.

CG is not currently considered a diagnosable mental health disorder. Prigerson et al. (2009) proposed diagnostic criteria for PGD to be included in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). Ultimately, the DSM-5 (APA, 2013) included "persistent complex bereavement disorder" only as a condition for further study (p. 789). Common symptoms may include persistent yearning for the deceased, intense sorrow and emotional pain, preoccupation with the deceased, bitterness or anger related to the loss, feeling alone or detached, feeling life is meaningless or empty without the deceased, and difficulty pursuing interests or planning for the future since the loss (APA, 2013). In summary, CG occurs when a loss of a significant loved one results in experiencing multiple symptoms for at least 6-12 months after the death; when daily functioning is significantly impaired; when symptoms are not better accounted for by other diagnoses; and when grief is out of proportion to or inconsistent with cultural. religious, or age-appropriate norms (APA, 2013; Lobb et ah, 2010; Prigerson et al., 2009).

CG may be mislabeled as post-traumatic stress disorder (PTSD) or major depressive disorder (MDD; Jordan & Litz, 2014). Some symptoms such as intense or prolonged psychological distress, depressed mood, desire to die, and/or avoidance are common among these conditions (APA, 2013). Each condition is distinguished partly by precipitating factors. CG is marked by focus on a loss and on the relationship to the deceased (Boelen, van de Schoot, van dens Hout, de Keijser, & van den Bout, 2010). Specific cognitions (e.g., ruminating disbelief that death loss has occurred) and emotional responses (e.g., yearning for the deceased) related to a loss event differentiate CG from MDD symptomology, where feelings of sadness are present generally without a specific-precipitating factor (Boelen et al., 2010; Prigerson et al., 2009). CG symptoms, such as preoccupation with the loss and yearning for the deceased, differ from PTSD svmptomology, where there is consistent avoidance of reminders of the distressing event (APA, 2013). Bonanno et al. (2007) longitudinally explored differences in these diagnoses and found that many participants with CG did not meet diagnostic criteria for PTSD and/or MDD and vice versa. This suggests CG is distinguishable from other diagnoses.

Individuals who experience CG can face significantly more life stressors and perceive lower social support overall (Ott, 2003). Stressors associated with secondary losses, such as change in residence or job, after the loss of a loved one can exacerbate CG symptoms. As CG persists, stress connected to prolonged distress can also increase risk for developing physical health concerns (Newson, Boelen, Hek, Hofman, & Tiemeier, 2011). Poor health outcomes including depression, suicidal ideation, and hypertension have been associated with CG (Prigerson et al., 2009). As a result, recognizing CG as a distinguishable issue with distinct needs for treatment is important to prevent additional physical and mental health issues.

RURAL APPALACHIA

Beyond its geographic makeup, the Appalachian region is classified by the economic status, history, and culture of its people (Keefe, 2005). Although the area's high poverty rates have declined over time, with recent surveys from 2011 to 2015 reporting around 17% poverty rate, they are still above the U.S. average (Pollard & Jacobsen, 2017). Overall, the household income in Appalachia is only 80% of the U.S. average, and the labor force participation is 5% lower (Pollard & Jacobsen, 2017). Although some within-group differences exist, most residents of rural Appalachia are White (Keefe, 2005). The region is geographically vast, and economic hardships vary, but common cultural values and norms distinguish Appalachians as a unique cultural group (Keefe, 2005).

Appalachian Culture

Core Appalachian cultural values have been influenced by history, immigration patterns, and challenging mountain environments (Keefe, 2005). Within-group differences, such as variances in race, regional location, and religious affiliation, influence unique expressions of cultural values (Keefe, 2005; Russ, 2010). However, in sum, core Appalachian cultural values include "egalitarianism, independence and individualism, personalism, familism, a religious world view, neighborliness, love of the land, and the avoidance of conflict" (Keefe, 2005, p. 10). Keller and Helton (2010) noted a firm appreciation for creativity and shared responsibility for maintaining the land as additional cultural values. Expressions of these values may vary across subcultures within the region, but connection to the roots of shared values commonly persists.

