1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Substance Abuse and Mental Health Issues in Native Communities: Problems, Strategies, and Solutions HIV in the Circle of Life Niagara Falls, New York. June 10, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer NY/NJ Aids Education and Training Center

2. 2 One Sky Center Opportunity, Research Excellence Tribal Leadership Training, Consultation, Technical Assistance Education Mentorship

3. 3 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

4. 4 One Sky Center Outreach

5. 5 Goals for Today Review An Environmental Scan for Natives Discuss Fragmentation and Integration Present Some Behavioral Health Care Issues Define Social Determinants of Health Present Examples of Treatment and Prevention Summarize Critical Issues for Native Peoples

6. 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 6

7. 7 INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

8. 8

9. 9

10. 10

11. American Indian Population 2000 STATEPOPULATION 1 CALIFORNIA313,642 2 OKLAHOMA262,581 3 ARIZONA261,168 4 NEW MEXICO165,944 5 WASHINGTON104,819 6 ALASKA101,352 7 NORTH CAROLINA 99,277 8 TEXAS 97,412 9 NEW YORK 76,755 10 FLORIDA 60,359 11

12. 12

13. Native Healthcare Resource Disparities 13

14. 14 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

15. 15 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven

16. 16 We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

17. 17 Behavioral Health Care Issues

18. 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 18

19. 19 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

20. 20 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):963-966.  American Indian/ Alaskan Native**  Hispanic  African-American**  White**  Asian, Pacific Islander** ** Non-Hispanic Year

21. 21 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

22. 22 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

23. 23 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

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

25. 25

26. 26 North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)

27. 27

28. 28 Models of Care

29. 29 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

30. 30 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, 1994. Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

31. 31 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

32. 32 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

33. 33 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

34. 34 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

35. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 35

36. 36 What are some promising strategies?

37. Whitehall Studies of British Civil Servants (Across Pay Grades ) 1977 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…. 37 www.thelancet.comwww.thelancet.com Dec 9, 2006. Marmot Amartya Sen 1998 Nicholas Stern 2004

38. The Social Determinants of Health The conditions in which people are born, grow, live, work and age. Shaped by the distribution of money, power and resources at global, national and local levels. Are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. 38 WHO Commission on Social Determinants of Health | August 28 2008

39. WHO Social Determinant Themes Social exclusion Urbanization Globalization Health systems Priority public health conditions Early child development Women and gender equity Employment conditions Measurement and evidence 39

40. Conceptual Framework of Health Determinants 40

41. 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 41

42. 42 An Ideal Intervention Broadly based: Includes individual, family, community, tribe, and society Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance Opportunity, empowerment, security, dignity

43. 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 43

44. 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 44

45. 45 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

46. Six Key Principles Evidence-based predictors of change Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 46

47. 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

48. 48 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org

49. 49 NIDA American Indian Research Scholars Mentorship Program

50. Location of Mentors = and Mentees = in Project 50 X X X X XX X X X