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1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Mental Health in Native Communities: Concepts and Care Johns Hopkins University - Bloomberg School of Public Health Baltimore, Maryland January 6, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer An Interdisciplinary Approach to Understanding the Health of Native Americans
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“Indian Country benefits significantly from health care reform legislation." If health care reform becomes law, so does the Indian Health Care Improvement Act. Opens up new revenue stream for the Indian Health system. New money for long-term care, cancer screening and better mental health treatment broader eligibility for Medicaid Higher reimbursement rates in rural areas. 2 12-21-2009. www.marktrahant.com
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3 One Sky Center
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4 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
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5 One Sky Center Outreach
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7 Goals for Today An Environmental Scan Fragmentation and Integration Behavioral Health Care Issues Best Practice = Evidence-Based + Indigenous Knowledge - You do both Treatment and prevention
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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?
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12 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated
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13 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
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14 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven
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15 We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven
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16 Behavioral Health Care Issues
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17 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001
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18 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
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19 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
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20 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
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21 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma
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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
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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
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24 Suicide: A Native Crisis Source: National Center for Health Statistics 2001
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Denise Middlebrook 1-5-2006R. Dale Walker, M.D., 2003 25
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26 North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)
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27 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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28 Biology/Genes Environment DRUG Addiction ADDICTION INVOLVES MULTIPLE FACTORS Brain Mechanisms
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29 Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample
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30 Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years R. Dale Walker, M.D. (4/99) * 100% Completion Sample Percentage ever used
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31 Age of Onset of Drug Use Among Urban A IA (Walkers, 2008) DrugLife PrevalenceAge of onset Alcohol91%13.6 Marijuana81%14.3 Cigarettes80%13.1 Hallucinogens50%14.7 Amphetamines24%14.6 Cocaine21%14.8 Inhalants14%14.7 Tranquilizers14%14.7 Crack Cocaine11%14.7
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32 Models of Care
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33 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/C ultural Community/Tribe Risk Protection
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34 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses
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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) 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
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36 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
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37 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources
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38 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.
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39 Implications for Treatment Teach adolescents how to cope with difficulties and adversity Increase their repertoire of coping strategies Cognitive therapy is most effective approach
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40 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health
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Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 41
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42 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
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43 Indigenous Knowledge Local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, used as a basis for decision-making for all of life’s needs. Definition:
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44 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:
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45 ID Best Practice Best Practice Clinical/services Research Traditional Medicine Mainstream Practice
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46 What are some promising strategies?
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47 An Ideal Intervention Broadly based: Includes individual, family, community, tribe, and society Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance
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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 48
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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 49
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50 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.)
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51 Comprehensive school planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs
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52 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
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53 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal
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54 Unified Services Plan Case management should address: Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health
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Five Key Principles Evidence-based predictors of change Understand & Involve the Community Focus on major problems Select the right change agent Seek ideas from outside the field and organization Evaluate 55
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Common Characteristics of Successful Native Programs Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 56
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57 Bethesda, Maryland October 14, 2009 NIDA American Indian Research Scholars Mentorship Program
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Location of Mentors = and Mentees = in Project 58 X X X X XX X X X
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59 – Albert Einstein “We cannot solve problems by using the same kind of thinking we used when we created them.”
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60 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org
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