The American Indian/Alaska Native National Resource Center
for Substance Abuse and Mental Health Services
A Strategy for Native Youth Mental Health
Treatment and Prevention Services and
Programming
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Bentson McFarland, MD, PhD, Michelle Singer
Oregon Health and Science University
Tribal Justice and Safety Regional Conference
Mystic Lake, Minnesota March 26, 2007
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One Sky
Center
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One Sky Center Partners
Cook Inlet Tribal Council
Alaska Native Tribal
Health Consortium
Northwest Portland Area
Indian Health Board
Tribal Colleges
and Universities
Prairielands ATTC
Red Road
One Sky
Center
United American
Indian Involvement
Harvard Native
Health Program
Jack Brown
Adolescent
Treatment Center
National Indian Youth
Leadership Project
Tri-Ethnic Center for
Na'nizhoozhi Center Prevention Research
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One Sky Center Outreach
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Goals for Today
•
•
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An Environmental Scan
Behavioral Health Care System Issues
Fragmentation and Integration
Discuss Mental Health and Comorbidity
Indigenous Knowledge + Evidence Based Knowledge
= Best Practice
• Integrated care approaches are best for treatment of
these chronic illnesses
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Five Missions Impossible?
• How do we define problems?
• How do we ask for help?
• How do we get Federal and State agencies to
work together and with us?
• How do we build our communities?
• How do we restore what is lost?
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Ten Leading Causes of
Disability in the World
•
•
•
•
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•
•
•
•
•
Unipolar Depression
Iron-deficiency Anemia
Falls
Alcohol Use
COPD
Bipolar disorder
Congenital anomalies
Osteoarthritis
Schizophrenia
Obsessive-compulsive
disorder
• 10.7%
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2
(WHO, 1997)
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Juvenile Justice Mental Disorder Rates
Males (n = 1,170)
Females (n = 656)
Prevalence
Prevalence
Any Listed
66.3
73.8
Conduct Disorder
5.4
3.8
Disruptive Behavior
41.4
45.6
ADHD
16.6
16.4
Affective
18.7
27.6
Anxiety
21.3
30.8
Psychotic
1.0
1.0
Substance Use
50.7
46.8
Type of disorder
Chicago Detention Center (Teplin,2002)
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Most Common Disabilities
Among Youth in the JJ System
• Learning Disabilities
• Post Traumatic Stress Disorder (higher in
girls) *
• Conduct Disorder
• Oppositional Defiant Disorder
• Depression
• Anxiety Disorders
• Substance Use/Abuse Disorders
• Developmental Disabilities
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Mental Health Needs: Across
Juvenile Justice Placements
A study compared mental health needs among a
random sample of youth (n=473) within the
juvenile justice system found mental health
problems in:
– 45.9 % of youth on probation,
– 67.5% youth incarcerated, and
– 88 % youth adjudicated to residential treatment
centers
(Lyons, Quigley, Erlich & Griffin, 2001)
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Native Health Problems
1.
2.
3.
4.
5.
Alcoholism 6X
Tuberculosis 6X
Diabetes 3.5 X
Accidents 3X
60% Over 65 live in poverty
(US 27%)
6. Depression 3x
7. Violence?
American Indians
• Have same disorders as general
population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated
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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
5. State and Local Agencies
6. Federal Agencies: SAMHSA, VAMC,
Justice
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Disconnect Between
Justice/Addictions/Mental Health
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•
•
•
Professionals are undertrained
Patients are underdiagnosed
Patients are undertreated
None integrates well with medical and social
services
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Difficulties of Program
Integration
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•
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•
•
•
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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
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell, 7/03)
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated
System (Carl Bell, 7/03)
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Suicide Among ages 15-17, 2001
Death rate per 100,000
16
14
12
10
8
6
4
2010
Target
2
00
Total
Females Males
Source: National Vital Statistics System - Mortality, NCHS, CDC.
