1. Cultural Competence and Holistic care
Presented by Johnna James, MSNAL
Tribal Liaison
Oklahoma Department of Mental Health & Substance Abuse Services

2. Introduction and responsibilities Tribal and multicultural Liaison
Provide consultation with Tribal Governments before any action by ODMHSAS is taken that will significantly affect American Indians
Collaborative Governance- collectively empowered to make a policy decision or make recommendations to a final decision-maker
Technical Assistance Collaboration-Agencies and Tribes
What we know about consultation is that for it to be effective, we need to practice “Collaborative governance” which incudes sitting at the table together as early as possible to have discusssions around :
Treatment options (best practices, effective in tribal communities)
Policy and Procedure
Grant writing
Date collection

3. There are 39 tribal nations headquartered in Oklahoma

4. Oklahoma Tribes
According to the 2015 US Census Bureau estimates, there are about 532, 016 American Indian and Alaska Native people living in Oklahoma representing 13.6% of the state’s population.
Federal recognition of an Indian tribe involves official acknowledgement by the United States of the political status of tribes as a government. Members of a federally recognized tribe are eligible for a number of unique federal programs such as those offered to Indian people by the Indian Health Service
Many federally recognized tribes have constitutions, others operate under articles of association or other bodies of law and some have found a way to combine their traditional systems of government within a modern governmental framework. Contemporary tribal governments are often modeled upon the federal system of the three branches: Legislative, Executive, and Judicial.
The chief executive of a tribe is usually called a chairman, chairwoman or chairperson, but may also be called a principal chief, Mekko, king, governor, president, mayor, spokesperson, or representative.
Many tribes have established, or are building, their judicial branch or tribal court system to interpret tribal laws and administer justice.
Source: 2016 Report from Native American Affairs Secretary

5. Historical Trauma
cumulative emotional and psychological wounding of an individual or generation caused by a traumatic experience or event.
This image is of Carlisle Indian School that was operated in Pennsylvania. It was the first Indian Boarding school established from 1879 to 1918 (nearly 40 years of existence).
*principle of establishing the school was to equalize American Indians as Euro-Americans and for AI to be immersed in Euro-American culture.

6. American Indian Mental Health And Substance ABuse
Historical Trauma Responses (HTR)- is a constellation of features in reaction to massive group trauma
•Survivor guilt
•Depression
•Sometimes PTSD symptoms
•Psychic numbing
•Fixation to trauma
•Somatic (physical) symptoms
•Low self-esteem
•Victim Identity
•Anger
(Maria Yellowhorse Braveheart, 1998, 1999, 2000)
•Self-destructive behavior including substance abuse
•Suicidal ideation
•Hypervigilance
•Intense fear
•Dissociation
•Compensatory fantasies
•Poor affect (emotion) tolerance

7. Influential Causes- Historical Trauma
Genocide: Beginning of contact with the white man, which led to shock and a lack of time to grieve in the greater interest of survival; (killing, “redskins”)
Ecocide: economic competition over buffalo, which was a large physical and spiritual loss of sustenance;
Termination: Invasion/war period, which led to extermination and the development of refugee symptoms;
Separation: Subjugation and reservation period, where natives were either confined or translocated and had no sense of security;
Boarding school period, Culturcide, which destroyed the family system and to this day is main reason why families remain so disconnected as traditional parenting was lost to the boarding schools; traditional and spiritual practice forbidden
Forced relocation and termination period, which involved a transfer to urban areas and prohibition of religious freedom.
Historical Trauma: a collection of characteristics are formed in relation to the trauma that a group of people have endured.
State: “The combination of symptoms may show up differently in communities and individuals, but its roots are still the same, originating from cultural genocide.”
Inter-generational Trauma:
Historical trauma is past down through generations. HT symptoms include elevated suicide rates, depression, self-destructive behavior, substance abuse, fixation to trauma, anxiety, guilt, chronic grief and identification with the pain ancestors endured.
Examples include: In this picture the father attended board school. He was shipped off to board school at the young age of eight (8) by an Indian agent. He did not see his parents for 12 years. The father experienced depression and anxiety. His children experienced chronic grief and they identified with his pain. His grandchildren continue to identify with his pain and have experienced depression and anxiety as symptoms of HT.”
Trauma endured at Boarding schools include identity loss, no connection of family, loss of familial values, no foundational belief system, loss of ceremonies (lost traditional ways of bonding with a group)
Maria BraveHorse Yellowheart

8. Influential Causes- Boarding Schools
While arriving to Boarding schools, against their will, children’s hairs were cut, clothes burned, and their names changed.
Native children were severely punished for trying to speak their language. Not only was physical abuse happening, but sexual and emotional abuse as well.
Lacked nurturing and their emotional needs were not met

