The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

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The American Indian/Alaska Native National
Resource Center for Substance Abuse and Mental
Health Services
A Strategy for Native Youth Mental Health
Treatment and Prevention Services and Programming
Dale Walker, MD Patricia Silk Walker, PhD
Douglas Bigelow, PhD Bentson McFarland, MD,
PhD, Michelle Singer Oregon Health and Science
University Tribal Justice and Safety Regional
Conference Mystic Lake, Minnesota March 26, 2007
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Native Communities
Advisory Council / Steering Committee
One Sky Center
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One Sky Center Partners
Tribal Colleges and Universities
Cook Inlet Tribal Council
Alaska Native Tribal Health Consortium
Prairielands ATTC
Red Road
Northwest Portland Area Indian Health Board
One Sky Center
Harvard Native Health Program
United American Indian Involvement
Jack Brown Adolescent Treatment Center
National Indian Youth Leadership Project
Tri-Ethnic Center for Prevention Research
Na'nizhoozhi Center
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One Sky Center Outreach
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Goals for Today

• An Environmental Scan
• Behavioral Health Care System Issues
• Fragmentation and Integration
• Discuss Mental Health and Comorbidity
• Indigenous Knowledge Evidence Based Knowledge
  Best Practice
• Integrated care approaches are best for treatment
  of these chronic illnesses

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Five Missions Impossible?

• How do we define problems?
• How do we ask for help?
• How do we get Federal and State agencies to work
  together and with us?
• How do we build our communities?
• How do we restore what is lost?

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Ten Leading Causes of Disability in the World

• Unipolar Depression
• Iron-deficiency Anemia
• Falls
• Alcohol Use
• COPD
• Bipolar disorder
• Congenital anomalies
• Osteoarthritis
• Schizophrenia
• Obsessive-compulsive disorder

• 10.7
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2

(WHO, 1997)
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Juvenile Justice Mental Disorder Rates
 
Chicago Detention Center (Teplin,2002)
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Most Common Disabilities Among Youth in the JJ
System

• Learning Disabilities
• Post Traumatic Stress Disorder (higher in girls)
  
• Conduct Disorder
• Oppositional Defiant Disorder
• Depression
• Anxiety Disorders
• Substance Use/Abuse Disorders
• Developmental Disabilities

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Mental Health Needs Across Juvenile Justice
Placements

•    A study compared mental health needs among a
  random sample of youth (n473) within the
  juvenile justice system found mental health
  problems in
• 45.9 of youth on probation,
• 67.5 youth incarcerated, and
• 88 youth adjudicated to residential treatment
  centers

(Lyons, Quigley, Erlich Griffin, 2001)
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Native Health Problems

1. Alcoholism 6X
2. Tuberculosis 6X
3. Diabetes 3.5 X
4. Accidents 3X
5. 60 Over 65 live in poverty
   (US 27)
6. Depression 3x
7. Violence?

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American Indians

• Have same disorders as general population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated

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Agencies Involved in B.H. Delivery

• 1. Indian Health Service (IHS)
• A. Mental Health
• B. Primary Health
• C. Alcoholism / Substance Abuse
• 2. Bureau of Indian Affairs (BIA)
• A. Education
• B. Vocational
• C. Social Services
• D. Police
• 3. Tribal Health
• 4. Urban Indian Health
• State and Local Agencies
• Federal Agencies SAMHSA, VAMC, Justice

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Disconnect Between Justice/Addictions/Mental
Health

• Professionals are undertrained
• Patients are underdiagnosed
• Patients are undertreated
• None integrates well with medical and social
  services

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Difficulties of Program Integration

• Separate funding streams and coverage gaps
• Agency turf issues
• Different treatment philosophies
• Different training philosophies
• Lack of resources
• Poor cross training
• Consumer and family barriers

