[Senate Hearing 109-66]
[From the U.S. Government Publishing Office]



                                                  S. Hrg. 109-66, Pt. 2

                        YOUTH SUICIDE PREVENTION

=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             FIRST SESSION

                                   ON

OVERSIGHT HEARING ON THE CONCERNS OF TEEN SUICIDE AMONG AMERICAN INDIAN 
                                 YOUTHS

                               __________

                             JUNE 15, 2005
                             WASHINGTON, DC

                               __________

                                 PART 2

                               __________

                    U.S. GOVERNMENT PRINTING OFFICE
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                      COMMITTEE ON INDIAN AFFAIRS

                     JOHN McCAIN, Arizona, Chairman

              BYRON L. DORGAN, North Dakota, Vice Chairman

PETE V. DOMENICI, New Mexico         DANIEL K. INOUYE, Hawaii
CRAIG THOMAS, Wyoming                KENT CONRAD, North Dakota
GORDON SMITH, Oregon                 DANIEL K. AKAKA, Hawaii
LISA MURKOWSKI, Alaska               TIM JOHNSON, South Dakota
MICHAEL D. CRAPO, Idaho              MARIA CANTWELL, Washington
RICHARD BURR, North Carolina
TOM COBURN, M.D., Oklahoma

                 Jeanne Bumpus, Majority Staff Director

                Sara G. Garland, Minority Staff Director

                                  (ii)

  
                            C O N T E N T S

                              ----------                              
                                                                   Page
Statements:
    Carmona, Richard, M.D., Surgeon General of the United States.     3
    Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice 
      chairman, Committee on Indian Affairs......................     1
    Flatt, Clark, president and CEO, Jason Foundation............    22
    Garreau, Julie, executive director, Cheyenne River Youth 
      Project, Cheyenne River Sioux Tribe........................    18
    Grim, Charles, director, Indian Health Services..............     3
    Johnson, Hon. Tim, U.S. Senator from South Dakota............     7
    McCain, Hon. John, U.S. Senator from Arizona, chairman, 
      Committee on Indian Affairs................................     3
    Rough Surface, Twila, Standing Rock Sioux Tribe..............    14
    Smith, Hon. Gordon, U.S. Senator from Oregon.................     5
    Stone, Joseph B., American Psychological Association.........    15
    Walker, R. Dale, director, One Sky Center, Oregon Health and 
      Sciences University........................................    20

                                Appendix

Prepared statements:
    American Academy of Child and Adolescent Psychiatry and the 
      American Psychiatric Association Joint Statement...........   168
    American Occupational Therapy Association....................   175
    Booth, Sr., Terrance H., Metiakatla Indian Community.........    34
    Carmona, Richard, M.D. (with responses to questions).........    36
    Estes, Tolly, Crow Creek Reservation.........................   179
    Flatt, Clark (with attachment)...............................    52
    Garreau, Julie (with attachment).............................    65
    Graham, Mike, member, Oklahoma Cherokee Nation (with 
      attachment)................................................   193
    Kitcheyan, Kathleen W., chairwoman, San Carlos Apache Tribe..   203
    Murphy, Charles W., chairman, Standing Rock Sioux Tribe......   207
    National Indian Child Welfare Association....................   214
    Rough Surface, Twila.........................................    34
    Smith, Hon. Gordon, U.S. Senator from Oregon.................    33
    Stone, Joseph B. (with attachment)...........................    71
    Walker, R. Dale (with attachment)............................   150
Additional material submitted for the record:
    Steroid Use Among Females, Centers for Disease Control and 
      Prevention, Department of Health Human Services............   229

 
                        YOUTH SUICIDE PREVENTION

                              ----------                              


                        WEDNESDAY, JUNE 15, 2005


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:30 a.m. in room 
485 Senate Russell Building, Hon. Byron Dorgan (vice chairman 
of the committee) presiding.
    Present: Senators McCain, Dorgan, Smith, and Johnson.

  STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH 
       DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

    Senator Dorgan. We will begin the hearing today.
    This is a hearing of the Senate Committee on Indian 
Affairs. My name is Senator Dorgan. I am joined by the chairman 
of the committee who has asked that I convene the hearing and 
appreciate very much your being here today and appreciate the 
leadership of Senator McCain. We have had the opportunity to 
work together for a long while and we have worked together on a 
lot of very important issues.
    The hearing this morning is for the purpose of discussing 
an issue that is very important and very sensitive. When I 
talked to Senator McCain about holding this hearing, he was 
very interested in having us do that. He has asked me to chair 
this hearing and I appreciate very much his graciousness in 
doing it.
    This is a hearing in many ways that all of us wish we were 
not attending, to discuss a subject that perhaps we would wish 
that we had not had to discuss, but we do. It is the issue of 
teen suicides. I do not want to imply that teen suicides 
represent only a problem on Indian reservations, but I do want 
to recognize that the problem is more acute there than in other 
areas.
    We know that suicide is the second leading cause of death 
of American Indians, Native Americans, aged 15 to 24, 2\1/2\ 
times the national average. Native American children under the 
age of 15 are 5 times more likely to take their own life than 
the population, the same age population generally. In the 
northern Great Plains, the rate is 10 times higher for teenage 
children on reservations taking their own life than other 
children of the same age in this country.
    There is in some areas an epidemic of teenage suicide. It 
would be more comfortable perhaps not to talk about it 
publicly, but it would be the wrong thing to continue watching 
this happen, seeing the broken hearts and deciding to do 
nothing about it.
    The Standing Rock Reservation in North Dakota and South 
Dakota which covers both States has had 12 suicides in the last 
6 months. I have spoken on the floor of the Senate. I have 
spoken on the floor of the Senate maybe four or five times 
about a young woman named Avis Little Wind, a 7th-grader, and I 
have used her name with the permission of her family, a young 
woman who felt that life was so hopeless that she took her 
life, this 7th-grader took her life. Her sister had taken her 
life 2 years previous to that. She lay in a bed for 90 days, 
missed 90 days of school.
    Mental treatment was not readily available. I went to that 
reservation and talked about this young 7th-grade girl, talked 
to her classmates in school, talked to the school officials, 
talked to the mental health officials, talked to the tribal 
officials, just to try to understand what has happened, not 
just in this situation, but in others.
    Because in this same situation on the same reservation, I 
held a hearing in Bismarck, ND and a young woman who on that 
reservation came to testify at the hearing broke down and began 
sobbing during the testimony. She said, you know, I just have 
to beg to try and find a car to see if I can help give a kid a 
ride to a clinic someplace. She said, I have a stack of 
allegations of child abuse on the floor in my office that have 
never been investigated because I have no resources.
    And then she said, I do not even have the vehicle to drive 
a troubled kid to get some help. And then she began sobbing. 
She quit her job about 1 month after that hearing.
    The point is we have very serious problems. Dr. Grim 
testified at a hearing I held in Bismarck, ND, again with the 
permission of the chairman of the committee, for which I am 
grateful. Dr. Grim, I think, made the point, and it is a really 
important point, he said, suicide is not a single problem. It 
is a single response to multiple problems. Neither is it a 
strictly clinical or individual problem, but one that affects 
and is affected by entire communities.
    Some families of children who had taken their lives came to 
see me after the last hearing, and some children who were 
friends of children who had taken their lives came to see me. 
One of the things that I remember about the classmates was they 
said, you know, so-and-so, naming one of their friends, really 
did not mean to die. He just wanted some attention to the 
things that he was going through, the problems he was facing in 
his life. He wanted some attention to those problems. We do not 
think that he wanted really to die.
    So look, we have some serious issues that we are facing on 
this committee. We are trying to reauthorize the Indian Health 
Care Improvement Act and we are going to do that this year. My 
hope is, and I believe the hope of the chairman, is that 
perhaps as we do that a portion of that, a piece of that might 
also begin to address this issue as we learn more about it and 
determine how we can try to apply some more attention and some 
more resources to this issue, and say to those young children 
who are too often now thinking about taking their lives, that 
you are not alone. This is not hopeless. You are not helpless. 
We are here and we want to do something to address this very 
difficult and very sensitive issue.
    So again, let me thank all of you for being here. I 
recognize that in calling this hearing we are dealing with a 
difficult topic, but I think it is time, long past the time for 
us to discuss it publicly and evaluate what we can do to reach 
out to these children.
    Senator McCain.

