1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services A Strategy for Native Youth Mental Health Treatment and Prevention Services and Programming Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Michelle Singer Oregon Health and Science University Tribal Justice and Safety Regional Conference Mystic Lake, Minnesota March 26, 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

5. 5

6. 6 Goals for Today An Environmental Scan Behavioral Health Care System Issues Fragmentation and Integration Discuss Mental Health and Comorbidity Indigenous Knowledge + Evidence Based Knowledge = Best Practice Integrated care approaches are best for treatment of these chronic illnesses

7. 7 Five Missions Impossible? How do we define 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?

8. 8

9. 9

10. 10

11. 11 Ten Leading Causes of Disability in the World Unipolar Depression Iron-deficiency Anemia Falls Alcohol Use COPD Bipolar disorder Congenital anomalies Osteoarthritis Schizophrenia Obsessive-compulsive disorder 10.7% 4.7 4.6 3.3 3.1 3.0 2.9 2.8 2.6 2.2 (WHO, 1997)

12. 12 Males (n = 1,170)Females (n = 656) Type of disorderPrevalence Any Listed66.373.8 Conduct Disorder5.43.8 Disruptive Behavior41.445.6 ADHD16.616.4 Affective18.727.6 Anxiety21.330.8 Psychotic1.0 Substance Use50.746.8 Juvenile Justice Mental Disorder Rates Chicago Detention Center (Teplin,2002)

13. 13 Most Common Disabilities Among Youth in the JJ System Learning Disabilities Post Traumatic Stress Disorder (higher in girls) * Conduct Disorder Oppositional Defiant Disorder Depression Anxiety Disorders Substance Use/Abuse Disorders Developmental Disabilities

14. 14 Mental Health Needs: Across Juvenile Justice Placements A study compared mental health needs among a random sample of youth (n=473) within the juvenile justice system found mental health problems in: –45.9 % of youth on probation, –67.5% youth incarcerated, and –88 % youth adjudicated to residential treatment centers (Lyons, Quigley, Erlich & Griffin, 2001)

15. Native Health Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5 X 4.Accidents 3X 5.60% Over 65 live in poverty (US 27%) 6.Depression 3x 7.Violence?

16. 16 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

17. 17 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

18. 18 Disconnect Between Justice/Addictions/Mental Health Professionals are undertrained Patients are underdiagnosed Patients are undertreated None integrates well with medical and social services

19. 19 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

20. 20 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

21. 21 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

22. 22

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 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

26. 26 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

27. 27 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

28. 28 Comorbidity Defined “Individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person….at least one disorder of each type can be diagnosed independently of the other.” - Report to Congress of the Prevention and Treatment of Co-Occurring Substance Abuser Disorders and Mental Disorders, SAMHSA, 2002

29. 29 Lifetime History Mental Disorder 22.5% Comorbidity 29% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990

30. 30 Lifetime Psychiatric Diagnoses Among Primary Caretakers (N=207) R. Dale Walker, M.D. (7/97)

31. 31 Multiple Diagnoses Increase Treatment seeking Use of services Likelihood of no services Treatment costs Poor outcome Suicide risk Dual diagnosis is an expectation, not an exception

32. 32

33. 33 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

34. 34 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

35. 35 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

36. 36 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

37. 37 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

38. 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.

39. 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

40. 40 Behavioral Health Programs Should.... Reduce Risk Factors 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 in the school, peer, and community environments

41. 41 strong family bonds parental monitoring parental involvement success in school performance prosocial institutions (e.g. such as family, school, religious, and tribal organizations) conventional norms about drug use Behavioral Health Programs Should.... Enhance Protective Factors

42. 42 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

43. 43 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

44. 44 Effective Interventions for Youth Family Therapy Multisystemic Therapy Case Management Therapeutic Communities Community Reinforcement Circles of Care Motivational Enhancement

45. 45 Treatment Settings - Social Support: A Native Advantage Tribal Community Family Sibs Peers Individual

46. 46 Cultural Approach Original Holistic Approach Psychopharmacology Approach The unconscious has always been there Group Therapy Network Therapy Recreational / Outdoors Traditional Interventions Indian is...

47. 47 Possible Treatment/Prevention Activities The Talking Circle Smudging Story telling Traditional Healers Medicine Person Herbal remedies Traditional ceremonies Sweat Lodge Traditional Experiences Preservation

48. 48

49. 49 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:

50. 50 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:

51. 51 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:

52. 52 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:

53. 53 ID Best Practice Best Practice Clinical/services Research Traditional Healing Mainstream Practice

54. 54 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

55. 55 Basic Science What Is Integrative Medicine? CAM literacy Evidence Based Medicine Wellness Power Of the Mind Cultural Sensitivity Patient Centered Care

56. 56 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.

57. 57 WHAT ARE SOME PROMISING STRATEGIES?

58. 58 Promising Strategies Home visitation Parent training Mentoring Heroes Social cognitive Cultural

59. 59 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.)

60. 60 Comprehensive school planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event occurs

61. 61 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

62. 62 Unified Services Plan Mental health Education/vocation Justice/safety Leisure/social Parenting/family Housing Financial Daily living skills Physical health

63. 63 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

64. 64 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

65. 65 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

66. 66 Evidence-based coordination– linkage mechanisms formal agreements among behavioral health, primary health care providers and justice; case management of behavioral health, justice, and primary health care; co-location of behavioral health, and primary health care services; delivery of mental, substance-use, and primary health care through clinically integrated practices of primary and M/SU care providers.

67. 67 Making It Work for Youth and Families Involved in Juvenile Justice Engage All Leaders on all Decisions Know the decision points in the JJ System At point of arrest/earliest point to divert At point where decisions to charge are made/diversion At intake to juvenile court/diversion Make information accessible Make resources/services more accessible Increased screening Target adolescents

68. 68 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org