Providing Behavioral Health Care in Native Communities: Social Determinants of Health

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Providing Behavioral Health Care in Native Communities: Social Determinants of Health Oregon Health and Science University Portland, Oregon March 2, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer Global Health Lecture Series

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

6. 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.

7. Social Determinants of Health • Ubiquitous • Powerful influence on health • Underlie: • Differences between individuals within countries • Differences between groups, populations and countries • Changes in health over time • Complex pathways

8. 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

9. 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

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

15. 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

16. Native Healthcare Resource Disparities

17. 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

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

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

20. Behavioral Health Care Issues

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

22. 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.

23. 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

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

25. 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: http://www.cdc.gov/HealthyYouth/healthtopics/index.htm

26. 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.

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

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

30. 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.

31. Models of Care

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

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

34. 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.

35. 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

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

37. 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

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

39. 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.

40. 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

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

42. What are some promising strategies?

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

44. 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

45. 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

46. 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.)

47. Comprehensive School Planning • Prevention and behavioral health programs/services on site • Handling behavioral health crises • Responding appropriately and effectively after an event • Public awareness and media campaigns • Youth Development Services • Social Interaction Skills Training Approaches • Mentoring • Tutoring • Rites of Passage

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

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

50. 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