Generational poverty, income equality, and rural bureaucracy:

Appalachian Addiction

How Alcohol Became a Community’s Desperate Mental Health Solution

Growing up in a small town of just over 5,000 people in southeast Kentucky, I learned from an early age that excessive drinking was normal. As a teenager and young adult, I’d lived a life tainted by alcohol without ever having taken a drink. It was common to have in libations in churches, hidden in classrooms for teachers to take a nip during recess, in nearly every home (both hidden and in plain sight), and was a great way to break the ice for a difficult conversation. If one had an emotional matter but wasn’t sure how to process it, especially since mental health support was difficult to obtain and sometimes even actively discouraged, processing using a fifth of Jack was recommended. An unwed, soon-to-be teenage mother who didn’t have health insurance but needed to give birth could use the same remedy in lieu of an epidural. A toothache caused by a lifetime devoid of dental care and bad genes was made tolerable by taking shots with the oldest child, most likely still in high school or at the very least, middle school, so one wasn’t drinking alone — which has such a negative connotation. Jack, Jim, and Jose became members of our families.

When you’re poor, cheap alcohol is a numbing agent in place of therapy for emotional, spiritual, and physical pain.

Appalachia’s alcohol addiction was neither dissimilar nor similar to alcoholism in more affluent areas; in some places, mostly “the city”, as people in the community would say, alcohol was a fun, social tool and sometimes liquid courage. People would have wine with dinner or very expensive scotch “three fingers, neat”, which sounded like it must have been another language, to me. When you’re poor, cheap alcohol is a numbing agent in place of therapy for emotional, spiritual, and physical pain. Even when you’re not poor, alcohol isn’t always glamorous. But, poverty disallows any sort of outside assistance in learning to cope, grieve, and grow. When one cannot afford health insurance or is on state-issued insurance, finding the time, energy, or motivation to attend therapy commonly as the first in the immediate family is truly a daunting task. In 2008, a study done by the Appalachian Regional Commission revealed six important components preventing Appalachian people from seeking treatment for alcohol addiction:

1. Stigma: something new is unfamiliar, and some community members take serious offense to a new solution to an age-old issue, despite the fact that the current solution is quite literally killing its addicts.
2. Transportation: recovery centers are rarely local, and if they are within a 30-minute drive, that would likely require a car in working condition that can make a trip to a neighboring city from a small town where Uber, Lyft, a bus route, and sometimes even taxis do not exist.
3. Payment options: In 2014, the per capita income of the Appalachian region of Kentucky was only $30,308, and the entire region as a whole was $37,260, while the entire US was at $46,049. Complete treatment for recovery can range from $25,000 to over $250,000 out-of-pocket if not covered by insurance. The Healthcare Cost, Coverage, and Access Index show Appalachian counties have, in the aggregate, more healthcare cost, coverage, and access disparities than their respective states’ or the United States’ average. For the health care payment and health care resources components of the HCCA, the average values for counties in the Appalachian Region are worse than all counties in the United States. Insurance coverage in the region is slightly better than the U.S. average; this is helped by high Medicare Disability enrollment and high Medicaid participation. Medicaid/Medicare is required to cover basic treatment for addiction, but is not widely accepted as a method of payment or insurance by many providers and is not required to pay lost wages, childcare, or other bills necessary for treatment.
4. Privacy issues: In small towns, word gets around, as they say. Treatment requires support, and in small towns, that can be difficult to find. Many times, if a treatment facility exists locally, employees are our friends, neighbors, and family members. Even though HIPPA exists, our small-town experiences can tell us that our news is unlikely to be kept secret.
5. Choice of facilities: Rurally, choices for most things are extremely limited. There may be two or three grocery stores, two gas stations, and possibly only one church. Therefore, choice of treatment facility would be limited or completely unlikely.
6. Cultural or family barriers: Because we have been taught to stay quiet about “family things”, revealing these concealed facts to anyone, including medical professionals or teachers, is frowned upon. Being honest so one can obtain treatment would require income replacement (73% of Kentucky Appalachia’s working adults ages 18–64 were employed, but income disparity shows a median income of $30,308–35% lower than the rest of the country, still supporting an average family of 2 adults, 2 children), a locally-available treatment facility, and support after treatment. Because generational addiction and alcoholism are common, support is extremely unlikely.

These statistics are recognized nationally as well. According to the National Institute for Health:

“Alcohol continues to be the most prevalent and widely used and abused substance among Appalachian adults (CDC, 2013). Sixty one percent of Appalachian adults reported alcohol use in the past year, and 20.6% reported heavy episodic drinking (Zhang et al., 2008). Although these rates are lower than those reported by adults nationally (61.0% vs. 70.2%), risky alcohol use has implications for a number of health outcomes and warrants further study. It also is reported to be the primary reason for seeking substance abuse treatment in the Appalachian region, surpassing drug abuse (CDC, 2013; Zhang et al., 2008).”

