1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services A Guide for Native Suicide Prevention and Intervention Programming Dale Walker, MD Patricia Silk Walker, PhD Doug Bigelow, PhD Laura Loudon, MS Michelle Singer Oregon Health and Science University IHS/SAMHSA Conference Albuquerque, New Mexico June 12, 2007

2. 2 One Sky Center

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

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6. 6 Goals for Today Background: The environment and the system of care The problem Contributing factors Warning signs Prevention strategies Indigenous Knowledge + Evidence Based Knowledge = Best Practice Promising programs Integrated care approaches are best for treatment of these chronic illnesses

7. 7 Five Missions How do we define our problems? How do we ask for help? How do we get Federal and State agencies to work together and with us? How do we build our communities? How do we restore what is lost?

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11. 11 Most Common Emotional Disabilities Among Native Youth Learning Disabilities Post Traumatic Stress Disorder (higher in girls) * Conduct Disorder Oppositional Defiant Disorder Depression Anxiety Disorders Substance Use/Abuse Disorders Developmental Disabilities

12. 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

13. 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?

14. 14 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

15. 15 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

16. 16 A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country, July 2003 Funding not sufficient to meet needs for: Health care Education Public safety Housing Infrastructure development needed U.S. Commission on Civil Rights

17. 17 Difficulties of Program Integration Separate funding streams and coverage gaps Agency turf issues Different treatment philosophies Different training philosophies Lack of resources Poor cross training Consumer and family barriers

18. 18 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

19. 19 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

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21. 21 Suicide: A National Crisis In the United States, more than 30,000 people die by suicide a year. 1 Ninety percent of people who die by suicide have a diagnosable mental illness and/or substance abuse disorder. 2 The annual cost of untreated mental illness is $100 billion. 3 1 The President’s New Freedom Commission on Mental Health, 2003. 2 National Center for Health Statistics, 2004. 3 Bazelon Center for Mental Health Law, 1999.

22. 22 Suicide Rate per 100,000 Population1981–1998 CDC

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 Age-Adjusted Suicide Death Rates CY 1996-1998 U.S. All Races (1997) = 10.6 IHS Adjusted Total - All Areas = 20.2 Unadjusted Adjusted for Race Misreporting

26. Denise Middlebrook 1-5-2006R. Dale Walker, M.D., 2003 26

27. 27 North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)

28. 28 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.

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30. 30 Suicide Warning Signs Changes in behavior Existence of crisis Changes in classroom performance Changes at home Changes with peers

31. 31 SUICIDE: A MULTI-FACTORIAL EVENT Neurobiology Severe Medical Illness Severe Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Suicidal Behavior Personality Disorder/Traits Psychiatric Illness Co-morbidity Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Suicide

32. 32 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 12 1. School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services

33. 33 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

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35. 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) P r e v e n t i o n T r e a t m e n t M a i n t e n a n c e 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

36. 36 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

37. 37 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

38. 38 IndividualGenetics Personality Attitudes beliefs Interpersonal Community Parent s Peers SchoolsLocal legal Personal situations Portrayal in media Cultural beliefs Stigma National attitudes Individual Environmental Interpersonal societal Tribal attitudes State attitudes

39. 39 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

40. 40 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.

41. 41 Implications for Treatment Teach adolescents how to cope with difficulties and adversity Increase their repertoire of coping strategies Cognitive therapy is most effective approach

42. 42 ineffective parenting chaotic home environment lack of mutual attachments/nurturing inappropriate behavior in the classroom failure in school performance poor social coping skills affiliations with deviant peers perceptions of approval of drug-using behaviors Prevention Programs Reduce Risk Factors

43. 43 Prevention Programs Enhance Protective Factors strong family bonds parental monitoring parental involvement success in school performance pro social institutions (e.g. such as family, school, and religious organizations) conventional norms about drug use

44. 44 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

45. 45 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

46. 46 Effective Interventions for Youth Family Therapy Multisystemic Therapy Case Management Therapeutic Communities Community Reinforcement Circles of Care Motivational Enhancement

47. 47 Treatment Settings - Social Support: A Native Advantage Tribal Community Family Sibs Peers Individual

48. 48 Cultural Approach Original Holistic Approach Psychopharmacology Approach The unconscious has always been there Group Therapy Network Therapy Recreational / Outdoors Traditional Interventions Indian is...

