1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Mental Health in Native Communities: Concepts and Care Johns Hopkins University - Bloomberg School of Public Health Baltimore, Maryland January 6, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer An Interdisciplinary Approach to Understanding the Health of Native Americans

“Indian Country benefits significantly from health care reform legislation." If health care reform becomes law, so does the Indian Health Care Improvement Act. Opens up new revenue stream for the Indian Health system. New money for long-term care, cancer screening and better mental health treatment broader eligibility for Medicaid Higher reimbursement rates in rural areas

3 One Sky Center

4 Jack Brown Adolescent Treatment Center Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Na'nizhoozhi Center Tribal Colleges and Universities One Sky Center National Indian Youth Leadership Project Cook Inlet Tribal Council Tri-Ethnic Center for Prevention Research Red Road Prairielands ATTC Harvard Native Health Program One Sky Center Partners

5 One Sky Center Outreach

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7 Goals for Today An Environmental Scan Fragmentation and Integration Behavioral Health Care Issues Best Practice = Evidence-Based + Indigenous Knowledge - You do both Treatment and prevention

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Native Health Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5 X 4.Accidents 3X 5.Poverty 3x 6.Depression 3x 7.Suicide 2x 8.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 5.State and Local Agencies 6.Federal Agencies: SAMHSA, VAMC, Justice

14 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven

15 We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

16 Behavioral Health Care Issues

17 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

18 Frequent Mental Distress by Race/Ethnicity and Year Percent * Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults — United States, 1993–2001. Centers for Disease Prevention and Control, MMWR 2004;53(41):  American Indian/ Alaskan Native**  Hispanic  African-American**  White**  Asian, Pacific Islander** ** Non-Hispanic Year

19 Mental Illness: A Multi-factorial Event Edu., Econ., Rec. Family Disruption/ Domestic Violence Family Disruption/ Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Individual

20 Adolescent Problems In Schools School Environment Bullying Fighting and Gangs Alcohol Drug Use Weapon Carrying Sexual Abuse Truancy Domestic Violence Drop Outs Attacks on Teachers Staff Unruly Students Sale of Alcohol and Drugs School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services

21 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

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

23 Suicide Among ages 15-17, 2001 Death rate per 100,000 0 Source: National Vital Statistics System - Mortality, NCHS, CDC Target Total American Indian Asian Hispanic Black White Females Males

24 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

Denise Middlebrook R. Dale Walker, M.D.,

26 North Dakota Teen Suicide Rates ( rate per 100,000 teens years old)

27 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.

28 Biology/Genes Environment DRUG Addiction ADDICTION INVOLVES MULTIPLE FACTORS Brain Mechanisms

29 Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample

30 Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years R. Dale Walker, M.D. (4/99) * 100% Completion Sample Percentage ever used

31 Age of Onset of Drug Use Among Urban A IA (Walkers, 2008) DrugLife PrevalenceAge of onset Alcohol91%13.6 Marijuana81%14.3 Cigarettes80%13.1 Hallucinogens50%14.7 Amphetamines24%14.6 Cocaine21%14.8 Inhalants14%14.7 Tranquilizers14%14.7 Crack Cocaine11%14.7

32 Models of Care

33 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/C ultural Community/Tribe Risk Protection

34 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

35 The Intervention Spectrum for Behavioral Disorders Case Identification Standard Treatment for Known Disorders Compliance with Long-Term Treatment (Goal: Reduction in Relapse and Recurrence) Aftercare (Including Rehabilitation) Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

36 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 Risk and Protective Factors: Individual

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

38 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.

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

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

Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 41

42 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

43 Indigenous Knowledge Local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, used as a basis for decision-making for all of life’s needs. Definition:

44 Traditional Medicine The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002 Definitions:

45 ID Best Practice Best Practice Clinical/services Research Traditional Medicine Mainstream Practice

46 What are some promising strategies?

47 An Ideal Intervention Broadly based: Includes individual, family, community, tribe, and society Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance

Choctaw Nation of Oklahoma Adventure Therapy “Natural Highs Program” Transformation process Experiential activities Relationship building Changing the way you live and think Changing how you think and how you believe about life and yourself Creation of challenge in a safe environment Horses, Canoes, Tradition Camps 48

Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation Meth Free Crowalition Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment Combine forces for Unity. Diverse community representation Youth and Community Development: mentorship, leadership, trust, establish community norms 49

50 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.)

51 Comprehensive school planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

52 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

53 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

54 Unified Services Plan Case management should address: Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health

Five Key Principles Evidence-based predictors of change Understand & Involve the Community Focus on major problems Select the right change agent Seek ideas from outside the field and organization Evaluate 55

Common Characteristics of Successful Native Programs Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 56

57 Bethesda, Maryland October 14, 2009 NIDA American Indian Research Scholars Mentorship Program

Location of Mentors = and Mentees = in Project 58 X X X X XX X X X

59 – Albert Einstein “We cannot solve problems by using the same kind of thinking we used when we created them.”

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