Russ (2010) described Appalachian culture as person oriented, where kinship ties and community heavily influence individual identity. The need for identity within the community creates a collectivistic culture that differs from mainstream American individualism (Gore, Wilburn, Treadway, & Plant, 2011). It is important, however, to clarify that Appalachian collectivistic culture includes elements of individualism. Specifically, Appalachians emphasize self-reliance (Keefe, 2005). Community' identity and support are fundamental, but individual effort and contribution make community possible (Keller & Helton, 2010). Appalachians value egalitarianism between community' members, as one individual is no more important than another. Everyone has a role and must fulfill it for community to function well (Russ, 2010). An additional individualistic trait within Appalachian culture is a value placed on autonomy to live independently from ruling dominions (Keefe, 2005). This creates reliance on the community and distrust of outsiders (Letvak, 2002). The interplay of individualism with collectivism creates unique cultural experiences embedded within the region and among the people within it.

Another key component within Appalachian culture is religiosity. Within-group differences exist, but evangelical Protestantism influences Appalachians' religious worldviews (Russ, 2010). Religiosity' impacts every aspect of Appalachian life, even for those who do not identify as religious, because religiosity is deeply rooted in Appalachian history and continues to play an active role for many in the region (Keefe, 2005). Appalachians often turn to their local church, second to their family unit, when they need help (Russ, 2010). Religiosity serves as an identity and a means of offering and seeking help, along with providing common beliefs that connect Appalachians to their communities. Therefore, Appalachians may seek mental health care on the recommendation of their family or church communities.

Because a value for community runs deep in Appalachia, distress can often occur when feelings of disconnection or isolation from the cultural group are present (Protivnak, Pusateri, Pavlo, & Choi, 2017). When Appalachians experience psychological distress, they often present with somatic symptoms and conceptualize their distress as "nerves" (Keefe & Greene, 2005, p. 304). Labeling distress as nerves is noted as a more culturally appropriate way to conceptualize overwhelming problems, as physical distress is less stigmatized than mental health issues (Keefe & Greene, 2005). Therefore, Appalachians may seek mental health care when they perceive no other option to reconcile severe and disruptive symptoms (Gore et al., 2016).

Risk Factors for Complicated Grief in Appalachia

Researchers noted three main categories of risk factors for the development of CG. The first category, personal psychological vulnerability, includes individual history of mood or anxiety disorders, insecure attachment style, history of multiple losses or trauma, and relationship to the deceased (Nolen-Hoeksema, Larson, & Larson, 2013; Van der Houwen, Stroebe, Schut, van den Bout, & Wijngaards-de Meij, 2010). The second category, circumstances of the death, addresses the nature of the death (e.g., untimely, unexpected, violent, or seemingly preventable; Shear et al., 2011). The third category, context in which the death occurs, includes inadequate social supports or concurrent stressors stemming from other life concerns (Harris & Winokuer, 2016; Wiley & Shear, 2007).

Little is known about rural Appalachians' specific grieving styles. However, the general description above provides information that suggests this population may experience heightened risk factors for CG. Related to the first risk factor category, personal psychological vulnerability, rates of depression are higher in rural Appalachia, with residents reporting 10% more mentally unhealthy days than those living in metro Appalachia (Marshall et al., 2017). Overall, 70% of rural Appalachian counties lack sufficient mental health service providers (Hendrvx, 2008), suggesting that many in need of counseling have never received services. In addition, those with depression often try to hide their symptoms; given the strong value of self-reliance and independence, they may be fearful about the reactions of their community (Snell-Rood et al., 2017).

The second risk category for CG, circumstances of death, also connects to the rural Appalachian population. In this region, suicide rates and alcohol disease mortality are higher than in the rest of the United States (Meit, Heffernan, Tanenbaum, & Hoffmann, 2017). Rates of death from overdose are also significantly higher than in other U.S. regions, primarily from opioid use (Meit et al., 2017). Houck (2012) noted significant differences in the religion-related coping strategies of Appalachians based on the reason for a death. More negative feelings and coping actions, such as discontent or blaming, arose when a loved one died of AIDS or suicide as compared to cancer, suggesting that stigma associated with reason for death can negatively affect the grieving process. Given that these types of deaths are often sudden, untimely, and unexpected, CG is more likely to develop as a result.

