Paulette Running Wolf, PhD, (Blackfeet) Secretary Treasurer Founding Executive Director First Nations Behavioral Health

1. American Indian and Alaska Native Best Practices in Behavioral HealthIHS/SAMHSA National Behavioral Health ConferenceBillings, Montana, August 22, 2008 Paulette Running Wolf, PhD, (Blackfeet) Secretary Treasurer Founding Executive Director First Nations Behavioral Health Association (FNBHA)

2. Recent Meeting • The Center for Mental Health Services (CMHS), SAMHSA, and FNBHA sponsored an expert panel meeting, May 3-4, 2008, in Portland Oregon. • The panel included American Indian/Alaska Native researchers, providers, and family advocates • Discussions included rural reservation, urban Indian, and Alaska Native perspectives • Recommendations from the meeting are to be disseminated in several venues

3. Purpose of the meeting • CMHS seeks to reduce disparities in the behavioral health system of care available to American Indian and Alaska Native (AI/AN) communities by: • increasing knowledge about mental health issues among AI/AN communities and, • increasing the effectiveness of those services by reducing cultural barriers

4. Expert Panel Meeting Agenda • To identify culture based engagement strategies • Barrier reduction • Service utilization • Service arrays • Sustainability partnerships • Implementation strategies for dissemination of tribal behavioral health best practices, including website updates.

5. Shannon Crossbear, (Ojibwe) Holly Echohawk, (Pawnee) Jill Shepard Erickson, (Dakota/Athabaskan) Joseph P. Gone, (Gros Ventre) Jeff King, (Muscogee Creek) Jackie Mercer, (NARA NW) Deb Painte, (Arikira) Alan Rabideau, (Ojibwe) Catherine Reimer, (Inupiaq) Paulette Running Wolf, (Blackfeet) Pam Thurman, (Cherokee) Expert Panel Participants

6. Participants set the stage by personalizing the need: • The system can be disrespectful to families (e.g., black-out period on entering treatment) • Some tribes are still recapturing traditions to increase self esteem and positive identity. • Ceremonies can teach self discipline to children. • There is no consistent standard for suicide watches.

7. Personalized need continued • Storytelling and participation in crafts can be important to establishing trust with families, as opposed to 50 minute office visits. • Cultural identity also involves identification with the land and subsistence activities, i.e., fish camps in Alaska. • Indian Country has potentially explosive issues around blood quantum, “color”, and levels of acculturation. • The Medicaid billing code for targeted case management supports home based wraparound, and is consistent with tribal values.

8. Personalized need continued • CMHS funded Circles of Care and Systems of Care (SOC) grants with tribes have revealed a common value that children are sacred. • Urban Indian youth may hide their cultural identity for safety if surrounded by a gang culture. • Tribal sovereignty must be a recognized component for all research initiatives. • Current epidemic rates of suicide in Indian Country have promoted federal (CMHS/SAMHSA) recognition & support for the integration of culture based traditional healing practices with western treatment.

9. Presentation: Joseph Gone, PhD, • Title: Mental Health Services for Native Americans in the 21st Century United States, 2004, (Journal: “Professional Psychology: Research & Practice”) • Legal, political and institutional contexts for mental health services for tribal people and their communities, and • The possibility for neo-colonial subversion of indigenous thought and practice. • “Are we only dressing up conventional therapy in beads and feathers?”

10. Dr. Gone Continued • There are currently two divergent movements in the field emphasizing evidence based practices (EBP) and culturally specific treatments (CST). • At worst, mainstream treatment may assimilate you into a quasi-healthy “white person”. • Establishing an EBP requires randomized clinical trials, difficult in small population/culturally diverse tribal communities. • The Native American Research Centers for Health (NARCH) are health research grants co-sponsored by IHS and NIH. • Native community psychology involves ethno-psychological analysis, attention to narrative, and facilitation of empowerment.

11. Discussion • Mainstream psychology involves talk therapy, putting feelings into words • Tribal ceremonies often do not emphasize verbal self-expression, and there are ethical issues around taking ceremonies and using them elsewhere. • Rigorous studies of medicine men and their practices may not be possible, but communities have their own way of validation.

12. Discussion Continued • Panelists stated that it is not so much the actual practice but the healing and community support. • The unique goal of tribal behavioral health services is to preserve the essence of cultural strengths while strengthening the tribal person’s ability to respond to changing external factors.

13. Evidence Based Practices and Tribal Alternatives: • SAMHSA maintains a National Registry of Evidence-Based Programs and Practices, (NREPP) to treat substance abuse or mental health disorders, with 3 minimum requirements: • One or more positive outcomes • Published in a peer reviewed journal • Documentation of the intervention and implementation in manuals, tool kits, etc.

14. Priority Points for NREPP approval: • Primary targeted outcome fits SAMHSA’s current priority areas. • Evaluated using a quasi-experimental or experimental study design: • Pre/post design with comparison or control group, or • Longitudinal/time series design with three pre-intervention or baseline measures and three post-intervention or follow up measures

15. Two tribal programs in NREPP • American Indian Life Skills Development, Zuni Pueblo, New Mexico. A school based suicide prevention initiative designed by Teresa LaFromboise, Ph.D., (Miami). • Project Venture, an outdoor experiential youth development program originated in the Navajo Nation by McClellan Hall, M.Ed., (Cherokee) • Both programs have been replicated widely in tribal and other settings.

16. Discussion • Panelists indicated that the fidelity measures required for EBP administration often prohibit cultural adaptations. • The historical trauma issues often vocalized by tribal communities refers to forced assimilation from generations of boarding school experiences outlawing indigenous languages, and culture which followed the years of warfare and moves to reservations, often manifested in violent behaviors today.