Credit: Author

Alcohol addiction in Appalachia can be summarized into two words: generational poverty. When one is poor and a dependency is created by previous generations, breaking that addiction is nearly impossible without professional help.

In the study mentioned above, participants noted the following list of factors contributing to substance abuse cited by members of Appalachian communities:

• Substance abuse can often be the result of self-medication for underlying factors such as depression, anxiety, and deeper psychological trauma, such as child abuse
• Geographical isolation (limited transportation, rurality) and distance from services
• Societal and cultural factors like stoicism, self-reliance or pride; Economic stressors like loss of community resources and scarcity of worthwhile employment
• The use of substances to escape from problems
• Intergenerational modeling of substance use behavior by parents engaging in the behavior, having a positive attitude towards the behavior, and/or allowing child substance use
• Societal factors including peer pressure, poor family values, expectations, and media marketing of prescription drugs as a “cure” all”
• The break-down of family and community values
• Boredom
• Limited recreational opportunities for youth
• Few positive adult role models

These reflect the statistics in the study referenced previously. Why do we have these specific issues when it comes to addiction that are seemingly isolated, in large part, to Appalachia? Something I didn’t consider and, judging from commentary from those who condemn addiction and alcoholism, alcohol can and does become a form of medication. Matt Salis wrote in Alcoholism isn’t about Drinking too Much; Alcoholism is about Pain:

“Alcoholism is about pain. It is about a failed attempt to medicate. It is about denying our reality and deceiving in order to hide from the truth. It is about the demise of love. It is the purest imaginable form of destruction.”

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Coping skills were not taught when I was a child, at home or in school. Seeing family members, as well as teachers and community leaders, subsist on whatever spirit strikes their fancies when stressful situations occurred, which was usually daily, showed community youth how to deal with problems: drown your sorrows in a bottle. Getting hammered on a regular basis on a weekday is not atypical in rural areas, especially when one lives in a small town with little else as entertainment. In 2008, 61% of Appalachian adults reported alcohol use in the last year, and 20.6% reported heavy, episodic alcohol use or binge drinking. The reporting of heavy alcohol use by adolescents was higher inside Appalachia (2.9%) than outside of Appalachia (2.5%).

From 2002–2005, roughly 5.9% Appalachian girls and boys ages 12+ felt they needed treatment for alcohol abuse, but did not receive it, compared to 5.8% of children nationwide. While these statistics are similar, there were 73.5 million children nationwide in 2005, but only 1.6 million children in Appalachia. 4,263,000 children in the rest of the entire country struggled with alcohol addiction, while nearly 100,000 children in the Appalachian region were grappling with their generational curse before many even learned to drive a car. This does not include other forms of addiction to which these children were possibly exposed, or the addictive tendencies these children had not yet experienced that came out later in life. Lacking positive role models certainly made a contribution to the delinquency, as well.

I grew up in a “dry county”, meaning alcohol could not be legally sold. However, just across the state line a mere twenty-minute drive, there were an abundance of drive-thru liquor marts. If that’s just too far, buying from a bootlegger (one who purchases alcohol and sells locally for an inflated price) or moonshine was also a possibility. What wasn’t readily available was therapy. Even if it had been, this debilitating form of self-medicating had “worked” for generations, hence the generational alcoholism and generational poverty, so why try something new?

Credit: Author

The stigma surrounding alcoholism, to fellow community members, is one engulfed first in denial, and then in condemnation. As long as the majority partakes, the addiction isn’t an issue. But, when one member commits any sort of indiscretion, hypocrisy abounds along with accusations, coming directly from a person’s own drinking buddies. The question of “why should we try something new?” is ever-present in the minds of many who still live in or have moved away from the Appalachian region. When those of us who have chosen therapy make the difficult decision to attend, we are often haunted by the displeased faces of our family members and ancestors who definitely think we’re “getting too big for our britches” by choosing to discontinue the generational poverty that raised us and self-medicating that comes with it. Despite the statistics showing that only half of Appalachian adults consumed alcohol in the last year, alcohol was not reported by the remaining 39% to have been replaced by a more functional coping skill.

Breaking the curse of generational poverty and addiction takes much more than sheer willpower: we need change, and support. Until we have readily-accessible mental health facilities as well as readily available access to education, nonjudgmental healthcare workers, an increase in wages for these poverty-stricken communities, and arguably most importantly — the ability to accept new coping techniques, these patterns will continue to repeat as we watch our parents, siblings, and family members succumb to their addiction and wonder if our own social drinking might lead us down the same path…which it will, undoubtedly, if we don’t seek change internally and have support to make that change. And, when I say internally, I’m referring to both our inner selves, and inside our communities.