1. Understanding Native Behavioral Health: Problems and Solutions One Sky Center R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer Doug Bigelow, PhD Contemporary Northwest Tribal Health Conference Portland, Oregon March 25, 2011

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

3. 3 One Sky Center Opportunity, Research Excellence Tribal Leadership Training, Consultation, Technical Assistance Education Mentorship

4. 4 One Sky Center Outreach

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7. Native Healthcare Resource Disparities 7

8. 8 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

9. 9 Behavioral Health Care Issues

10. 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 10

11. 11 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

12. 12 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

13. 13 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

14. 14 Models of Care

15. Practice (Service) 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 10/16/2015 15 Using the OPRE Review

16. Logic Model 1. Causes Goals 2. Target Population Intervention Outcomes 10/16/2015Using the OPRE Review 16 4. Theory of Change 5. Operations Manual 3. Strategy 8. Long term (Impact) 7. Medium term 6. Short term

17. 17 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

18. 18 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

19. 19 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

20. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 20

21. 21 What are some promising strategies?

22. 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…. 22 www.thelancet.comwww.thelancet.com Dec 9, 2006. Marmot Amartya Sen 1998 Nicholas Stern 2004

23. 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 23

24. 24 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

25. 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

26. 26 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org