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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning? (Carl Bell, 7/03)
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Best Practice
Culturally Specific
Outcome Driven
Integrating Resources
We need Synergy and an Integrated System (Carl
Bell, 7/03)
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Suicide Among ages 15-17, 2001
Death rate per 100,000
2010 Target
Females
Males
Total
American Indian
White
Black
Hispanic
Asian
Source National Vital Statistics System -
Mortality, NCHS, CDC.
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Suicide A Native Crisis
Source National Center for Health Statistics
2001
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SUICIDE A MULTI-FACTORIAL EVENT
Psychiatric IllnessCo-morbidity
Neurobiology
Personality Disorder/Traits
Impulsiveness
Substance Use/Abuse
Hopelessness
Severe Medical Illness
Suicide
Family History
Access To Weapons
Psychodynamics/ Psychological Vulnerability
Life Stressors
Suicidal Behavior
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Adolescent Problems In Schools
1. School Admin 2. Law 3. FBI 4. DEA 5. State
MH 6. State AD 7. Courts 8. Child Services
Alcohol Drug Use
Fighting and Gangs
Bullying
Weapon Carrying
School Environment
Sale of Alcohol and Drugs
Sexual Abuse
Unruly Students
Truancy
Attacks on Teachers Staff
Domestic Violence
Drop Outs
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Key Adolescent Risk Factors
Aggressive/Impulsive
Depression
Substance Abuse
Trauma
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Comorbidity Defined

• Individuals who have at least one mental
  disorder as well as an alcohol or drug use
  disorder. While these disorders may interact
  differently in any one person.at least one
  disorder of each type can be diagnosed
  independently of the other.
• - Report to Congress of the Prevention and
  Treatment of Co-Occurring Substance Abuser
  Disorders and Mental Disorders, SAMHSA, 2002

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Lifetime History
Mental Disorder 22.5 Comorbidity 29
Alcohol Disorder 13.5 Comorbidity 45
Drug Disorder 6.1 Comorbidity 72
Regier, 1990
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Lifetime Psychiatric DiagnosesAmong Primary
Caretakers (N207)
R. Dale Walker, M.D. (7/97)
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Multiple Diagnoses Increase

• Treatment seeking
• Use of services
• Likelihood of no services
• Treatment costs
• Poor outcome
• Suicide risk
• Dual diagnosis is an expectation, not an
  exception

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The Intervention Spectrum for Behavioral
Disorders
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Source Mrazek, P.J. and Haggerty, R.J. (eds.),
Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC National Academy
Press, 1994.
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Spectrum of Intervention Responses
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
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Ecological Model
Individual
Peer/Family
Society
Community/ Tribe
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Environmental
Interpersonal societal
Stigma
Community
Tribal attitudes
Parents
Peers
National attitudes
Personality
Attitudes beliefs
Individual
Genetics
Cultural beliefs
Schools
Local legal
Interpersonal
State attitudes
Personal situations
Individual
Portrayal in media
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Individual Intervention

• Identify risk and protective factors
• counseling
• skill building
• improve coping
• support groups
• Increase community awareness
• Access to hotlines other help resources

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Effective Family Intervention Strategies
Critical Role of Families

• Parent training
• Family skills training
• Family in-home support
• Family therapy
• Different types of family interventions are used
  to modify different risk and protective factors.

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Implications for Treatment

• Teach adolescents how to cope with difficulties
  and adversity
• Increase their repertoire of coping strategies
• Cognitive therapy is most effective approach

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Behavioral Health Programs Should . . . . Reduce
Risk Factors

• ineffective parenting
• chaotic home environment
• lack of mutual attachments/nurturing
• inappropriate behavior in the classroom
• failure in school performance
• poor social coping skills
• affiliations with deviant peers
• perceptions of approval of drug-using behaviors
  in the school, peer, and community environments

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Behavioral Health Programs Should . . . . Enhance
Protective Factors

• strong family bonds
• parental monitoring
• parental involvement
• success in school performance
• prosocial institutions (e.g. such as family,
• school, religious, and tribal organizations)
• conventional norms about
• drug use

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Sources of Strength
Family Support
Access to Mental Health
Positive Friends
Access to Medical
Caring Adults
Spirituality
Positive Activities
Generosity/Leadership
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Effective Interventions for Adults

• Cognitive/Behavioral Approaches
• Motivational Interventions
• Psychopharmacological Interventions
• Modified Therapeutic Communities
• Assertive Community Treatment
• Vocational Services
• Dual Recovery/Self-Help Programs
• Consumer Involvement
• Therapeutic Relationships

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Effective Interventions for Youth

• Family Therapy
• Multisystemic Therapy
• Case Management
• Therapeutic Communities
• Community Reinforcement
• Circles of Care
• Motivational Enhancement

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Treatment Settings - Social Support A Native
Advantage

• Tribal
• Community
• Family
• Sibs
• Peers
• Individual

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Cultural Approach

• Original Holistic Approach
• Psychopharmacology Approach
• The unconscious has always been there
• Group Therapy
• Network Therapy
• Recreational / Outdoors
• Traditional Interventions
• Indian is...

