The%20American%20Indian/Alaska%20Native%20National%20Resource%20Center%20for%20Substance%20Abuse%20and%20Mental%20Health%20Services

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The American Indian/Alaska Native National
Resource Center for Substance Abuse and Mental
Health Services
Native Adolescent Suicide Cofactors Prevention
and Treatment Best Practices Rapid City, South
Dakota July 26-27, 2006
Dale Walker, MD Patricia Silk Walker, PhD
Douglas Bigelow, PhD
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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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Presentation Overview

• Behavioral Health and Education System Issues
• Fragmentation and Integration
• Discuss Suicide, Addiction, Comorbidity
• Integrated Care Approaches and Interagency
  Coordination are Best Overall Solutions

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Native Health/ Educational Problems

1. Alcoholism 6X
2. Tuberculosis 6X
3. Diabetes 3.5X
4. Accidents 3X
5. Suicide 1.7 to 4x
6. Health care access -3x
7. Poverty 3x
8. Poor educational achievement
9. Substandard housing

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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 Edn. B.H.

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

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Disconnect Between Education/Behavioral Health

• Professionals are undertrained in one of the two
  domains
• Students as patients are under diagnosed and
  under treated
• Students have less opportunity for education
• Neither system integrates well with medical,
  emergency, legal, and social services

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Difficulties of System Integration

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

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Barriers to Change

• Even when we know that a change is needed and
  its OK, getting there from here can be
  tricky--especially if existing funding mechanisms
  support the current practice.

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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.

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Our Native Community Issue

• For every suicide, at least six people are
  affected.4
• There are higher rates of suicide among survivors
  (e.g., family members and friends of a loved one
  who died by suicide).5
• Communities are closely linked to each other,
  increasing the risk of cluster suicide.
• 4 National Center for Health Statistics, 1999.
• 5 National Institute of Mental Health, 2003.

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Suicide Rates by Age, Race, and Gender 1999-2001
Source National Center for Health Statistics
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Native Suicide A Multi-factorial Event
Psychiatric Illness Stigma
-Edn,-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
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Current Cluster Suicide Crisis in a Tribal
Community

• 300 attempts in last 12 months
• 70 attempts since November
• 13 completions in 12 months
• 8 completions in 3 months
• 4 to 5 attempts per week
• Some attempts are adult
• Age range of completions 14-24 years of age
• Most completed suicides are female
• 80 Alcohol related
• All hanging

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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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An Ideal intervention

• Includes individual, family, community, tribe and
  society
• Comprehensive
• Universal
• Selective
• Indicated
• Treatment
• Maintenance

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Interventions

• To date slim data regarding evidence based
  suicide prevention
• More studies based on prevention instead of
  intervention
• Emphasis is placed on
• individual
• family/peer
• school/community
• society

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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
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Ecological Model
Individual
Peer/Family
Society
Community/Tribe
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Suicide Individual FactorsRisk Protective

• Mental illness
• Age/Sex
• Substance abuse
• Loss
• Previous suicide attempt
• Personality traits Incarceration
• Failure/academic problems

• 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

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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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Suicide Peer/Family FactorsRisk Protective

• History of interpersonal violence/abuse/
• Bullying
• Exposure to suicide
• No-longer married
• Barriers to health care/mental health care

• Family cohesion (youth)
• Sense of social support
• Interconnectedness
• Married/parent
• Access to comprehensive health care

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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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Suicide Community FactorsRisk
Protective

• Isolation/social withdrawal
• Barriers to health care and mental health care
• Stigma
• Exposure to suicide
• Unemployment

• Access to healthcare and mental health care
• Social support, close relationships, caring
  adults, participation and bond with school
• Respect for help-seeking behavior
• Skills to recognize and respond to signs of risk

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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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Suicide Societal FactorsRisk Protective

• Western
• Rural/Remote
• Cultural values and attitudes
• Stigma
• Media influence
• Alcohol misuse and abuse
• Social disintegration
• Economic instability

• Urban/Suburban
• Access to health care mental health care
• Cultural values affirming life
• Media influence

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Stress Management Suggestions

• Mental health professionals with child/family
  training
• Information, information, information
• Provide energy outlets for kids
• Provide parents with time away from kids
• Provide best possible sleep environment
• Therapeutic play (drawing, role play)

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Lifetime, Annual and 30 Day Prevalence of
Intoxication Among 224 Urban Indian Youth
R. Dale Walker, M.D. (4/99) 100 completion
sample
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Changes in Lifetime Substance Use Among Urban
Indian Youth Over Nine Years
Percentage ever used
Percentage ever used
R. Dale Walker, M.D. (4/99)

100 Completion
Sample
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Age of Onset of Substance Use Among Urban
American Indian Adolescents, by Substance Used
R. Dale Walker, M.D. (5/2000) Cohorts 4 5
were sampled every third year recall and
sampling bias apply
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Reasons for Use

• Momentary power
• Freedom
• Love
• Euphoria
• Peer acceptance
• Alleviate pain

• Boredom
• Self concept problems
• Loneliness
• Loss
• Nothingness
• Depression
• Shame

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How Teens View Counseling

• Witch Hunt
• Helpless
• Target
• Danger
• Waste of time

What to do

• Non - judgmental
• Honesty
• Consistency
• Confidentiality
• Always a ? of accuracy

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Evidence-Based Practices for Alcohol Treatment

• Brief intervention
• Social skills training
• Motivational enhancement
• Community reinforcement
• Behavioral contracting
• Miller et al., (1995) What works A
  methodological analysis of the alcohol treatment
  outcome literature. In R. K. Hester W. R.
  Miller (eds.) Handbook of Alcoholism Treatment
  Approaches Effective Alternatives. (2nd ed., pp
  12 44). Boston Allyn Bacon.

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Scientifically-Based Approaches to Addiction
Treatment

• Cognitivebehavioral interventions
• Community reinforcement
• Motivational enhancement therapy
• 12-step facilitation
• Contingency management
• Pharmacological therapies
• Systems treatment
• L. Onken (2002). Personal Communication.
  National Institute on Drug Abuse.
• Principles of Drug Addiction Treatment A
  research-based guide (1999). National Institute
  on Drug Abuse

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Prevention Programs Should . . . .
Target all Forms of Drug Use
. . .and be Culturally Sensitive
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Prevention Programs 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

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Prevention Programs Enhance Protective Factors

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

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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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WHAT ARE SOME PROMISING SCHOOL-BASED STRATEGIES?
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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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American Indian Life Skills Curriculum

• Build self-esteem
• Identify emotions and stress
• Increase communication, problem-solving skills
• Recognize and eliminate self-destructive
  behaviors
• Receive suicide information
• Receive suicide intervention training
• Set personal and community goals
• Curriculum three times a week for 30 weeks in a
  required language arts class

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Promising Strategies

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

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Recommendations

• Make information accessible
• Make resources/services more accessible
• Increased screening
• Target adolescents

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Partnered Collaboration

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
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Potential Organizational Partners

• Education
• Family Survivors
• Health/Public Health
• Mental Health
• Substance Abuse

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

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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