49. 49 Possible Treatment/Prevention Activities The Talking Circle Smudging Story telling Traditional Healers Medicine Person Herbal remedies Traditional ceremonies Sweat Lodge Traditional Experiences Preservation

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51. 51 Indigenous Knowledge Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs. Definitions:

52. 52 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:

53. 53 Evidence-based Practices Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings. SAMHSA 2003 Definitions:

54. 54 Best Practices Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness. WHO 2002 Definitions:

55. 55 ID Best Practice Best Practice Clinical/services Research Traditional Healing Mainstream Practice

56. 56 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

57. 57 Basic Science What Is Integrative Medicine? CAM literacy Evidence Based Medicine Wellness Power Of the Mind Cultural Sensitivity Patient Centered Care

58. 58 Principles of Integrative Medicine 1.It is better to prevent than to treat later. 2.Recognition of the interaction between body, mind, spirit, and environment. 3.Integrate the best of conventional and traditional medicine. 4.Belief that bodies respond uniquely, so treatment must be customized. 5.Belief in innate healing powers of the body.

59. 59 WHAT ARE SOME PROMISING STRATEGIES?

60. 60 Promising Practices for Suicide Prevention ASIST C-CARE/CAST Columbia University Teen Screen Means Reduction Lifelines Reconnecting Youth ER intervention for attempters Signs of Suicide US Air Force program Yellow Ribbon Suicide Prevention American Indian Life Skills http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp

61. 61 Promising Strategies Home visitation Parent training Mentoring Heroes Social cognitive Cultural

62. 62 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.)

63. 63 BIA Schools 184 elementary and secondary schools and dormitories (55) as well as 27 colleges In 23 states 60,000 total students 238 different tribes Majority of the schools are located in Arizona and New Mexico Second greatest number of schools in the states of North Dakota and South Dakota Third greatest lie in the northwest

64. 64 Why should schools be involved? Schools cannot achieve their mission of education when students’ problems are barriers to learning and development. From Carnegie Task Force on Education. Schools are at times a source of the problem and need to take steps to minimize factors that lead to student alienation and despair. Schools also are in a unique position to promote healthy development and protective buffers, offer risk prevention programs, and help to identify and guide students in need of special assistance.

65. 65 Comprehensive school planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

67. 67 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

68. 68 Unified Services Plan Mental health Education/vocation Justice/safety Leisure/social Parenting/family Housing Financial Daily living skills Physical health

69. 69 Potential Organizational Partners Education Family Survivors Health/Public Health Mental Health Substance Abuse Traditional Healers Elders Law Enforcement Juvenile Justice Medical Examiner Faith-Based County, State, and Federal Agencies Girls/Boys Clubs

70. 70 Tribal Crisis Intervention Team Tribal Council Tribal Health Department Community Health Representative Indian Health Service –Behavioral Health Department –Emergency Room (a physician and nurse) –Ambulance team Police Department Fire Department Middle and High School (Administrator, teacher, counselor) Spiritual leaders Alcohol and Drug Abuse Prevention programs Youth Centers or other Youth programs Peer Counselors Parents known and trusted by the young people

71. 71 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

72. 72 Recommendations Develop interagency task forces Bring in supportive/interested state partners Reach out to bring in new resources Be clear, positive, and direct Remember what this effort is all about

73. 73 Coordination Strategies formal agreements amongst behavioral health, primary health, schools, and justice case management of behavioral health, justice, and primary health care co-location of behavioral health, and primary health care services, access to school sites delivery of mental, substance-use, and primary health care through clinically integrated practices of primary care providers.

74. 74 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org