The third category, context, directly relates to how environment and cultural values connected to rural Appalachian life may affect the development of CG. Rural Appalachians are more likely to live in poverty, a risk factor for developing CG (Kerstin, Brahler, Glaesmer, & Wagner, 2011), as compared to the overall U.S. population. The impact of poverty can become dire when a death causes loss of income, especially for families already experiencing financial difficulties. In addition, other life stressors, such as changes in relationships or caregiving responsibilities after experiencing the death of a loved one, also increase the risk of CG (Ott, 2003). Cultural norms and values can also affect the grieving process. For example, values such as commonality or strong religiosity may make extended grief symptoms unacceptable to others. Relatedly, religion can be a source of support for grieving individuals, but it may create isolation or concern if grievers feel a lack of faith due to their loss (Chang, Sequeria, McCord, & Garney, 2016). When individual grief expressions or behaviors conflict with prescribed cultural norms, rural Appalachians may experience isolation from their cultural group, another risk factor for CG (Lobb et al., 2010). CG also may not be fully acknowledged by rural Appalachians, who are more likely to consider the need for mental health assistance when they notice externalizing behaviors (Gore et al., 2016). As CG symptoms may be more internalized (e.g., intense yearning for the deceased and feelings of emptiness), one's community may not recognize the depth of CG. Contextual factors common within the rural Appalachian environment and culture (e.g., increased likelihood of poverty, values such as commonality, and potential disclaim of CG symptoms) place the population at heightened risk for developing CG.

In summary, although CG is experienced individually, its development is culturally rooted. As noted, CG can form when cultural norms and expectations conflict with individual experiences of grief (Shear et al., 2011). Common symptoms of CG may challenge rural Appalachians' values and norms. For example, a rural Appalachian experiencing CG may struggle to comply with the cultural norm to contribute to the community when preoccupation with the deceased results in one's time being spent primarily with activities involving the deceased (e.g., looking at photos of the deceased, watching home movies, or visiting the grave site) rather than activities that support the community. Diverging from cultural expectations can lead to lower levels of social support and to experiences of isolation, both of which increase one's risk for developing CG (Lobb et al., 2010; Ott, 2003). Because the manifestation and expression of CG among rural Appalachians directly relates to cultural values and expectations, methods of reconciling CG must be considerate of these cultural contexts.

Rural Appalachians' experiences of CG also may be intensified because Appalachian cultural values are deeply rooted in community membership, familism, and egalitarianism. Thus, experiencing conflict between cultural expectations and individual expressions not only causes internal distress but also creates challenges throughout the individual's environment. To reconcile CG, rural Appalachians need to secure support to combat isolation, reframe their expectations for appropriate expressions of grief, and adjust the role they play in a community of grievers. A treatment modality like feminist therapy, which prioritizes cultural values, intervenes at individual and social levels, and reflects common values of rural Appalachians (e.g., egalitarianism and importance of culture), can address the cultural roots of CG and help rural Appalachians reconcile their grief in ways congruent to their cultural values.

FEMINIST THEORY

The modern understanding and use of feminist theory as applied to counseling, or feminist therapy, is grounded on "the core principles of resistance to power imbalances and oppression, affirmation of diversity, egalitarianism, and empowerment" (Conlin, 2017, p. 78). Feminist therapy is an amalgamation of contributions from many scholars, social movements, political contexts, and evolving cultural landscapes (Enns & Williams, 2012). Because feminist therapy is a social constructivist approach that attends to individuals' unique perceptions and constructions of their lived experiences (Brown, 2010), it is well suited for use with diverse populations, including but not exclusive to rural Appalachians.