   STATEMENT OF HON. JOHN McCAIN, U.S. SENATOR FROM ARIZONA, 
             CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

    The Chairman. Thank you very much, Senator Dorgan. And 
thank you for your leadership and the commitment you have made 
on this issue.
    There is very little I can say which would add to your very 
compelling opening comments, so I will not, except to say that 
I am pleased that Vice Admiral Richard Carmona, the Surgeon 
General of the United States, could be here today. Admiral 
Carmona, I know you have faced numerous challenges in your 
career as a professor, a health professional, a deputy sheriff, 
and even a SWAT team leader. Throughout your career, you have 
demonstrated exceptional leadership, particularly in addressing 
psychological and mental trauma in communities. I am encouraged 
that you are taking a leadership role in addressing Indian 
youth suicide.
    I thank you again, Senator Dorgan, and I appreciate your 
very compelling and strong leadership on this issue. Thank you.
    Senator Dorgan. Senator McCain, thank you very much.
    I might point out that we will have a vote in the Senate 
probably somewhere between 10 a.m. and 10:30 a.m., we expect, 
so at that point I will recess the hearing just for 15 minutes 
to go and vote.
    In the meantime, we have two panels of witnesses. The first 
panel is Dr. Carmona. Senator McCain has described in some 
detail, Dr. Carmona, your very interesting background. We 
appreciate your public service. You are accompanied by Charles 
Grim. Dr. Carmona is the Surgeon General of the United States. 
Dr. Grim is the Director of the Indian Health Service. Dr. Grim 
testified at a previous hearing on this subject. We held a 
hearing in Bismarck, ND.
    We appreciate both of you being here. Dr. Carmona, we will 
include your full statement as a part of the record, and you 
may proceed orally.

  STATEMENT OF RICHARD CARMONA, M.D., SURGEON GENERAL OF THE 
 UNITED STATES, ACCOMPANIED BY CHARLES GRIM, DIRECTOR, INDIAN 
                         HEALTH SERVICE

