The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

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

2. “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. 12-21-2009. www.marktrahant.com

3. Empowering Tribal Nations The President’s 2010 budget for the BIA - $2.3 billion – 7.1% increase. • “Self-determination, sovereignty, self-government, empowerment, and self-reliance are not abstract concepts; they are the tools that enable Indian Country to shape its own destiny.” • Violence, incidents of infant mortality, alcoholism, and substance abuse are far in excess of the rest of America Ken Salazar, Secretary of the Interior November 5, 2009

4. IHS Budget and Goals The President’s 2010 budget for the IHS - $4.03 billion - 13% increase - largest in 20 years. • To renew and strengthen partnership with tribes • In the context of national health reform, bring reform to IHS • To improve the quality and access to care for patients served by IHS • To have everything we do be transparent, accountable, fair, and inclusive Yvette Roubideaux , MD, IHS Director. Feb 4, 2010

5. Native Communities Advisory Council / Steering Committee One Sky Center

6. One Sky Center Partners Tribal Colleges and Universities Cook Inlet Tribal Council Alaska Native Tribal Health Consortium Prairielands ATTC Red Road Northwest Portland Area Indian Health Board One Sky Center Harvard Native Health Program United American Indian Involvement Jack Brown Adolescent Treatment Center National Indian Youth Leadership Project Tri-Ethnic Center for Prevention Research Na'nizhoozhi Center

7. One Sky Center Outreach

9. 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

13. Native Health Problems Alcoholism 6X Tuberculosis 6X Diabetes 3.5 X Accidents 3X Poverty 3x Depression 3x Suicide 2x Violence?

14. AmericanIndians • Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

15. 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 • State and Local Agencies • Federal Agencies: SAMHSA, VAMC, Justice

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

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

18. Behavioral Health Care Issues

19. Adult Serious Mental Illness By Race/Ethnicity: 2001 SAMHSA Office of Applied Studies, 2001

20. Frequent Mental Distress by Race/Ethnicity and Year Percent American Indian/ Alaskan Native** African-American** Hispanic White** Asian, Pacific Islander** ** Non-Hispanic Year * 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.

21. Mental Illness: A Multi-factorial Event Psychiatric Illness& Stigma Edu., Econ., Rec. Cultural Distress Impulsiveness Substance Use/Abuse Hopelessness Family Disruption/ Domestic Violence Individual Family History Negative Boarding School Psychodynamics/ Psychological Vulnerability Historical Trauma Suicidal Behavior

22. Adolescent Problems In Schools Alcohol Drug Use Fighting and Gangs 1. School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services Bullying Weapon Carrying School Environment Sale of Alcohol and Drugs Sexual Abuse Unruly Students Truancy Attacks on Teachers Staff Domestic Violence Drop Outs 12

23. Key Adolescent Risk Factors Aggressive/Impulsive Substance Abuse Depression Trauma

24. Tobacco use • Poor nutrition • Alcohol and other drug abuse • Behaviors resulting in intentional or unintentional injury • Physical inactivity • Risky sex Six behaviors that contribute to serious health problems:

25. 0 Suicide Among ages 15-17, 2001 Death rate per 100,000 2010 Target Females Males Total American Indian White Black Hispanic Asian Source: National Vital Statistics System - Mortality, NCHS, CDC.

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

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

29. 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.

30. ADDICTION INVOLVES MULTIPLE FACTORS Biology/Genes Environment DRUG Brain Mechanisms Addiction

31. Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth R. Dale Walker, M.D. (4/99) *100% completion sample

32. Changes in Lifetime Substance Use Among Urban Indian Youth * Over Nine Years Percentage ever used R. Dale Walker, M.D. (4/99) * 100% Completion Sample

33. Age of Onset of Drug Use Among Urban A IA (Walkers, 2008)

34. Models of Care

35. Domains Influencing Behavioral Health: A Native Ecological Model Risk Protection Individual Peers/Family Community/Tribe Society/Cultural

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

37. The Intervention Spectrum for Behavioral Disorders Treatment C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t f o r K n o w n Indicated— Diagnosed Youth D i s o r d e r s Prevention Maintenance C o m p l i a n c e Selective— Health Risk Groups w i t h L o n g - T e r m T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

38. Risk and Protective Factors: Individual • 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

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

40. 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.

41. Implications for Treatment • Teach adolescents how to cope with difficulties and adversity • Increase their repertoire of coping strategies • Cognitive therapy is most effective approach

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

43. Culture-Based Interventions • Story telling • Sweat Lodge • Talking circle • Vision quest • Wiping of tears • Drumming • Smudging • Traditional Healers • Herbal remedies • Traditional activities

44. 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

45. Definition: 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.

46. Definitions: 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

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

48. What are some promising strategies?

49. An Ideal Intervention • Broadly based: Includes individual, family, community, tribe, and society • Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance

50. 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 Choctaw Nation of Oklahoma