Major Tenets

Feminist therapy includes an overarching goal of empowering clients and creating a feminist consciousness, or awareness of how oppression caused by broader cultural norms affects the individual (Brown, 2010; Enns & Williams, 2012). Grounding tenets of feminist therapy include core beliefs that the personal is political, that distress stems from environmental sources of oppression, and that change occurs through empowerment in egalitarian relationships (Brown, 2006, 2010; Conlin, 2017; Enns & Williams, 2012). According to feminist therapy, the politics of gender, power, and social location are central to our personal identities (Brown, 2006). Power "create[s] distress, resilience, dysfunction, and competence" (Brown, 2006, p. 17). As a result, avenues for individual and sociopolitical change are discovered by examining sources and impacts of power in individuals' lives (Brown, 2010; Enns & Williams, 2012).

According to Brown (1994), "Feminist therapy concerns itself not simply with individual suffering, but with the social and political meanings of both pain and healing" (p. 17). In feminist therapy, distress stems from imbalances of power and internalized oppression, which impact all individuals, not just women (Brown, 2010; Wolf, Williams, Darby, Herald, & Schultz, 2017). Mental health issues are not typically viewed as diagnostic disorders of the individual; rather, diagnoses are considered within the context of unhealthy environments where the individual lives (Brown, 2006). Counselors using feminist therapy look to social contexts and explore messages clients receive that may impact their individual experiences of power imbalances and oppression. This focus on social contexts and power creates an optimal framework to approach rural Appalachians' dealing with CG as they experience isolation from their communities.

Feminist therapy centers environmental contexts and recognizes impacts of sociopolitical influences beyond the individual (Brown, 2006). In fact, feminist theory's strengths-based, empowering framework can effectively meet the needs of Appalachian clients (Keller & Helton, 2010). Empowering interventions inherent in feminist therapy that build on existing Appalachian values and community identity can lead to successful therapeutic outcomes (Ambrose & Hicks, 2006). Additionally, the egalitarian therapeutic relationship within feminist theory is congruent with the Appalachian value for egalitarianism (Keller & Helton, 2010). In sum, counselors using feminist theory can centralize the importance of culture in people's lives, which makes it a compelling option for Appalachians, who often look to their cultural group for support (Keefe, 2005; Keller & Helton, 2010).

Feminist Therapy With Rural Appalachians Experiencing Complicated Grief

The process of feminist therapy with rural Appalachians experiencing CG can be understood as occurring within three phases. The first phase begins with building rapport and trust to establish an egalitarian relationship (Brown, 2010). The egalitarian relationship is viewed as a primary mechanism for change and pathway for empowerment (Brown, 2010; Remer & Hahn Oh, 2012). As client and counselor engage in the egalitarian relationship, examinations of power, social contexts, oppression, gender, and other political factors are more openly confronted and explored (Brown, 2010; Conlin, 2017; Enns & Williams, 2012). The egalitarian relationship goes beyond its purpose of empowerment by also serving as a relationship model the client may strive for in all social contexts (Brown, 2006).

The counselor should promote relationship building with consideration of the Appalachian cultural norms of being mistrustful of outsiders and feeling self-reliant in the context of community (Keefe, 2005; Letvak, 2002). Engaging in socialization, inquiring about the client's daily life, and self disclosing will promote egalitarianism and orient the client into the therapeutic relationship in a culturally sensitive manner. Counselors can introduce discussion of grief via psychoeducation about the wide range of typical grief responses people face after loss. This may normalize and destigmatize grief and help clients feel more comfortable discussing their specific experiences. This orientation is essential to establish before directly discussing presenting issues (Keefe & Greene, 2005). Building trust with this population may take time, so counselors should be prepared to follow the client's pace of disclosure during this initial phase of counseling (Brown, 2010; Russ, 2010). Even through a slower beginning, the counselor may indirectly begin learning about the source(s) of distress contributing to CG as clients share information about their family, community, roles, and daily activities. This process can orient the counselor to adjust to rural Appalachians' manner of discussing problems, considering direct conflict is often avoided and indirect means of dealing with problems are preferred (Keefe, 2005).

