American Indian and Alaska Native Best Practices in Behavioral Health IHS/SAMHSA National Behavioral Health Conference Billings, Montana, August 22, 2008 - PowerPoint PPT Presentation


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American Indian and Alaska Native Best Practices in Behavioral Health IHS/SAMHSA National Behavioral Health Conference Billings, Montana, August 22, 2008


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Title: American Indian and Alaska Native Best Practices in Behavioral Health IHS/SAMHSA National Behavioral Health Conference Billings, Montana, August 22, 2008

American Indian and Alaska Native Best Practices
in Behavioral HealthIHS/SAMHSA National
Behavioral Health ConferenceBillings, Montana,
August 22, 2008
  • Paulette Running Wolf, PhD, (Blackfeet)
  • Secretary Treasurer
  • Founding Executive Director
  • First Nations Behavioral Health Association

Recent Meeting
  • The Center for Mental Health Services (CMHS),
    SAMHSA, and FNBHA sponsored an expert panel
    meeting, May 3-4, 2008, in Portland Oregon.
  • The panel included American Indian/Alaska Native
    researchers, providers, and family advocates
  • Discussions included rural reservation, urban
    Indian, and Alaska Native perspectives
  • Recommendations from the meeting are to be
    disseminated in several venues

Purpose of the meeting
  • CMHS seeks to reduce disparities in the
    behavioral health system of care available to
    American Indian and Alaska Native (AI/AN)
    communities by
  • increasing knowledge about mental health issues
    among AI/AN communities and,
  • increasing the effectiveness of those services by
    reducing cultural barriers

Expert Panel Meeting Agenda
  • To identify culture based engagement strategies
  • Barrier reduction
  • Service utilization
  • Service arrays
  • Sustainability partnerships
  • Implementation strategies for dissemination of
    tribal behavioral health best practices,
    including website updates.

Expert Panel Participants
  • Shannon Crossbear, (Ojibwe)
  • Holly Echohawk, (Pawnee)
  • Jill Shepard Erickson, (Dakota/Athabaskan)
  • Joseph P. Gone,
  • (Gros Ventre)
  • Jeff King,
  • (Muscogee Creek)
  • Jackie Mercer,
  • (NARA NW)
  • Deb Painte, (Arikira)
  • Alan Rabideau, (Ojibwe)
  • Catherine Reimer, (Inupiaq)
  • Paulette Running Wolf, (Blackfeet)
  • Pam Thurman, (Cherokee)

Participants set the stage by personalizing the
  • The system can be disrespectful to families
    (e.g., black-out period on entering treatment)
  • Some tribes are still recapturing traditions to
    increase self esteem and positive identity.
  • Ceremonies can teach self discipline to children.
  • There is no consistent standard for suicide

Personalized need continued
  • Storytelling and participation in crafts can be
    important to establishing trust with families, as
    opposed to 50 minute office visits.
  • Cultural identity also involves identification
    with the land and subsistence activities, i.e.,
    fish camps in Alaska.
  • Indian Country has potentially explosive issues
    around blood quantum, color, and levels of
  • The Medicaid billing code for targeted case
    management supports home based wraparound, and is
    consistent with tribal values.

Personalized need continued
  • CMHS funded Circles of Care and Systems of Care
    (SOC) grants with tribes have revealed a common
    value that children are sacred.
  • Urban Indian youth may hide their cultural
    identity for safety if surrounded by a gang
  • Tribal sovereignty must be a recognized component
    for all research initiatives.
  • Current epidemic rates of suicide in Indian
    Country have promoted federal (CMHS/SAMHSA)
    recognition support for the integration of
    culture based traditional healing practices with
    western treatment.

Presentation Joseph Gone, PhD,
  • Title Mental Health Services for Native
    Americans in the 21st Century United States,
    2004, (Journal Professional Psychology
    Research Practice)
  • Legal, political and institutional contexts for
    mental health services for tribal people and
    their communities, and
  • The possibility for neo-colonial subversion of
    indigenous thought and practice.
  • Are we only dressing up conventional therapy in
    beads and feathers?

