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The American IndianAlaska Native National Resource Center for Substance Abuse and Mental Health Serv

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Title: The American IndianAlaska Native National Resource Center for Substance Abuse and Mental Health Serv


1
The American Indian/Alaska Native National
Resource Center for Substance Abuse and Mental
Health Services
Suicide Prevention for American Indian and Alaska
Native Communities
Dale Walker, MD Laura Loudon, MS Patricia
Silk Walker, PhD Doug Bigelow, PhD Michelle
Singer Oregon Health and Science University
Sioux Falls, South Dakota July 31, 2007
2
Native Communities
Advisory Council / Steering Committee
One Sky Center
3
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
4
One Sky Center Outreach
5
Goals for Today
  • Background The environment and the system of
    care
  • The problem
  • Contributing factors
  • Warning signs
  • Prevention strategies
  • Promising programs
  • Integrated care approaches are best for treatment
    of these chronic illnesses

6
Indian Country 1491
7
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8
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9
Most Common Emotional Disabilities Among Native
Youth
  • Learning Disabilities
  • Post Traumatic Stress Disorder
  • Conduct Disorder
  • Oppositional Defiant Disorder
  • Depression Disorders
  • Anxiety Disorders
  • Substance Use/Abuse Disorders
  • Developmental Disabilities

10
Six behaviors that contribute to serious health
problems
  • Tobacco use
  • Poor nutrition
  • Alcohol and other drug abuse
  • Behaviors resulting in intentional or
    unintentional injury
  • Physical inactivity
  • Risky sex

11
Native Health Problems
  • Alcoholism 6X
  • Tuberculosis 6X
  • Diabetes 3.5 X
  • Accidents 3X
  • Poverty 3x
  • Depression 3x
  • Suicide 2x
  • Violence?

12
American Indians
  • Have same disorders as general population
  • Greater prevalence
  • Greater severity
  • Much less access to Tx
  • Cultural relevance more challenging
  • Social context disintegrated

13
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

14
A Quiet Crisis Federal Funding and Unmet Needs
in Indian Country, July 2003
  • Funding not sufficient to meet needs for
  • Health care
  • Education
  • Public safety
  • Housing
  • Infrastructure development needed

U .S. Commission on Civil Rights
15
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

16
Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning? (Carl Bell, 7/03)
17
Best Practice
Culturally Specific
Outcome Driven
Integrating Resources
We need Synergy and an Integrated System (Carl
Bell, 7/03)
18
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19
Suicide A National Crisis
  • In the United States, more than 30,000 people die
    by suicide a year.1
  • Ninety percent of people who die by suicide have
    a diagnosable mental illness and/or substance
    abuse disorder.2
  • The annual cost of untreated mental illness is
    100 billion.3
  • 1 The Presidents New Freedom Commission on
    Mental Health, 2003.
  • 2 National Center for Health Statistics, 2004.
  • 3 Bazelon Center for Mental Health Law, 1999.

20
CDC
Suicide Rate 1981-1998
                                      Suicide
Rate per 100,000 Population19811998
21
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.
22
Suicide A Native Crisis
Source National Center for Health Statistics
2001
23
Age-Adjusted Suicide Death RatesCY 1996-1998
U.S. All Races (1997) 10.6
IHS Adjusted Total - All Areas 20.2
24
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25
North Dakota Teen Suicide Rates
(2000-2004 rate per 100,000 teens 13-19 years old)
26
Disaster Defined
  • FEMA A natural or man-made event that
    negatively affects life, property, livelihood or
    industry often resulting in permanent changes to
    human societies, ecosystems and environment.
  • NHTSA Any occurrence that causes damage,
    ecological destruction, loss of human lives, or
    deterioration of health and health services on a
    scale sufficient to warrant an extraordinary
    response from outside the affected community
    area.
  • NOAA A crisis event that surpasses the ability
    of an individual, community, or society to
    control or recover from its consequences.

