1. Native Adolescent Suicide: Emerging Community Based Integrative Care Models One Sky Center R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer AAIP 38 th Annual Meeting Alexandria, Virginia July 25, 2009

2. 2 One Sky Center

3. 3 One Sky Center Outreach

4. 4 Goals for Today An Environmental Scan Fragmentation and Integration Gain understanding of youth health issues Examine Native youth suicide data Discuss suicide prevention and intervention

5. 5

6. 6 How are we functioning? (Carl Bell and Dale Walker 7/03 ) One size fits all Different goals Resource silos Activity-driven

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

8. 8

9. Age Distribution American Indians 2004

10. 10 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

11. 11 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

12. Poverty Status by Race and Age 2000

13. 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

14. Barriers to Health Care for American Indian Youth Waiting may be 2 to 6 months Great distances to travel to reach facilities Trust is difficult to establish Some services, depending on the provider, require the presence of a parent/adult Lack of transportation Lack of privacy in community health clinics 14

15. 15 Suicide: A Multifactorial 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

16. Suicide Decedents with BAC ≥0.08 by Ethnicity and Age 16 MMWR June 19, 2009

17. 17 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.

18. Blog # 1 I started smoking at the age of eight. Provoking my life of sin to a life of hate, drinking was what made it worse. Thinking of myself while my family hurt. Coming home at late nights with a liquored up shirt, so now I bring it home for my future isn't set in stone. 18

19. Blog #2 Jealousy, Frustration, Emptiness, Loneliness, Not dependable at all times, Laziness, Pain There Is A Boy Named xxxx. He Always Tries To Fight Me. 19

20. Blog # 3 My Dad Is Dead. I Struggle With Wanting to Drink or to take Control of My life And Do Whatever I want even if It Hurts Me Emotionally. I will Struggle When I Have Kids One Day, How They Will turn out. 20

21. Blog #4 There are so many deaths because of stuff Like diabetes, heart diseases, and not Taking good care of your self. And all The drugs and Alcohol… 21

22. 22 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

23. 23 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

24. 24 Suicide Rate per 100,000 Population1981–1998 CDC Suicide Rate 1981-1998

25. Denise Middlebrook 1-5-2006R. Dale Walker, M.D., 2003 25

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

27. 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.

28. 28 Models of Care

29. Suicide Prevention Programs Among American Indian Youth : Three Main Approaches – Do them All Adoption of mental health focus on Risk and Protection factors across life span Adaptation of public-health based interventions that promote opportunities for youth to gain self- esteem and avoid substance abuse/risky behavior Incorporation of traditional tribal responses as effective prevention strategies 29

30. 30 Domains Influencing Suicidal Behavior: A Native Ecological Model IndividualPeers/FamilySociety/ Cultural Community/Tribe Risk Protection

31. 31 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

32. 32 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

33. 33 80% No Problems No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems 5% Severe Problems Thresholds for Action Spectrum of Intervention Responses 15%

34. 34 Sources of Strength Family Support Positive Friends Caring Adults Positive Activities Generosity/Leadership Spirituality Access to Medical Access to Mental Health

35. 35 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:

36. 36 ID Best Practice Best Practice Clinical/services Research Traditional Medicine Mainstream Practice

37. 37 What are some promising strategies?

38. AI/AN Prevention, Treatment, and Rehabilitation Interventions Story Telling Talking Circles Sweat Lodge Ceremonies and Ritual –Purification –Passages –Naming –Grieving Drumming, singing, dancing Vision Quest Flute playing/meditation Reconciliation Mentoring Service learning Traditional Experiences Preservation 38

39. Adapted Interventions American Indian Life Skills Canoe Journey Gathering of Native Americans Project Venture Helping Our People Endure (HOPE) 39

40. Native Interventions American Indian Life Skills Gathering of Native Americans (GONA) Native Helping Our People Endure (HOPE) Crisis Response Teams Family Canoe Journey Community Readiness Model Peer Counselors Mentoring Suicide Prevention Camp Contests/races/special events 40

41. 41 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.)

42. 42 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

43. Reasons for Not Seeking Formal Help When Suicidal REASON%Example Did not perceive need for help 28.8Nothing really happened Stigma, embarrassment23.7Care what people think Had other support23.7went to friends for help Self-reliance15.3figured it out on my own Felt hopeless, alone15.2didn’t think they could help Fear of consequences11.9someone might put me in a hospital Costs 3.4No money No services available1.7No help around 43

44. Reasons for Not Seeking Informal Help When Suicidal Reason%Example Stigma, embarrassment 34.8Think I was weird Felt hopeless, alone16.6Felt no one cared Fear of consequences16.6They might lock me up Did not perceive need for help 10.8Didn’t need them Self-reliance10.8It was my problem Had other support2.7All alone. Find someone whose job it is to help 44

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46. Common Characteristics of Successful Native Programs Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 46

47. 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 Do evaluation 47

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