Dr. Gone Continued
  • There are currently two divergent movements in
    the field emphasizing evidence based practices
    (EBP) and culturally specific treatments (CST).
  • At worst, mainstream treatment may assimilate you
    into a quasi-healthy white person.
  • Establishing an EBP requires randomized clinical
    trials, difficult in small population/culturally
    diverse tribal communities.
  • The Native American Research Centers for Health
    (NARCH) are health research grants co-sponsored
    by IHS and NIH.
  • Native community psychology involves
    ethno-psychological analysis, attention to
    narrative, and facilitation of empowerment.

  • Mainstream psychology involves talk therapy,
    putting feelings into words
  • Tribal ceremonies often do not emphasize verbal
    self-expression, and there are ethical issues
    around taking ceremonies and using them
  • Rigorous studies of medicine men and their
    practices may not be possible, but communities
    have their own way of validation.

Discussion Continued
  • Panelists stated that it is not so much the
    actual practice but the healing and community
  • The unique goal of tribal behavioral health
    services is to preserve the essence of cultural
    strengths while strengthening the tribal persons
    ability to respond to changing external factors.

Evidence Based Practices and Tribal Alternatives
  • SAMHSA maintains a National Registry of
    Evidence-Based Programs and Practices, (NREPP) to
    treat substance abuse or mental health disorders,
    with 3 minimum requirements
  • One or more positive outcomes
  • Published in a peer reviewed journal
  • Documentation of the intervention and
    implementation in manuals, tool kits, etc.

Priority Points for NREPP approval
  • Primary targeted outcome fits SAMHSAs current
    priority areas.
  • Evaluated using a quasi-experimental or
    experimental study design
  • Pre/post design with comparison or control group,
  • Longitudinal/time series design with three
    pre-intervention or baseline measures and three
    post-intervention or follow up measures

Two tribal programs in NREPP
  • American Indian Life Skills Development, Zuni
    Pueblo, New Mexico. A school based suicide
    prevention initiative designed by Teresa
  • LaFromboise, Ph.D., (Miami).
  • Project Venture, an outdoor experiential youth
    development program originated in the Navajo
    Nation by McClellan Hall, M.Ed., (Cherokee)
  • Both programs have been replicated widely in
    tribal and other settings.

  • Panelists indicated that the fidelity measures
    required for EBP administration often prohibit
    cultural adaptations.
  • The historical trauma issues often vocalized by
    tribal communities refers to forced assimilation
    from generations of boarding school experiences
    outlawing indigenous languages, and culture which
    followed the years of warfare and moves to
    reservations, often manifested in violent
    behaviors today.

EBP Discussion
  • Panelists agreed that culture can not just be
    added to EBPs, and that treatment as usual
    harbors the potential to hurt, not help tribal
  • Traditional practices vary widely, are specific
    to tribal cultures, and would be devalued if
    subjected to evaluation, measurement, and used by
    persons of a different culture. (Some pan-Indian
    ceremonies have been replicated and exploited by
    non-Indian populations).

Practice Based Evidence (PBE)
  • Community accepted healing approaches
  • Evaluation of the PBE certification of the
    provider is provided by the community!
  • Western-based mental health practices must be
    integrated into the culture (PBE) rather than the
    reverse (adding culture to the EBP).

Modern cultural issues
  • Youth gang cultures, pop culture, and
    technology/You Tube/My Space etc.
  • Social issues resulting from casinos gaming
  • FAS/FAE youth with impulse control legal issues
  • Dramatic increase misuse of prescription drugs
  • New populations of veterans with potential for
    PTSD impacting family relationships
  • Racism and violence a reality in rural
    reservation communities

Barrier reduction strategies
  • Workforce training, of tribal members with
    expertise in both mental health and cultural
    nuances specific to the community, involving
    tribal colleges and universities.
  • Expand and support community-based counselor
    training programs (e.g., UAFs Village Based
    Counselor training program).
  • Scheduled clinical supervision and cultural
    consultation agreements between paraprofessional
    and licensed staff, possibly with telemedicine
    for remote locations.

Barrier reduction strategies (continued)
  • Honor family choice for support system,
    spiritual, extended family, tribal, IHS, or
    mainstream programs and churches for increased
  • Staff training to emphasize strength-based
    assessments treatment planning inclusion of
    cultural supports.
  • Multidisciplinary family led treatment planning,
    with strict HIPPA compliance.

