Suicide Prevention for American Indian and Alaska Native Communities

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Suicide Prevention for American Indian and Alaska Native Communities Dale Walker, MD Laura Loudon, MS Patricia Silk Walker, PhD Doug Bigelow, PhD Michelle Singer Oregon Health and Science University Sioux Falls, South Dakota July 31, 2007

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

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 • Background: The environment and the system of care • The problem • Contributing factors • Warning signs • Prevention strategies • Promising programs • Integrated care approaches are best for treatment of these chronic illnesses

6. Indian Country 1491

9. Most Common Emotional Disabilities Among Native Youth • Learning Disabilities • Post Traumatic Stress Disorder • Conduct Disorder • Oppositional Defiant Disorder • Depression Disorders • Anxiety Disorders • Substance Use/Abuse Disorders • Developmental Disabilities

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

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

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

13. 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

14. A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country, July 2003 Funding not sufficient to meet needs for: • Health care • Education • Public safety • Housing • Infrastructure development needed U .S. Commission on Civil Rights

15. 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

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

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

19. 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.

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

21. 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.

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

23. Adjusted for Race Misreporting Unadjusted Age-Adjusted Suicide Death RatesCY 1996-1998 U.S. All Races (1997) = 10.6 IHS Adjusted Total - All Areas = 20.2

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

26. 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. Contents Background information Contributing factors Suicide warning signs Prevention strategies Information for schools Promising programs Garrett Lee Smith Programs Consultation and Technical assistance Consultants Community Suicide Assessment Tool Practice guidelines and evidence-based practices Resources

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

30. "The tribe is always hopeful we have a solution, but the problem with intervention is that it comes up on the backside of a suicide; usually after the fact. Tribes need to find out what is leading tribal people and the youth to suicide. They need to look at what is causing the despair." - Ron His Horse Is Thunder, Standing Rock Sioux

31. Domains Influencing Suicidal Behavior: A Native Ecological Model Individual Peer/Family Community/Tribe Society

32. Interacting Spheres of Influence

33. Interpersonal societal Stigma Environmental Tribal attitudes Community Parents Peers National attitudes Personality Genetics Individual Attitudes beliefs Local legal Cultural beliefs Interpersonal Schools State attitudes Personalsituations Individual Portrayal in media

34. 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

35. Risk and Protective Factors: Peer/Family • Risk • History of interpersonal violence/abuse/ • Bullying • Exposure to suicide • No-longer married • Barriers to health care/mental health care • Protective • Family cohesion • Sense of social support • Interconnectedness • Married/parent • Access to comprehensive health care

36. Risk and Protective Factors: Community/Tribal • Protective • Access to health care • Social support, close relationships, caring adults, school participation and bond • Respect for help-seeking • Skills to recognize and respond to risk • Traditional and cultural activities • Risk • Isolation/social withdrawal • Barriers to health care and mental health care • Stigma • Exposure to suicide • Unemployment • Poverty

37. Risk and Protective Factors: Societal • Risk • Rural/Remote • Loss or conflict of cultural values and attitudes • Stigma, racism • Media influence • Alcohol/drug misuse/abuse • Social disintegration • Economic instability • Protective • Urban/Suburban • Access to health care and mental health care • Cultural values affirming life • Media influence

38. Suicide Warning Signs • Changes in behavior • Acute stressful situations: violence, death, trouble with law, relationships ending • Chronic stressful situations: abuse, illness, family conflict • Changes in classroom performance: academic, behavioral • Changes at home: moving, parental conflict • Changes with peers: withdrawal, personality changes

39. 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.

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

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

42. 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.

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

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

45. Treatment Settings - Social Support: A Native Advantage • Tribal • Community • Family • Siblings • Peers • Individual

46. Cultural Approach • Original Holistic Approach • Psychopharmacology Approach • The unconscious has always been there • Group Therapy • Network Therapy • Recreational / Outdoors • Traditional Interventions • Indian is...

47. Possible Treatment/Prevention Activities • The Talking Circle • Smudging • Story telling • Traditional Healers • Medicine Person • Herbal remedies • Traditional ceremonies • Sweat Lodge • Traditional Experiences Preservation

48. 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

49. Effective Interventions for Youth • Family Therapy • Multisystemic Therapy • Case Management • Therapeutic Communities • Community Reinforcement • Circles of Care • Motivational Enhancement

50. Definitions: 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