17. EBP Discussion • Panelists agreed that culture can not just be added to EBP’s, and that treatment as usual harbors the potential to hurt, not help tribal communities. • Traditional practices vary widely, are specific to tribal cultures, and would be devalued if subjected to evaluation, measurement, and used by persons of a different culture. (Some pan-Indian ceremonies have been replicated and exploited by non-Indian populations).

18. Practice Based Evidence (PBE) • Community accepted healing approaches • Evaluation of the PBE & “certification” of the provider is provided by the community! • Western-based mental health practices must be integrated into the culture (PBE) rather than the reverse (adding culture to the EBP).

19. Modern cultural issues • Youth gang cultures, pop culture, and technology/You Tube/My Space etc. • Social issues resulting from casino’s & gaming • FAS/FAE youth with impulse control & legal issues • Dramatic increase & misuse of prescription drugs • New populations of veterans with potential for PTSD impacting family relationships • Racism and violence a reality in rural reservation communities

20. Barrier reduction strategies • Workforce training, of tribal members with expertise in both mental health and cultural nuances specific to the community, involving tribal colleges and universities. • Expand and support community-based counselor training programs (e.g., UAF’s Village Based Counselor training program). • Scheduled clinical supervision and cultural consultation agreements between paraprofessional and licensed staff, possibly with telemedicine for remote locations.

21. Barrier reduction strategies (continued): • Honor family choice for support system, spiritual, extended family, tribal, IHS, or mainstream programs and churches for increased anonymity. • Staff training to emphasize strength-based assessments & treatment planning & inclusion of cultural supports. • Multidisciplinary family led treatment planning, with strict HIPPA compliance.

22. Culture-Based Engagement Strategies: • Consultation on the local protocols for approaching elders for cultural and spiritual advice • Due to boarding schools and relocation policies, urban families and some reservation families may be re-learning and building cultural identity and practices. • Circles of Care grantees redefined Serious Emotional Disturbance (SED), to a local definition of a well child, based on tribal values. • Lakota and Athabascan assessment scales have been developed during System of Care (SOC) projects.

23. Culture-based Engagement Strategies (cont.): • Urban programs & some acculturated tribal communities are recreating traditional ceremonies & practices - helping youth & families to learn tribal history, language & culture. • Re-introduce tribal rites of passage ceremonies to reduce teen pregnancies and support sobriety. • 12 Step programs encourage spiritual education & practices. • Equine therapy fits well with tribal culture. • Many tribes are using their own resources for cultural immersion programs, i.e., fish camps in Alaska

24. FNBHA: Mission First Nations Behavioral Health Association (FNBHA) was established in September 2003 to provide an organization for Native Americans to advocate for the mental well being of Native Peoples by increasing the knowledge and awareness of issues impacting Native mental health

25. Objectives of FNBHA • To promote and support development of policies, programs, and initiatives that educate and address the needs of tribal consumers, families, communities, and service providers, • To promote and support research for improving American Indian and Alaska Native behavioral health services, • To promote and support quality, comprehensive and effective services for tribal communities, • To provide awareness and input to mental health and substance abuse commissioners, governors, legislators, Board, communities, consumers and families regarding system needs, and • To provide other forms of technical assistance regarding the Association mission as may be indicated by the Board of Directors and/or membership.

26. Purpose • The purpose of FNBHA is to provide national leadership to all groups, institutions and individuals that plan, provide and access Native American behavioral health services • Initial funding was provided by the Center for Mental Health Services, SAMHSA, and Indian Health Service

27. American Indian Life Skills Program Project Venture Positive Indian Parenting, (NICWA) Community Readiness Scale, Tri-Ethnic Center Gathering of Nations (GONA) Nanizhoozhi Center, Inc. Rural Human Service Program, (UAF) Sacred Child Program, (SOC, ND tribes) Sault Ste. Marie Tribe, (SOC program) Wakanyeja Pawicayapi, Inc, (SOC program, Oglala Sioux Tribe) FNBHA Effective Practices, 2005

28. Past Initiatives of FNBHA • 2003: Foundational “Think Tank”, 32 providers, researchers, students, family representatives, representatives of IHS and SAMHSA. • 2005: Joint meeting with National Alliance of Multi-Ethnic Behavioral Health Associations, to identify culturally respectful practices. • www.fnbha website established. • 2006: Subcontract with Suicide Prevention Research Center.

29. President: Jeff King, PhD, (Muscogee Creek) Vice President: Pam Thurman, PhD, (Cherokee) Secretary Treasurer and Founding Executive Director:: Paulette Running Wolf, PhD, (Blackfeet) Public Information Officer: Holly Echohawk, MS, (Pawnee) Family Representative: Shannon Cross Bear (Ojibwe) Founding President: Dale Walker, MD, (Cherokee) Dolores Subia Bigfoot, PhD, (Caddo) Candace Fleming, PhD, (Kickapoo/Oneida/Cherokee) Joseph P. Gone, PhD, (Gros Ventre) Ethleen Iron Cloud-Two Dogs, MS, (Oglala Lakota) Carolyn Thomas Morris, PhD, (Dine) Deborah Painte, MPA, (Arikira Alan Rabideau, (Ojibwe) Catherine Swan Reimer, EdD, (Inupiaq) Warren Skye Jr., MSW, (Seneca) Current Board of Directors

30. Staff • Executive Director: Jill Shepard Erickson, MSW, (Dakota/Athabascan) • PO Box 55127 • Portland, OR 97238 • 503-953-0237 • info@fnbha.org • www.fnbha.org