1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Building on Success : A National Strategy for Native Youth Mental Health Treatment and Prevention 2006 Juvenile Justice National Conference Washington, DC January 11, 2006 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Michelle Singer

2. 2 One Sky Center

3. 3 Native Aspirations!

4. 4 Overview An Environmental Scan Behavioral Health Care System Issues Fragmentation and Integration Discuss Suicide, Comorbidity, Disaster Indigenous Knowledge + Evidence Based Knowledge = Best Practice Integrated care approaches are best for treatment of these chronic illnesses

5. 5 Six Missions Impossible? How do we define problems? How do we define disaster? 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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9. Health Problems 1.Alcoholism 6X 2.Tuberculosis 6X 3.Diabetes 3.5 X 4.Accidents 3X 5.Physicians 72/100,000 (US 242) 6.60% Over 65 live in poverty (US 27%)

10. 10 American Indians Have same disorders as general population Greater prevalence Greater severity Much less access to Tx Cultural relevance more challenging Social context disintegrated

11. 11 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

12. 12 Disconnect Between Addictions / Mental Health Professionals are undertrained in one of two domains Patients are underdiagnosed Patients are undertreated Neither integrates well with medical and social service

13. 13 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

14. 14 How are we functioning? (Carl Bell, 7/03) One size fits all Different goals Resource silos Activity-driven

15. 15 We need Synergy and an Integrated System (Carl Bell, 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

16. 16 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.

17. 17 Our Community Issue For every suicide, at least six people are affected. 4 There are higher rates of suicide among survivors (e.g., family members and friends of a loved one who died by suicide). 5 Communities are linked to each other via a national network. Healthy communities are stronger communities. 4 National Center for Health Statistics, 1999. 5 National Institute of Mental Health, 2003.

18. 18 Suicide Rates by Age, Race, and Gender 1999-2001 Source: National Center for Health Statistics

19. 19 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

20. 20 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

21. 21 Lifetime History Mental Disorder 22.5% Comorbidity 29% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990

22. 22 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

23. 23 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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25. 25 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

26. 26 Ecological Model IndividualPeer/FamilySocietyCommunity/ Tribe

27. 27 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

28. 28 Suicide: Individual Factors RiskProtective Mental illness Age/Sex Substance abuse Loss Previous suicide attempt Personality traits Incarceration Failure/academic problems 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

29. 29 Suicide: Peer/Family Factors RiskProtective History of interpersonal violence/abuse/ Bullying Exposure to suicide No-longer married Barriers to health care/mental health care Family cohesion (youth) Sense of social support Interconnectedness Married/parent Access to comprehensive health care

30. 30 Suicide: Community Factors Risk Protective Isolation/social withdrawal Barriers to health care and mental health care Stigma Exposure to suicide Unemployment Access to healthcare and mental health care Social support, close relationships, caring adults, participation and bond with school Respect for help-seeking behavior Skills to recognize and respond to signs of risk

31. 31 Suicide: Societal Factors Risk Protective Western Rural/Remote Cultural values and attitudes Stigma Media influence Alcohol misuse and abuse Social disintegration Economic instability Urban/Suburban Access to health care & mental health care Cultural values affirming life Media influence

32. 32 Addictions: 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

33. 33 Addictions: Effective Interventions for Youth Family Therapy Multisystemic Therapy Case Management Therapeutic Communities Community Reinforcement Circles of Care Motivational Enhancement

34. 34 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:

35. 35 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:

36. 36 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:

37. 37 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:

38. 38 ID Best Practice Best Practice Clinical/services Research Traditional Healing Mainstream Practice

39. 39 Circle of Care Best Practices Child & Adolescent Programs Prevention Programs Primary Care Emergency Rooms Traditional Healers A&D Programs Colleges & Universities Boarding Schools

40. “Creating both vertical and horizontal partnerships at and between each level of government is essential for effective … prevention efforts; this requires overcoming traditional agency boundaries in order to focus on both broader populations and symptomatic individuals immediately in need of care.” Caine, E., Preventing Suicide, Attempted Suicide, and their antecedents Among Men in the Middle Years of Life. Executive Summary of a Scientific Consensus Conference, 11-12 June 2003, Washington, D.C.

41. 41 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations

42. 42 The good news and the bad news While there are no easy solutions to complex problems; there are complex solutions.

43. 43 Community Based Prevention Interventions Public awareness and media campaigns Youth Development Services Social Interaction Skills Training Approaches Mentoring Programs Tutoring Programs Rites of Passage Programs

44. 44 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.

45. 45 Suicide Prevention Resources Suicide Prevention Resource Center http://www.sprc.org/ http://www.sprc.org/ Indian Health Service Director’s Initiatives http://www.ihs.gov/ http://www.ihs.gov/ Office of Juvenile Justice Model Programs http://www.dsgonline.com/mpg2.5/mpg_index.htm http://www.dsgonline.com/mpg2.5/mpg_index.htm One Sky Center http://www.oneskycenter.org/http://www.oneskycenter.org/ Screening for mental health http://www.mentalhealthscreening.org/ http://www.mentalhealthscreening.org/ Jason Foundation http://www.jasonfoundation.com/home.html

46. 46 Addiction Resources SAMHSA Co-occurring Disorders http://alt.samhsa.gov/Matrix/matrix_cooc.asp National Institute of Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov National Institute of Drug Abuse http://www.nida.nih.gov National Institute of Mental Health http://www.nimh.nih.gov Treatment Improvement Protocol (TIP) Series –(800) 729-6686 Monitoring the Future Study http://www.monitoringthefuture.org

47. 47 For information, 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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