Native Adolescent Suicide: Emerging Community Based Integrative Care Models

1. Native Adolescent Suicide: Emerging Community Based Integrative Care Models One Sky Center R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer Navajo Nation Window Rock, Arizona November 6, 2009

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

3. One Sky Center Outreach

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

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

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

9. Age Distribution American Indians 2004

10. 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

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

12. Poverty Status by Race and Age 2000

13. 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:

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

15. Suicide: A Multifactorial 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

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

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.

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.

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.

21. Blog #4 • There are so many deaths because of stuffLike diabetes, heart diseases, and notTaking good care of your self.And all The drugs and Alcohol…

22. 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.

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

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

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

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. 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

30. Domains Influencing Suicidal Behavior: A Native Ecological Model Risk Protection Individual Peers/Family Community/Tribe Society/Cultural

31. 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, empathy • perseverance, optimism, • Intellectual competence, reasons • for living

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

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

35. Definitions: 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.

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

37. What are some promising strategies?

38. 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 AI/AN Prevention, Treatment, and Rehabilitation Interventions

39. 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. 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.)

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

42. Reasons for Not Seeking Formal Help When Suicidal

43. Reasons for Not Seeking Informal Help When Suicidal

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

46. Five Key PrinciplesEvidence-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 • Evaluate

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