Once an egalitarian relationship is established, counselors can enter the second phase of feminist therapy to begin exploring power, roles, and internalized oppression within the client's social contexts (Brown, 2010). Exploration of perceived norms and expectations for grief in clients' social contexts is central in this phase. Common techniques to accomplish this discussion include analyses of gender, culture, social contexts, and power through collaborative exploration; self-reflective activities and counselor self-disclosure to raise feminist consciousness; and refraining and relabeling to confront and adapt internalized oppression (Brown, 2010; Remer & Hahn Oh, 2012). Clients may begin to realize the impact of their community on their beliefs about grief. Client and counselor also explore methods of enactment for social change. Rural Appalachians experiencing CG may benefit from this dual focus, as community is central to their cultural values.

Using feminist therapy, the counselor conceptualizes clients' symptoms of CG with an understanding that cultural norms and expectations can lead to feelings of isolation, difficulty processing grief, and disruption in daily functioning when norms conflict with the client's experience of grief. Rural Appalachians may not believe the source of their symptoms can stem from their social contexts (Protivnak et al., 2017). Exploration specific to cultural contexts may remedy this challenge. For example, counselors can facilitate a gender role analysis by asking clients about the responsibilities of men and women within their family unit; counselors may also ask about responsibilities of men and women in clients' religious communities. Highlighting responsibilities will allow client and counselor to identify any conflicts with clients' individual experiences of grief. Using clients' language and approaching them with humility will be important to explore social contexts as possible sources of distress (Keefe, 2005).

The third phase of feminist therapy begins when client and counselor have a mutual understanding of social contexts and how they contribute to the client's distress (Enns & Williams, 2012). Together, they can evaluate roles and expectations, potentially reframe the client's view of self in social contexts (Remer & Hahn Oh, 2012), and address needs for reconciling grief. Some reconciliation areas to consider include validating the loss experience, refraining expectations for grief, identifying sources of support, empowering clients to communicate their needs in ways that their community can understand and accommodate, exploring religiosity as a potential coping mechanism and source of support, and searching for means of adjusting to a new life without the deceased (Brown, 2010; Shear et al., 2011). As the client begins reconciling grief, it is important to normalize that the experience of grief will be ongoing throughout the life span (Harris & Winokuer, 2016). Helping the client prepare for resurgences of grief (e.g., during birthdays, anniversaries of the death, or special occasions where the deceased would have been present) can prevent CG from reemerging (Shear et al., 2011). The client may be ready to terminate counseling when symptoms have decreased in intensity, support systems have been identified and secured, and the client is seeking out and engaging in various tasks to reconcile grief and improve daily functioning. The following hypothetical case example demonstrates for illustrative purposes how feminist therapy may be used with a rural Appalachian experiencing CG.

CASE ILLUSTRATION

Sam, a 40-year-old woman, is seeking counseling on the recommendation of her pastor due to struggling with the unexpected death loss of her first cousin, Emma. Emma was killed in a car accident two years ago. Sam has been married to Jack, a 41-year-old man, for 18 years and has three children. Sam and Jack come from large families who have lived in rural eastern Tennessee for decades. The integrated families live within 5 miles of each other and are very close. Sam is a registered nurse at the local hospital.

Sam reports her family is fed up with her missing family events, moping around, and relying on them to raise her children. Sam notes her family and friends often tell her that everyone else has moved on with their lives and she should too. Sam reports no one in her family talks about Emma. When she tries to talk to Jack, he says something like "She would want you to move on, not continue talking about it." Members of Sam's church pray for her to find strength, which she reports is comforting. However, Sam states that she has overheard members of the congregation saving things like "She lost her cousin, not her child. I don't understand why she can't get a grip." Sam states that she knows Emma is in a better place, but she wishes Emma were still here. She reports oscillating between feeling angry and extremely sad, but always feels lonely since Emma died. She has trouble sleeping, and her appetite is minimal. Sam notes she does not know how to feel differently, even though she needs to move on. She is fearful that she may get fired because of missing so much work, and she feels like she needs to take better care of her children. She reports that no one cares to understand how hard life is without Emma.