Culture-Based Engagement Strategies
  • Consultation on the local protocols for
    approaching elders for cultural and spiritual
  • Due to boarding schools and relocation policies,
    urban families and some reservation families may
    be re-learning and building cultural identity and
  • Circles of Care grantees redefined Serious
    Emotional Disturbance (SED), to a local
    definition of a well child, based on tribal
  • Lakota and Athabascan assessment scales have been
    developed during System of Care (SOC) projects.

Culture-based Engagement Strategies (cont.)
  • Urban programs some acculturated tribal
    communities are recreating traditional ceremonies
    practices - helping youth families to learn
    tribal history, language culture.
  • Re-introduce tribal rites of passage ceremonies
    to reduce teen pregnancies and support sobriety.
  • 12 Step programs encourage spiritual education
  • Equine therapy fits well with tribal culture.
  • Many tribes are using their own resources for
    cultural immersion programs, i.e., fish camps in

FNBHA Mission
  • First Nations Behavioral Health Association
    (FNBHA) was established in September 2003 to
    provide an organization for Native Americans to
    advocate for the mental well being of Native
    Peoples by increasing the knowledge and awareness
    of issues impacting Native mental health

Objectives of FNBHA
  • To promote and support development of policies,
    programs, and initiatives that educate and
    address the needs of tribal consumers, families,
    communities, and service providers,
  • To promote and support research for improving
    American Indian and Alaska Native behavioral
    health services,
  • To promote and support quality, comprehensive and
    effective services for tribal communities,
  • To provide awareness and input to mental health
    and substance abuse commissioners, governors,
    legislators, Board, communities, consumers and
    families regarding system needs, and
  • To provide other forms of technical assistance
    regarding the Association mission as may be
    indicated by the Board of Directors and/or

  • The purpose of FNBHA is to provide national
    leadership to all groups, institutions and
    individuals that plan, provide and access Native
    American behavioral health services
  • Initial funding was provided by the Center for
    Mental Health Services, SAMHSA, and Indian Health

FNBHA Effective Practices, 2005
  • Nanizhoozhi Center, Inc.
  • Rural Human Service Program, (UAF)
  • Sacred Child Program,
  • (SOC, ND tribes)
  • Sault Ste. Marie Tribe,
  • (SOC program)
  • Wakanyeja Pawicayapi, Inc, (SOC program, Oglala
    Sioux Tribe)
  • American Indian Life Skills Program
  • Project Venture
  • Positive Indian Parenting, (NICWA)
  • Community Readiness Scale, Tri-Ethnic Center
  • Gathering of Nations (GONA)

Past Initiatives of FNBHA
  • 2003 Foundational Think Tank, 32 providers,
    researchers, students, family representatives,
    representatives of IHS and SAMHSA.
  • 2005 Joint meeting with National Alliance of
    Multi-Ethnic Behavioral Health Associations, to
    identify culturally respectful practices.
  • www.fnbha website established.
  • 2006 Subcontract with Suicide Prevention
    Research Center.

Current Board of Directors
  • President Jeff King, PhD, (Muscogee Creek)
  • Vice President Pam Thurman, PhD, (Cherokee)
  • Secretary Treasurer and Founding Executive
    Director Paulette Running Wolf, PhD,
  • Public Information Officer Holly Echohawk, MS,
  • Family Representative Shannon Cross Bear
  • Founding President Dale Walker, MD, (Cherokee)
  • Dolores Subia Bigfoot, PhD, (Caddo)
  • Candace Fleming, PhD, (Kickapoo/Oneida/Cherokee)
  • Joseph P. Gone, PhD, (Gros Ventre)
  • Ethleen Iron Cloud-Two Dogs, MS, (Oglala Lakota)
  • Carolyn Thomas Morris, PhD, (Dine)
  • Deborah Painte, MPA, (Arikira
  • Alan Rabideau, (Ojibwe)
  • Catherine Swan Reimer, EdD, (Inupiaq)
  • Warren Skye Jr., MSW, (Seneca)

  • Executive Director Jill Shepard Erickson, MSW,
  • PO Box 55127
  • Portland, OR 97238
  • 503-953-0237