9. Adverse Childhood Experiecences Study
The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and later-life health and well-being.
The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.
“Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” published in the American Journal of Preventive Medicine in 1998, Volume 14, pages 245–258.
ACE (Abuse, Neglect, Household dysfunction)
The Centers for Disease Control and Prevention (CDC) hosts the official website for information about the ACE Study, including the original ACE Study questionnaires and articles resulting from the Study.  In 2007, responding to popular demand for a condensed version of the original questionnaires, Dr. Anda created The ACE Score Calculator, which allows individuals to calculate their own ACE Scores, based on the original scoring criteria of the ACE Study.  To use this survey, add up all of the YES responses.  The sum is the ACE Score.  The ACE Score can range from "0", meaning no exposure to the ten categories of child abuse and trauma investigated by the Study, to "10", meaning exposure to all ten categories.  The Study found the higher the ACE Score, the greater the risk of experiencing poor physical and mental health, and negative social consequences later in life.

10. Results of ACES Among AI/AN 2011-2012
Hindawi Publishing Corporation
Scientifica
Volume 2016, Article ID , 14 pages

11. Aces Score Greater than 4
The likelihood of
Chronic pulmonary lung disease increases 390 %
Hepatitis, 240%
Depression 460%
Suicide, 1,220 %
(ACES STUDY )

12. Health Affects of ADversity
Physiological Response-Trauma affects pleasure and reward part of the brain, impulse control and brains fear response center (More likely to engage in high risk behavior and more likely to develop heart disease and cancer) Adaptive vs Maladaptive- Fight or Flight , releases adrenaline and Cortisol (Dr Nadine Burke Harris, 2015)

13. American Indian Health Disparities Data
American Indians have a life expectancy that is 4.2 years less than the U.S. all races population (73.7 yrs to respectively) (IHS, 2015)
American Indians and Alaska Natives continue to die at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases.
12.6 /100,000 suicide deaths for AI in 2015
Highest use of commercial tobacco in the state at 29.2/100,000 (Oklahoma State Department of Health, 2014)
Please note that Oklahoma data is not collected as a whole. Most of the data for mortality would be collected by the OSDH. Morbidity would be by the OSDH, however, the Indian Health Service and Tribal Nations themselves. There is no collective database to find Oklahoma tribal nation information unless you are using a primary data to gather the information internally within your organization.
First bullet: IHS---
Second bullet: Oklahoma State Department of Health. (2014). State of the State’s Health Report. Retrieved from

14. Cultural Competency treatment
Recognize Trauma (Screening) Tribal Best Practices- Awareness, Holistic approaches Reduce the dose of adversity

15. American indian mental health
Cultural Differences:
Historic Distrust
Identity (Where do you come from vs what do you do)
Stigma of Mental Illness
Consumer fears of experiencing discrimination
Lack of familiarity with westernized mental health services
health is harmony of mind, body, and spirit;
illness is disharmony of mind, body, and spirit;
Lack of Trust for providers (Matriarch/Elder)
Spirituality—a system of belief that focuses on intangible elements that impart vitality and meaning to life’s events (Maugans, 1996) and that is so important to Indians and other Natives—is pointedly absent from the perspectives that guide the bulk of the care available. There is growing evidence that various aspects of spiritual practice, affiliation, and belief are beneficial for mental health. The findings are strongest for a link to subjective well-being, life satisfaction, and reduced risk of suicide (e.g., Ellison & Smith, 1991; Garroutte, Goldberg, Beals, Herrell, & Manson, in press; Jarvis & Northcott, 1987; Koenig, George, & Peterson, 1988; Levin, 1994). (

16. Strengths in American Indian Communities
Extended Family/Kinship Ties
Long-term natural support
Shared Sense of collective community responsibility
Physical Resources (food, plant, animal, water)
Indigenous knowledge/wisdom
Historical perspective and strong connection to past
Survival skills and resiliency in face of multiple challenges
Retention and reclamation of traditional language and cultural practices
Ability to walk in two worlds
Community Pride
American Indian Culture Guide, OSDH

17. SAMHSA (Substance Abuse and Mental Health Association)
National Tribal Behavioral Health Agenda-12/16
Historical and Intergenerational Trauma
Socio-Cultural-Ecological Approach
Prevention and Recovery
Behavioral Health Systems and Support
National Awareness and Visibility

18. Medicine Wheel

19. Treatment for Historical Trauma
Treatment should be aimed at a renewal of destroyed culture, spiritual beliefs, customs, family connections, and focus on reaffirming one's self-image and place within a community. Without proper treatment and understanding, historical trauma will continue to plague generations of afflicted communities.

20. Focus wheel for Historical Loss

21. Samhsa Wellness

22. Questions or Feedback

23. THANK YOU!
Johnna James, MSNAL
Tribal Liaison
ODMHSAS