1. Marcy Ronyak, Ph.D., LICSW, CDP Director, OIASA, SAMHSA Tribal Behavioral Health Agenda – An Approach to Improving Wellness in Tribal Communities National Council of Urban Indian Health 2015 Annual Leadership Conference Salt Lake City, UT — May 21, 2015 Rose Weahkee, Ph.D. Acting Area Director, Phoenix Area Office, IHS

2. WHY THIS DISCUSSION? American Indians and Alaska Natives continue to face significant behavioral health problems—the issues that impact behavioral health include many factors Behavioral health issues are not isolated—there are important correlations with physical health Federal agencies beyond IHS and BIA have responsibility for improving the health and well-being of AI/AN people Lack of a guiding national document to prioritize future funding and strategies to address behavioral health There is an urgency for federal agencies to partner with tribes and other stakeholders to meaningfully improve well-being of AI/AN people 2

3. THE URGENCY: Behavioral Health Services Future of Native Communities 3

4. URGENCY: Behavioral Health Services Suicide is the second leading cause of death— 2.5 times the national rate—for Native male youth in the 15 to 24 year old age group AI/ANs experience serious psychological distress 1.5 times more than the general population AI/ANs have twice the rate of violent victimization than African Americans and more than 2.5 times that of whites Drug related death rates have doubled from 2000 to 2008 4

5. WHAT IS ENVISIONED? A lean (and mean) joint national document that: –Is developed in consultation with tribal leaders –Includes broad input from relevant stakeholders –Includes crosscutting issues (youth, culture, identity, individual self-sufficiency) –Is built upon foundational elements (i.e. root causes—historical trauma, ecological factors, etc.) –Includes a more inclusive scope of the problem –Identifies key national behavioral health priorities –Proposes key actions that leverage investments 5

6. National TBHA Framework Four cross-cutting issues: −Youth, culture, identity, individual self-sufficiency Five foundational elements upon which priorities and actions can be built −Historical & Intergenerational Trauma −National Awareness & Visibility −Socio-Ecological Approach −Prevention & Recovery Support −Behavioral Health Service & Systems Improvement Priorities and actions 6

7. #1: Historical & Intergenerational Trauma QUESTION: How should historical and intergenerational trauma be framed? RECOMMENDATIONS: Based on communities--engage separately (14) Define historical trauma as root cause (8) Focus on healing (3) Educate individuals Different impacts for the 566 tribes Ensure focus is not “one size fits all” tribes 7

8. #2: National Awareness & Visibility QUESTIONS:  How might behavioral health issues, and their underlying causes, be more effectively communicated within tribal communities and across broader national audiences?  How can all levels of governments and other stakeholders improve national visibility?  How might communication and collaborative actions be incorporated into existing efforts? 8

9. National Awareness and Visibility RECOMMENDATIONS: Start within family and community (9) Change school curriculum (5) Positive native-focused media images, campaigns, and role models (4) Involve youth through social media (3) Use voices of survivors and tribal strengths (2) Identify budget and resources 9

10. #3: Social-Ecological Approach QUESTIONS:  Are there other partnerships at all levels of government with tribes to address social, policy, and economic factors that have shown improvement?  Are there AI/AN-specific models that address social, policy, and economic factors that should be show-cased in the TBHA? 10

11. Social-Ecological Approach RECOMMENDATIONS: Sovereignty approach—one size does not fit all (13) Importance of matrilineal society (12) Protect environmental resources (spiritual connection—one with the environment) (5) Teach to build housing to reduce dependence (4) Impact of lack of activity/extracurricular activity (3) Need to grow own foods to address food deserts (1) 11

12. #4: Prevention and Recovery Support QUESTIONS:  What should be included to address discrimination and negative attitudes about behavioral health?  What factors should be considered in facilitating engagement of individuals, families, and communities in culturally appropriate prevention and recovery support?  What strength-based approaches would best capture culturally appropriate prevention and recovery support? 12

13. Prevention and Recovery Support RECOMMENDATIONS: Tribal evidence-based research (14) Discretionary grants based on community needs (5) Early Intervention (5) Community planning followed by funding (3) Mind, body, and spirit are inseparable (1) Use social marketing tools 13

14. #5: BH Services & Systems Improvement QUESTIONS:  How might federal, tribal, state, and/or local programs be better aligned to address behavioral health and other health care personnel shortages in AI/AN communities?  What efforts are needed to support a clinically skilled and culturally competent behavioral health workforce for AI/AN communities?  What points on a care continuum, including traditional Native medicine, should be integrated to improve the health and well-being of AI/ANs? 14

15. BH Services & Systems Improvement RECOMMENDATIONS:  Value traditional evidence-based practices (14)  Cultural competency for non-Native providers (7)  “Grow our own” models and “keep or own” incentive packages (6)  Lack of government-to-government recognition at all levels (affects funding) (2)  Better networks and coordination (2)  Parity across services (i.e., law enforcement, behavioral health) 15

16. Your Input What are your thoughts about the cross- cutting issues? Do you agree with them? Are the foundational elements sufficient? Do they support the priority behavioral health issues for your community or organization? Are there other considerations that SAMHSA and IHS should address? 16 16

17. NEXT STEPS Proposed elements and questions will be updated based on NCUIH input Updated elements and questions will be used to develop the initial structure for the national TBHA NCUIH input will be used to frame listening and consultation sessions over the next months with: o Broad group of tribal leaders o National and regional AI/AN organizations o Federal partners o Other stakeholders 17