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Suicide: A Native Crisis
AI Male
Black Male
AI Female
50
40
30
20
Age Groups
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Source: National Center for Health Statistics 2001
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
60
White Male
SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality
Disorder/Traits
Neurobiology
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness
Family History
Access To Weapons
Life Stressors
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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Adolescent Problems In Schools
1. School Admin
Fighting
and
Gangs
2. Law
3. FBI
Alcohol
Drug
Use
Weapon
Carrying
Bullying
4. DEA
5. State MH
6. State A&D
Sexual
Abuse
Environment
7. Courts
8. Child Services
School
Sale of
Alcohol
and Drugs
Unruly
Students
Truancy
Attacks
on Teachers
Staff
Drop
Outs
Domestic
Violence
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Key Adolescent Risk Factors
Aggressive/Impulsive
Substance Abuse
Depression
Trauma
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Comorbidity Defined
“Individuals who have at least one mental
disorder as well as an alcohol or drug use
disorder. While these disorders may interact
differently in any one person….at least one
disorder of each type can be diagnosed
independently of the other.”
- Report to Congress of the Prevention and
Treatment of Co-Occurring Substance Abuser
Disorders and Mental Disorders, SAMHSA, 2002
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Lifetime History
Mental Disorder
22.5%
Comorbidity
29%
Alcohol Disorder
13.5%
Comorbidity
45%
Drug Disorder
6.1%
Comorbidity
72%
Regier, 1990
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Lifetime Psychiatric Diagnoses
Among Primary Caretakers (N=207)
40
Percentage
30
20
10
0
Lifetime
Depression
Panic Disorder
Antisocial
Personality
Clean
R. Dale Walker, M.D. (7/97)
Current
Depression
Dysthymia
Confounded
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Multiple Diagnoses Increase
• Treatment seeking
• Use of services
• Likelihood of no services
• Treatment costs
• Poor outcome
• Suicide risk
Dual diagnosis is an expectation, not an
exception
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The Intervention Spectrum
for Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
Compliance
with Long-Term
Treatment
(Goal:Reduction in
Relapse and Recurrence)
Aftercare
(Including
Rehabilitation)
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of
Medicine, Washington, DC: National Academy Press, 1994.
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Spectrum of Intervention Responses
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
Severe
Problems
Treatment
Brief Intervention
Universal/Selective
Prevention
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Ecological Model
Society
Community/
Tribe
Peer/Family Individual
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Environmental
Interpersonal
societal
Stigma
Community
Tribal
attitudes
Parents
Peers
Personality
National
attitudes
Genetics Individual Attitudes
beliefs
Cultural
beliefs
Schools
Interpersonal
Local
legal
State
attitudes
Personal situations
Individual
Portrayal in media
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Individual Intervention
• Identify risk and protective factors
counseling
skill building
improve coping
support groups
• Increase community awareness
• Access to hotlines other help resources
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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.
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Implications for Treatment
•
•
•
Teach adolescents how to cope
with difficulties and adversity
Increase their repertoire of
coping strategies
Cognitive therapy is most
effective approach
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Behavioral Health Programs
Should . . . . Reduce Risk Factors








ineffective parenting
chaotic home environment
lack of mutual attachments/nurturing
inappropriate behavior in the classroom
failure in school performance
poor social coping skills
affiliations with deviant peers
perceptions of approval of drug-using
behaviors in the school, peer, and community
environments
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Behavioral Health Programs
Should . . . . Enhance Protective Factors
 strong family bonds




parental monitoring
parental involvement
success in school performance
prosocial institutions (e.g. such as family,
school, religious, and tribal organizations)
 conventional norms about
drug use
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Sources of Strength
Access to Mental Health
Access to Medical
Spirituality
Generosity/Leadership
Family Support
Positive Friends
Caring Adults
Positive Activities
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Effective Interventions for Adults
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Cognitive/Behavioral Approaches
Motivational Interventions
Psychopharmacological Interventions
Modified Therapeutic Communities
Assertive Community Treatment
Vocational Services
Dual Recovery/Self-Help Programs
Consumer Involvement
Therapeutic Relationships
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Effective Interventions for Youth
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Family Therapy
Multisystemic Therapy
Case Management
Therapeutic Communities
Community Reinforcement
Circles of Care
Motivational Enhancement
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Treatment Settings - Social
Support: A Native Advantage
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Tribal
Community
Family
Sibs
Peers
Individual
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Cultural Approach
• Original Holistic Approach
• Psychopharmacology Approach
• The unconscious has always been
there
• Group Therapy
• Network Therapy
• Recreational / Outdoors
• Traditional Interventions
• Indian is...
