1. Understanding Native Behavioral Health: Problems and Solutions One Sky Center R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer Doug Bigelow, PhD Association of American Indian Physicians Annual Meeting Portland, Oregon August 12, 2011

2. One Sky Center Staff 2 Susan Michelle Patricia Doug Dale

3. 3 One Sky Center 1.Opportunity 2. Research 3.Excellence 8.Tribal Leadership 4.Training 5. Consultation 6. Technical Assistance 7. Education 9. Mentorship

4. 4 One Sky Center Outreach

5. WHO ARE INDIGENOUS PEOPLES? “Indigenous peoples remain on the margins of society: they are poorer, less educated, die at a younger age, are much more likely to commit suicide, and are generally in worse health than the rest of the population." (Source: The Indigenous World 2006, International Working Group on Indigenous Affairs (IWGIA) WHO 5

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8. Native Healthcare Resource Disparities 8

9. 9 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

10. Social Determinates of Health: Whitehall Studies Within a hierarchical society, there is a social gradient for morbidity and mortality. (Poverty, sanitation, nutrition, and shelter are controlled.) Higher status folks live longer and healthier. Health Care Improvement Needs More Than Money: Opportunity, Empowerment, Security, Control, and Dignity…. 10 www.thelancet.comwww.thelancet.com Dec 9, 2006. Marmot Amartya Sen 1998 Nicholas Stern 2004

11. Critical Elements for Native Peoples Self determination Ecology and environment Economic prosperity, fairness and equity Leadership and capacity strengthening Racism / dominance / imperialism Healing, services, systems, structures Cultural sustainability, protection, stewardship Land Human rights 11

12. DETERMINANTS OF HEALTH: RACE AND ETHNICITY Economic Political Social Educational Employment Income Access to health care Environment Law Enforcement / Justice Home Colonialism as a Broader Social Determinant of Health 12

13. It’s the Economy, Stupid Recession hit minorities much harder than whites, report says Overall, whites suffered a fraction of the loss that hit Hispanics, Blacks. Orlando Sentinel. Race, Gender and Structural Inequalities in the Great Recession and the Recovery (Joel Wendland, Political Affairs) America's massive racial wealth gap (The Week) Separate but unequal: Charts show growing rich-poor gap (CNN NEWS) It’s the inequality, Stupid (Zachary Roth | The Lookout)Zachary RothThe Lookout White Americans Are A Record 20 Times Wealthier Than Black Americans (Business Insider)

14. Building a Better America—One Wealth Quintile at a Time Michael I. Norton1 and Dan Ariely2

15. Recession Worsens Racial Wealth Gap

16. Who Rules America? Wealth, Income, and Power. Net WorthFinancial Wealth

18. 18 Behavioral Health Care Issues

19. Native Health Issues 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? 1.Same disorders as general population 2.Greater prevalence 3.Greater severity 4.Much less access to Tx 5.Cultural relevance more challenging 6.Social context disintegrated 19

20. 20 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

21. 21 Suicide Among ages 15-17, 2001 Death rate per 100,000 0 Source: National Vital Statistics System - Mortality, NCHS, CDC. 2010 Target Total American Indian Asian Hispanic Black White Females Males

22. 22 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

23. 23 Models of Care

24. Practice (Service) Culture Values Culture Values  Philosophies  Belief about causes of problems and solutions  Local innovation, trial and error  Medicinal use of wild plants and minerals  Healing procedures  Oral transmission of knowledge  Community evaluation and acceptance Best Practice Science & Scholarship 5/2/2015 24 Using the OPRE Review

25. Community Based Logic Model 1. Causes Goals 2. Target Population Intervention Outcomes 5/2/2015Using the OPRE Review 25 4. Theory of Change 5. Operations Manual 3. Strategy 8. Long term (Impact) 7. Medium term 6. Short term

26. Parent Knowledge Skills Motivation Performance Home Visiting Education Training/Demonstration Support/Encouragement Linking Child Safe Healthy School ready Culture Vision/Aspiration Morale Values Principles Stories Images Local Context Employment Housing Recreation Community Activities/Events Social Structure Politics Services/Resources Income support LE/Justice Physical MD Mental Health Sobriety Education Emergency Shelter Food 5/2/2015 26 Evaluation in Indian Country

27. 27 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

28. 28 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

29. 29 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

30. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 30

31. 31 What are some promising strategies?

32. 32 Native Partnered Collaboration Research-Education-Treatment OHSU Grassroots Groups Community-Based Organizations State/Federal "SHARED VISIONS: BLENDING TRADITION, CULTURE AND HEALTH CARE FOR OUR NATIVE COMMUNITIES”

33. Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Health Equity in all Policies Fair Financing Good Governance Responsibility Gender Equity Political empowerment – inclusion and voice Areas for Action

34. NIDA Native Mentorship Mentors: 17 Mentees: 21

35. 35 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org