This was one call for water-leak help that the next-door neighbors in Middletown, Ohio, could not ignore.

"The landlord arrived and found Pattie topless, stoned and unconscious on her living room couch. Upstairs the bathtub was overflowing -- hence, the leaking roof," noted J.D. Vance, in his "Hillbilly Elegy" memoir about the crisis in America's working class that shaped his family.

"Pattie had apparently drawn herself a bath, taken a few prescription painkillers and passed out. … This is the reality of our community. It's about a naked druggie destroying what little of value exists in her life."

Vance was in high school at the time and dramas of this kind kept creating a dark cloud over his life. Many of his questions had moral and religious overtones, especially among people with roots back to the Bible Belt culture of the Kentucky mountains.

"Why didn't our neighbor leave that abusive man?", wrote Vance. "Why did she spend her money on drugs? Why didn't she see that her behavior was destroying her daughter?" And ultimately, "Why were all of these things happening … to my mom?"

Economic woes played a part, he said, but the elegy of hillbilly life involves psychology, morality, culture, shattered communities and families that are broken, or that never formed in the first place. Yes, there are religious issues in that mix.

"It's a classic chicken and egg problem," said Vance, reached by telephone. "Which comes first, poverty and economic problems or people making bad moral decisions that wreck marriages and homes? Clearly people -- children especially -- are caught in a vicious cycle."

It's crucial that religious leaders face this crisis, rather than continuing to build their sanctuaries and schools in prosperous areas, he said. After all, problems that plague distressed urban and rural settings will reach many "safe" suburbs -- soon.

Anyone who knows Appalachia knows that some of these woes -- poverty, alcohol and others -- have been around for generations. But "conditions keep changing and making things worse," he said, such as the lose of industrial "Rust Belt" jobs, waves of new drugs and generations of young people who have never lived in a stable home, with their fathers under the same roof.

Vance's own life story is both typical and highly unusual. He grew up in what locals called "Middletucky," after his family left Jackson, Ken., in the heart of coal country. His mother was trained as a nurse, yet she struggled with drugs, at least five marriages and countless romantic partners.

Depending on how one defines family ties, Vance said he has about a dozen stepsiblings. In one searing biographical passage, he describes the seemingly endless series of households, addresses and relationships he experienced between third and ninth grade. Nothing was more destructive than the "revolving door" of father figures, he said.

Vance escaped, even graduating from Yale Law School, because of his grandparents and disciplines he learned in the U.S. Marines. His "Mamaw and Papaw" are heroes in this story, providing love, stability and a quirky sense of moral order.

Social workers, clergy and others who want to help those trapped in the underclass must focus on saving marriages and the extended-family ties that can protect children, he said. That will require face-to-face work with troubled people.

When his Mamaw moved north, he noted, her Bible stayed in her lap, she prayed constantly and she insisted that God had a plan. However, she never felt comfortable in local churches. Back in Jackson, church people knew who she really was, including the fact she almost killed a man when she was 12 and later lost nine children, in agonizing miscarriages. The fact that she cursed like a sailor and had a gun wasn't the whole story, back home.

In those hills, stressed Vance, his people were poor, but they retained a sense of identity linked to the towns, churches and schools they called home. For better or worse, they had big families and a real community.

"You simple have to have help," he said. "You can't do this alone. If it's just me and my mom and all her boyfriends, then I never would have made it out. … The single individual, or even one stressed-out nuclear family, is not enough. You have to see the bigger picture."