Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Substance Abuse and Mental Health Issues in Native Communities: Problems, Strategies, and Solutions HIV in the Circle of Life Niagara Falls, New York. June 10, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer NY/NJ Aids Education and Training Center

2. Native Communities Advisory Council / Steering Committee Education Opportunity, Research Mentorship One Sky Center Training, Consultation, Technical Assistance Excellence Tribal Leadership

3. 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

4. One Sky Center Outreach

5. Goals for Today • Review An Environmental Scan for Natives • Discuss Fragmentation and Integration • Present Some Behavioral Health Care Issues • Define Social Determinants of Health • Present Examples of Treatment and Prevention • Summarize Critical Issues for Native Peoples

6. Who are indigenous peoples? “Indigenous peoples remain on the margins of society: they are poorer, less educated, die at a younger age, are much more likely to commit suicide, and are generally in worse health than the rest of the population." (Source: The Indigenous World 2006, International Working Group on Indigenous Affairs (IWGIA) WHO

7. INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

11. American Indian Population 2000

13. Native Healthcare Resource Disparities

14. 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

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

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

17. Behavioral Health Care Issues

18. Native Health Issues • Alcoholism 6X • Tuberculosis 6X • Diabetes 3.5 X • Accidents 3X • Poverty 3x • Depression 3x • Suicide 2x • Violence? • Same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

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

23. 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.

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

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

28. Models of Care

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

30. 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.

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

32. 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

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

34. 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

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

36. What are some promising strategies?

37. Whitehall Studies of British Civil Servants (Across Pay Grades ) 1977 • Within a hierarchical society, there is a social gradient for morbidity and mortality. (Poverty, sanitation, nutrition, and shelter are controlled.) • Higher status folks live longer and healthier. Health Care Improvement Needs More Than Money: • Opportunity, Empowerment, Security, Control and Dignity…. www.thelancet.com Dec 9, 2006. Marmot AmartyaSen 1998 Nicholas Stern 2004

38. The Social Determinants of Health • The conditions in which people are born, grow, live, work and age. • Shaped by the distribution of money, power and resources at global, national and local levels. • Are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. WHO Commission on Social Determinants of Health | August 28 2008

39. WHO Social Determinant Themes • Social exclusion • Urbanization • Globalization • Health systems • Priority public health conditions • Early child development • Women and gender equity • Employment conditions • Measurement and evidence

40. Conceptual Framework of Health Determinants

41. Critical Elements for Native Peoples • Self determination • Ecology and environment • Economic prosperity, fairness and equity • Leadership and capacity strengthening • Racism / dominance / imperialism • Healing, services, systems, structures • Cultural sustainability, protection, stewardship • Land • Human rights

42. An Ideal Intervention • Broadly based: Includes individual, family, community, tribe, and society • Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance • Opportunity, empowerment, security, dignity

43. 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

44. Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation Meth Free Crowalition • Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment • Combine forces for Unity. • Diverse community representation • Youth and Community Development: mentorship, leadership, trust, establish community norms

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

46. Six Key PrinciplesEvidence-based predictors of change • Leadership • Mobilization Community driven • Public health approach • Strength based • Culturally informed • Proactive

47. Areas for Action Health Equity in all Policies Good Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Responsibility Gender Equity Political empowerment – inclusion and voice

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

49. NIDA American Indian Research Scholars Mentorship Program

50. Location of Mentors = and Mentees = in Project X X X X X X X X X