Sam is presenting with multiple symptoms of CG. She is experiencing persistent longing for Emma and intense emotional pain related to her loss. She also appears preoccupied with thoughts of Emma, feels alone and detached from her family and coworkers, and feels like life is meaningless without Emma. Her symptoms have persisted for 2 years, as the result of Emma's death, and her daily functioning appears impaired, as she is neglecting family events and missing a lot of work. Sam has attempted to reach out to Jack to process her grief but has been unable to share her thoughts and feelings as she would have hoped. Sam's family and church communities have offered their thoughts about how to grieve, yet Sam cannot reconcile her grief. She is experiencing disconnect and a lack of appropriate support from her community. Her grief appears to be out of proportion to her cultural norms. Feminist therapy may focus on how Sam can reconcile her grief within the context of her cultural group.

Phase 1: Egalitarian Relationship Building

To begin counseling with Sam, the counselor, Jill, must be patient in building a trusting, egalitarian relationship that meets Sam where she is in her current grief experience and cultural contexts. Jill may promote conversation about Sam's family, daily life activities, and current feelings about her visit to counseling to establish comfort in the therapeutic relationship. Jill can also disclose her experiences participating in activities throughout the community. Sam will more readily engage in the therapeutic relationship as she learns how Jill is a part of their community. Providing space for Sam to express her experiences when she has been unable to express them freely elsewhere is an important component to establishing rapport and moving forward into Phase 2 of feminist therapy.

Phase 2: Exploring Power, Roles, and Internalized Oppression

As levels of disclosure between Jill and Sam increase, Jill begins to press into Sam's thoughts and feelings surrounding the loss of Emma. Jill probes Sam to explore how her cultural contexts--namely, family, work, and church community--have influenced her perceptions of how she should grieve and contributed to her current symptoms. Jill facilitates an analysis of culture and role expectations to explore Sam's worldview. Specifically, Jill asks Sam what her responsibilities as a mother and wife are in her family unit. Sam elaborates on her responsibility to take care of her children and help her family with daily activities. They explore how the responsibilities Sam identifies can be challenging when Sam is unable to share or process her grief with her family. Jill gently pushes Sam to explore how those responsibilities may contribute to her feelings of isolation, sadness, and being stuck in her grief. Then Jill normalizes Sam's experience by reflecting on the dissonance Sam is facing between her cultural environments' expectations and her need to reconcile grief.

Phase 3: Evaluating, Refraining, and Reconciling

After recognizing that the source of distress rests in cultural contexts, Jill and Sam move to exploring Sam's specific needs to reconcile grief in a culturally sensitive manner. Jill provides reflections and affirmations throughout this process to reduce any shame or guilt Sam may experience. Some of Sam's needs to reconcile grief include validating the significance of her loss, refraining her expectations of grief, identifying sources of support, empowering her to communicate her needs to family in ways they can reasonably adjust to meet her needs, exploring how her religiosity can play a role in her grieving process, and finding meaningful rituals or tasks that can promote a continued bond with Emma. As Sam and Jill work together to meet her needs, Jill prepares Sam for moments where grief can resurface and cause distress. Exploring how to maintain engagement with the process of grieving throughout the life span will be important before counseling ends. Sam will be ready to move forward from counseling as she reframes her expectations, secures support from her family and/or community after communicating her needs and experiences, and feels empowered to navigate her cultural contexts in ways that still allow her to engage in her unique grieving process.

IMPLICATIONS

Feminist therapy is a suitable treatment modality for rural Appalachians experiencing CG because it provides a framework to explore cultural contexts of family and community with humility in an egalitarian relationship--all of which are common Appalachian values (Keefe, 2005). It is important to recognize, however, that examining cultural contexts central to Appalachian identity must be pursued with care. The purpose of exploring cultural contexts in feminist therapy is not to challenge values or separate clients from their communities. Instead, the purpose is to increase clients' awareness of their cultural contexts and how discrepancies between cultural messages and personal experiences may cause distress (Brown, 2010; Shear et al., 2011). It is important to consider within-group differences when exploring rural Appalachians' unique experiences, norms, and values that may contribute to the manifestation of CG. The goals of feminist therapy with this population are to reframe clients' perspectives, empower clients to reconnect to their community in new ways, and engage in grieving tasks that help reconcile grief.