27
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28
Contents
Background information Contributing
factors Suicide warning signs Prevention
strategies Information for schools Promising
programs Garrett Lee Smith Programs Consultation
and Technical assistance Consultants Community
Suicide Assessment Tool Practice guidelines and
evidence-based practices Resources
29
Suicide A Multi-factorial Event
Psychiatric Illness Stigma
Edu., Econ., Rec.
Cultural Distress
Impulsiveness
Substance Use/Abuse
Hopelessness
Family Disruption/ Domestic Violence
Suicide
Family History
Negative Boarding School
Psychodynamics/ Psychological Vulnerability
Historical Trauma
Suicidal Behavior
30
"The tribe is always hopeful we have a solution,
but the problem with intervention is that it
comes up on the backside of a suicide usually
after the fact. Tribes need to find out what is
leading tribal people and the youth to suicide.
They need to look at what is causing the
despair."
- Ron His Horse Is Thunder, Standing Rock Sioux
31
Domains Influencing Suicidal Behavior A Native
Ecological Model
32
Interacting Spheres of Influence
33
Interpersonal societal
Stigma
Environmental
Tribal attitudes
Community
Parents
Peers
National attitudes
Personality
Genetics
Individual
Attitudes beliefs
Local legal
Cultural beliefs
Interpersonal
Schools
State attitudes
Personal situations
Individual
Portrayal in media
34
Risk and Protective Factors Individual
  • Risk
  • Mental illness
  • Age/gender
  • Substance abuse
  • Loss
  • Previous suicide attempt
  • Personality traits
  • Incarceration
  • Failure/academic problems
  • Protective
  • Cultural/religious beliefs
  • Coping/problem solving skills
  • Ongoing health and mental health care
  • Resiliency, self esteem, direction, mission,
    determination, perseverance, optimism, empathy
  • Intellectual competence, reasons for living

35
Risk and Protective Factors Peer/Family
  • Risk
  • History of interpersonal violence/abuse/
  • Bullying
  • Exposure to suicide
  • No-longer married
  • Barriers to health care/mental health care
  • Protective
  • Family cohesion
  • Sense of social support
  • Interconnectedness
  • Married/parent
  • Access to comprehensive health care

36
Risk and Protective Factors Community/Tribal
  • Protective
  • Access to health care
  • Social support, close relationships, caring
    adults, school participation and bond
  • Respect for help-seeking
  • Skills to recognize and respond to risk
  • Traditional and cultural activities
  •  
  • Risk
  • Isolation/social withdrawal
  • Barriers to health care and mental health care
  • Stigma
  • Exposure to suicide
  • Unemployment
  • Poverty
  •  

37
Risk and Protective Factors Societal
  • Risk
  • Rural/Remote
  • Loss or conflict of cultural values and attitudes
  • Stigma, racism
  • Media influence
  • Alcohol/drug misuse/abuse
  • Social disintegration
  • Economic instability
  •  
  • Protective
  • Urban/Suburban
  • Access to health care and mental health care
  • Cultural values affirming life
  • Media influence
  •  

38
Suicide Warning Signs
  • Changes in behavior
  • Acute stressful situations violence, death,
    trouble with law, relationships ending
  • Chronic stressful situations abuse, illness,
    family conflict
  • Changes in classroom performance academic,
    behavioral
  • Changes at home moving, parental conflict
  • Changes with peers withdrawal, personality
    changes

 
 
39
The Intervention Spectrum for Behavioral
Disorders
Treatment
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K
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Indicated Diagnosed Youth
D
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s
o
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d
e
r
s
Prevention
Maintenance
C
o
m
p
l
i
a
n
c
e
Selective Health Risk Groups
w
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h

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Universal General Population
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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.
40
Spectrum of Intervention Responses
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
41
Individual Intervention
  • Identify risk and protective factors
  • counseling
  • skill building
  • improve coping
  • support groups
  • Increase community awareness
  • Access to hotlines other help resources

42
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.
43
Implications for Treatment
  • Teach adolescents how to cope with difficulties
    and adversity
  • Increase their repertoire of coping strategies
  • Cognitive therapy is most effective approach

44
Sources of Strength
Family Support
Access to Mental Health
Positive Friends
Access to Medical
Caring Adults
Spirituality
Positive Activities
Generosity/Leadership
45
Treatment Settings - Social Support A Native
Advantage
  • Tribal
  • Community
  • Family
  • Siblings
  • Peers
  • Individual

46
Cultural Approach
  • Original Holistic Approach
  • Psychopharmacology Approach
  • The unconscious has always been there
  • Group Therapy
  • Network Therapy
  • Recreational / Outdoors
  • Traditional Interventions
  • Indian is...