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Possible Treatment/Prevention
Activities
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The Talking Circle
Smudging
Story telling
Traditional Healers
Medicine Person
Herbal remedies
Traditional ceremonies
Sweat Lodge
Traditional Experiences Preservation
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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.
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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
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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
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Definitions:
Best Practices
• Examples and cases that illustrate the use of
community knowledge and science in
developing cost effective and sustainable
survival strategies to overcome a chronic
illness.
WHO 2002
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ID Best Practice
Best Practice
Clinical/services
Research
Mainstream
Practice
Traditional
Healing
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Circle of Care
Traditional
Healers
Primary Care
A&D
Programs
Best
Practices
Child &
Adolescent
Programs
Boarding
Schools
Colleges &
Universities
Prevention
Programs
Emergency
Rooms
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What Is Integrative Medicine?
Basic
Science
Wellness
CAM
literacy
Patient
Evidence Centered
Care
Based
Cultural
MedicinePower
Sensitivity
Of the
Mind
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Principles of Integrative
Medicine
1. It is better to prevent than to treat later.
2. Recognition of the interaction between
body, mind, spirit, and environment.
3. Integrate the best of conventional and
traditional medicine.
4. Belief that bodies respond uniquely, so
treatment must be customized.
5. Belief in innate healing powers of the
body.
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WHAT ARE SOME PROMISING STRATEGIES?
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Promising Strategies
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Home visitation
Parent training
Mentoring
Heroes
Social cognitive
Cultural
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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.)
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Comprehensive school
planning
• Prevention and behavioral health
programs/services on site
• Handling behavioral health crises
• Responding appropriately and
effectively after an event occurs
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Community Driven/School Based
Prevention Interventions
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Public awareness and media campaigns
Youth Development Services
Social Interaction Skills Training Approaches
Mentoring Programs
Tutoring Programs
Rites of Passage Programs
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Unified Services Plan
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Mental health
Education/vocation
Justice/safety
Leisure/social
Parenting/family
Housing
Financial
Daily living skills
Physical health
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Potential Organizational
Partners
• Education
• Law Enforcement
• Family Survivors
• Juvenile Justice
• Health/Public Health
• Medical Examiner
• Mental Health
• Faith-Based
• Substance Abuse
• County, State, and
Federal Agencies
• Traditional Healers
• Elders
• Girls/Boys Clubs
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Partnered Collaboration
State/Federal
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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Recommendations
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•
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•
•
Develop interagency task forces
Bring in supportive/interested state partners
Reach out to bring in new resources
Be clear, positive, and direct
Remember what this effort is all about
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Evidence-based coordination–
linkage mechanisms
• formal agreements among behavioral health,
primary health care providers and justice;
• case management of behavioral health, justice,
and primary health care;
• co-location of behavioral health, and primary
health care services;
• delivery of mental, substance-use, and primary health
care through clinically integrated practices
of primary and M/SU care providers.
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Making It Work for Youth and
Families Involved in Juvenile Justice
• Engage All Leaders on all Decisions
• Know the decision points in the JJ System
At point of arrest/earliest point to divert
At point where decisions to charge are made/diversion
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•
•
•
At intake to juvenile court/diversion
Make information accessible
Make resources/services more accessible
Increased screening
Target adolescents
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Contact us at
503-494-3703
E-mail
Dale Walker, MD
onesky@ohsu.edu
Or visit our website:
www.oneskycenter.org
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