Considering the Appalachian cultural norm to seek help within the family, along with the common mistrust of outsiders, counselors in rural Appalachia must advocate for mental health care throughout the community. Counselors may be at more of an advantage if they are insiders to the community (Protivnak et al., 2017). For counselors moving into rural Appalachia, it is important to expand typical boundaries and become involved in the community to learn and build trust with community members (Keefe & Greene, 2005). A feminist therapy approach with rural Appalachians may consequently be better received.

Counselors using feminist therapy with this population can go beyond the individual context and address sociopolitical components in the community that may contribute to CG. Internalized messages that inform beliefs, values, and practices of grief can become problematic when personal experiences conflict with those messages (Brown, 2010). Therefore, counselors can provide psychoeducation to the community about loss and grief and normalize the universal phenomenon of grief, which may prevent community members from developing CG. Counselors must be mindful of cultural factors as they communicate with the community and use avenues that are normed and accepted within the community. For example, providing psychoeducation in the context of church communities, perhaps in collaboration with religious leaders, may be prudent. Overall, connections at the individual and community level will be important for counselors working with this population.

Feminist therapy may also be used in treatment of CG with individuals from other cultural backgrounds. All cultures include norms and expectations for grief (Shear et al., 2011), which influence individual experiences. Although we described cultural conflicts specific to rural Appalachians, other cultures have similar norms and values that may present conflict. For example, African Americans carry similar values for strong senses of faith and reliance on the family unit; they also similarly face poverty at disproportionate rates compared to the wider U.S. population and have been observed as experiencing higher rates of CG (Goldsmith, Morrison, Vanderwerker, & Prigerson, 2008). Overall, feminist therapy can be valuable when working with any group that may not represent the majority, where cultural expectations conflict with individual experiences, because cultural identity becomes central to understanding distress and exploring pathways to healing.

Feminist therapy may be applicable for treatment of CG generally when the root of distress is based on conflict between sociocultural norms or expectations and individual experiences. As we outlined above, engaging in each phase of feminist therapy with specific consideration for clients' cultural backgrounds and the norms and values within them may lead to reconciliation of conflict and engagement in the grieving process. The goals of feminist therapy with clients experiencing CG, regardless of cultural identity and type of conflict, are to reframe expectations for grief, empower clients to identify and secure supports, and engage one's unique grieving process (Harris & Winokuer, 2016).

A potential limitation of feminist therapy with rural Appalachians experiencing CG is timeliness of treatment. The phase approach to treatment works alongside individual needs and pace of progress (Brown, 2010), which may be challenging to certain managed care plans. Furthermore, the nature of counseling grieving clients generally can take time, as the grieving process is not time limited (Harris & Winokuer, 2016). Other limitations are more practical; rural Appalachians may lack the financial means to afford counseling or may be unable to travel long distances to find a mental health counselor.

Current understandings of Appalachian cultural norms and values provide context to the ways rural Appalachians may experience CG. We recommended using feminist therapy to treat CG by bridging existing knowledge of rural Appalachian cultural values and CG. Communities who embrace the universal phenomenon of grief may work toward shifting the narrative of avoidance toward one of mutual understanding and support, which may prevent CG from emerging. Using feminist therapy, counselors can impact the community by destigmatizing the experience of grief, in addition to providing culturally sensitive individualized care.

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Nancy E. Thacker, Department of Special Education, Rehabilitation and Counseling, Auburn University: Melinda M. Gibbons, Department of Educational Psychology and Counseling, University of Tennessee, Knoxville.

Correspondence concerning this article should be addressed to Nancy E. Thacker, Department of Special Education. Rehabilitation and Counseling, Auburn University. 2084 Haley Center, Auburn, AL 36849.

E-mail: net0013@auburn.edu

https://doi.org/10.17744/mehc.41.4.02
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Title Annotation:THEORY
Author:Thacker, Nancy E.; Gibbons, Melinda M.
Publication:Journal of Mental Health Counseling
Geographic Code:1U2NY
Date:Oct 1, 2019
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