47
Possible Treatment/Prevention Activities
  • The Talking Circle
  • Smudging
  • Story telling
  • Traditional Healers
  • Medicine Person
  • Herbal remedies
  • Traditional ceremonies
  • Sweat Lodge
  • Traditional Experiences Preservation

48
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

49
Effective Interventions for Youth
  • Family Therapy
  • Multisystemic Therapy
  • Case Management
  • Therapeutic Communities
  • Community Reinforcement
  • Circles of Care
  • Motivational Enhancement

50
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

51
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

52
What are some promising strategies?
53
Promising Practices for Suicide Prevention
  • ASIST
  • C-CARE/CAST
  • Columbia University Teen Screen
  • Means Reduction
  • Lifelines
  • Reconnecting Youth
  • ER intervention for attempters
  • Signs of Suicide
  • US Air Force program
  • Yellow Ribbon Suicide Prevention
  • American Indian Life Skills

http//www.sprc.org/featured_resources/ebpp/ebpp_f
actsheets.asp
54
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.)

55
BIA Schools
  • 184 elementary and secondary schools and
    dormitories (55) as well as 27 colleges
  • In 23 states
  • 60,000 total students
  • 238 different tribes
  • Majority of the schools are located in Arizona
    and New Mexico
  • Second greatest number of schools in the states
    of North Dakota and South Dakota
  • Third greatest lie in the northwest

56
Why should schools be involved?
  • Schools cannot achieve their mission of education
    when students problems are barriers to learning
    and development. From Carnegie Task Force on
    Education.
  • Schools are at times a source of the problem and
    need to take steps to minimize factors that lead
    to student alienation and despair.
  • Schools also are in a unique position to promote
    healthy development and protective buffers, offer
    risk prevention programs, and help to identify
    and guide students in need of special assistance.

57
Adolescent Problems In Schools
Alcohol Drug Use
Fighting and Gangs
1. School Admin 2. Law 3. FBI 4. DEA 5. State
MH 6. State AD 7. Courts 8. Child Services
Bullying
Weapon Carrying
School Environment
Sale of Alcohol and Drugs
Sexual Abuse
Unruly Students
Truancy
Attacks on Teachers Staff
Domestic Violence
Drop Outs
12
58
Comprehensive school planning
  • Prevention and behavioral health
    programs/services on site
  • Handling behavioral health crises
  • Responding appropriately and effectively after an
    event occurs

59
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

60
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61
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

62
Partnered Collaboration
State/Federal

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
63
Coordination Strategies
  • Formal agreements among behavioral health,
    primary health, schools, and justice
  • Case management of behavioral health, justice,
    and primary health care
  • Co-location of behavioral health, and primary
    health care services, access to school sites
  • Delivery of mental, substance-use, and primary
    health care through clinically integrated
    practices of primary care providers.

64
Tribal Crisis Intervention Team
  • Tribal Council
  • Tribal Health Department
  • Community Health Representative
  • Indian Health Service
  • Behavioral Health Department
  • Emergency Room (a physician and nurse)
  • Ambulance team
  • Police Department
  • Fire Department
  • Middle and High School (Administrator, teacher,
    counselor)
  • Spiritual leaders
  • Alcohol and Drug Abuse Prevention programs
  • Youth Centers or other Youth programs
  • Peer Counselors
  • Parents known and trusted by the young people

65
Tribal leaders unveil new meth Initiative
Indian Country Today  
NCAI President, Joe Garcia Anchorage, Alaska
June 15, 2007
66
Contact us at 503-494-3703 E-mail Dale Walker,
MD onesky_at_ohsu.edu Or visit our
website www.oneskycenter.org
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