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Possible Treatment/Prevention Activities

• The Talking Circle
• Smudging
• Story telling
• Traditional Healers
• Medicine Person
• Herbal remedies
• Traditional ceremonies
• Sweat Lodge
• Traditional Experiences Preservation

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Indigenous Knowledge
Definitions

• Is local knowledge unique to a given culture or
  society it has its own theory, philosophy,
  scientific and logical validity, which is used as
  a basis for decision-making for all of lifes
  needs.

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Traditional Medicine
Definitions

• The sum total of health knowledge, skills and
  practices based upon theories, beliefs and
  experiences indigenous to different culturesused
  in the maintenance of health.
• WHO 2002

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Evidence-based Practices
Definitions

• Interventions that show consistent scientific
  evidence of improving a persons outcome of
  treatment and/or prevention in controlled
  settings.
• SAMHSA 2003

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Best Practices
Definitions

• Examples and cases that illustrate the use of
  community knowledge and science in developing
  cost effective and sustainable survival
  strategies to overcome a chronic illness.
• WHO 2002

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ID Best Practice
Best Practice
Clinical/services Research
Mainstream Practice
Traditional Healing
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Circle of Care
Traditional Healers
Child Adolescent Programs
Primary Care
Best Practices
AD Programs
Boarding Schools
Colleges Universities
Prevention Programs
Emergency Rooms
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What Is Integrative Medicine?
Wellness
Basic Science
CAM literacy
Patient Centered Care
Evidence Based Medicine
Cultural Sensitivity
Power Of the Mind
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Principles of Integrative Medicine

• It is better to prevent than to treat later.
• Recognition of the interaction between body,
  mind, spirit, and environment.
• Integrate the best of conventional and
  traditional medicine.
• Belief that bodies respond uniquely, so treatment
  must be customized.
• Belief in innate healing powers of the body.

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WHAT ARE SOME PROMISING STRATEGIES?
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Promising Strategies

• Home visitation
• Parent training
• Mentoring
• Heroes
• Social cognitive
• Cultural

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Integrated Treatment

• Premise treatment at a single site, featuring
  coordination of treatment philosophy, services
  and timing of intervention will be more effective
  than a mix of discrete and loosely coordinated
  services
• Findings
• decrease in hospitalization
• lessening of psychiatric and substance abuse
  severity
• better engagement and retention
• (Rosenthal et al,
  1992, 1995, 1997 Hellerstein et al 1995.)

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Comprehensive school planning

• Prevention and behavioral health
  programs/services on site
• Handling behavioral health crises
• Responding appropriately and effectively after an
  event occurs

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Community Driven/School Based Prevention
Interventions

• Public awareness and media campaigns
• Youth Development Services
• Social Interaction Skills Training Approaches
• Mentoring Programs
• Tutoring Programs
• Rites of Passage Programs

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Unified Services Plan

• Mental health
• Education/vocation
• Justice/safety
• Leisure/social
• Parenting/family
• Housing
• Financial
• Daily living skills
• Physical health

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Potential Organizational Partners

• Education
• Family Survivors
• Health/Public Health
• Mental Health
• Substance Abuse
• Traditional Healers
• Elders

• Law Enforcement
• Juvenile Justice
• Medical Examiner
• Faith-Based
• County, State, and Federal Agencies
• Girls/Boys Clubs

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Partnered Collaboration
State/Federal

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
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Recommendations

• Develop interagency task forces
• Bring in supportive/interested state partners
• Reach out to bring in new resources
• Be clear, positive, and direct
• Remember what this effort is all about

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Evidence-based coordinationlinkage mechanisms

• formal agreements among behavioral health,
  primary health care providers and justice
• case management of behavioral health, justice,
  and primary health care
• co-location of behavioral health, and primary
  health care services
• delivery of mental, substance-use, and primary
  health care through clinically integrated
  practices of primary and M/SU care providers.

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Making It Work for Youth and Families Involved
in Juvenile Justice

• Engage All Leaders on all Decisions
• Know the decision points in the JJ System 
• At point of arrest/earliest point to
  divert
• At point where decisions to charge are
  made/diversion
• At intake to juvenile court/diversion
• Make information accessible
• Make resources/services more accessible
• Increased screening
• Target adolescents

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Contact us at 503-494-3703 E-mail Dale Walker,
MD onesky_at_ohsu.edu Or visit our
website www.oneskycenter.org