    Mr. Carmona. Thank you, sir. Senator McCain and Senator 
Dorgan, thank you for the privilege of being with you today and 
allowing me to address this very important issue.
    My name is Rich Carmona. I am the Surgeon General. I 
certainly do appreciate this opportunity. I am joined today by 
my colleague Rear Admiral Charles Grim, also Assistant Surgeon 
General and Director of the Indian Health Service.
    As you know, the mental health of our Nation is a critical 
component of our Nation's public health. Suicide is one of the 
most tragic events that a family can endure. Suicide costs us 
more than 30,000 lives a year. That is almost 1 person every 15 
minutes. Once every 45 seconds, someone engages in suicidal 
behavior.
    Even if the life is spared, the heartache and pain are so 
severe that the spirit may never fully heal. The science tells 
us that the suicide rates in Indian country are generally 
higher and are characterized by younger people engaging in 
fatal and nonfatal suicidal behavior at much higher rates than 
the overall U.S. population.
    For 5 to 15 year-olds, the suicide rate is more than twice 
the average of the national average and there is an even 
greater disparity in the later teenage years and into young 
adulthood. The suicide rate for American Indian and Alaska 
Native youth aged 15 to 24 is more than 3 times higher than the 
national average. In fact, young people aged 15 to 24 make up 
40 percent of all suicides in Indian country.
    The reality is that in many of our tribal communities, 
suicide is not just an individual clinical condition, but also 
a community condition. To address it appropriately requires 
public health and community interventions, as much as clinical 
interventions. It also requires resources to understand and 
support the interventions. The Administration's 2006 budget 
request for IHS includes $59 million for mental health. That is 
a $4-million increase over 2005.
    This leads me to the next critical question: What are we 
doing to prevent suicide in Indian country? My predecessor, 
Surgeon General David Satcher, shined a bright light on the too 
often darkened pain of suicide. In 1999, he issued the 
Surgeon's General Call to Action to Prevent Suicide. It brought 
the best science together with the best experience on the 
subject of suicide prevention. Dr. Satcher was also 
instrumental in developing the national strategy for suicide 
prevention. The strategy is the national blueprint for action 
for suicide prevention.
    Today, it is an ongoing joint effort of SAMHSA, the CDC, 
NIH, PHSA and in Indian country, the Indian Health Service. I 
am proud to report that for the general population, the long-
term trend in the United States has been toward a decline in 
the suicide rate. However, suicide in Indian country is not 
declining.
    One of Dr. Grim's first acts as Interim Director of the IHS 
in 2002 was to convene a tribal consultation on behavioral 
health. Representing over 200 tribal organizations, the 
consultation provided recommendations for long-term goals to 
revitalize and promote behavioral health in Indian country. In 
the past 3 years, every one of those goals has been addressed.
    But this marks only the beginning of a much longer process 
to bring leadership programs and resources to this ongoing 
crisis. For example, the Jicarilla Apache of Northern New 
Mexico have engaged in a successful effort to develop a 
community-based intervention strategy. It brought together 
tribal leadership, community members, youth, as well as 
university and IHS clinicians and researchers to design and 
implement the program.
    The result is that over the past decade, suicidal activity 
has fallen by approximately 60 percent among the Apaches and 
has been maintained at that level. This success is more 
evidence that effective programs require clinical, educational, 
community, interagency, and intergovernmental input.
    Work like this is ongoing, led from the top by President 
Bush and Secretary Leavitt, our bosses. We are working to 
address the risks for suicide. The first international meeting 
of the Indian Health Service Director's National Behavioral 
Health Initiative will be coming up this fall, led by Rear 
Admiral Grim. The charge is to provide strategic leadership and 
implement ongoing work groups for action.
    As I mentioned, the National Strategy for Suicide 
Prevention is being implemented across the Nation, including 
Indian country. Of course, the funds available made under the 
Garrett Lee Smith Memorial Act that President Bush signed in 
October 2004 will help enable States, Indian tribes, colleges 
and universities to develop suicide prevention and intervention 
programs.
    In closing, there are many positives that can result from 
discussions like the one we are having today. By talking about 
suicide and suicidal behavior, we take it out of the darkness, 
shine a light on it. It should always be okay to talk about 
being depressed or about having suicidal thoughts. Young people 
should be able to go to their parents, teachers and other 
caring adults for help with depression and even anger, without 
feeling like they will be labeled weak or bad or broken.
    Paramedics and emergency room doctors are often heralded as 
life-saving heroes. Each of them deserves praise, that is true. 
But so does everyone who has ever held out a hand, given a hug, 
or spoken words of encouragement when a person considering 
suicide needs it most. Everyone has an important role in this 
cause and we must all band together for hope.
    With that, I will end my testimony. I would ask to be able 
to submit my entire written statement into the record. Thank 
you. I look forward to our discussion this morning.
    [Prepared statement of Dr. Carmona appears in appendix.]
    Senator Dorgan. Dr. Carmona, thank you very much.
    We have been joined by our fellow Senator from Oregon. Let 
me say that all of us understand that his family has been 
visited by this tragedy and has been a catalyst for him to lead 
the U.S. Senate and the Congress in a very constructive 
direction to address these issues. I am very proud of the work 
that he has done, as are all of my colleagues. Let me see if he 
would like to make an opening statement.

    STATEMENT OF HON. GORDON SMITH, U.S. SENATOR FROM OREGON

    Senator Smith. Senator Dorgan and Mr. Chairman, thank you 
for holding this hearing. I have an opening statement, but I do 
not think I can get through it. So let me ask that it be 
included in the record. Let me also thank you for helping to 
highlight this issue.
    When President Bush signed this into law, the Garrett Lee 
Smith Memorial Act, which the Senate unanimously passed, the 
substantial piece of legislation designed to help young people 
in college, in high school, in Indian tribes specifically, to 
get the help they need so that they can cope with an illness 
which is just as lethal as physical illness.
    President Bush signed this on a day in the midst of a very 
difficult political campaign. He did it quietly. He did it 
quietly because of the sensitivity of the issue and the desire 
on my wife's and my part that it not be in any way politicized. 
There were present on that occasion some of the President's 
political opponents, but not his enemies, specifically Senator 
Kennedy among them. But by doing it quietly, perhaps there was 
one disadvantage. That is that many people do not know about 
what the Federal Government is now trying to do.
    So again, Mr. Chairman, thank you for having this hearing, 
with this clarion call saying to tribes and to States and 
universities, apply for these funds; develop suicide 
intervention programs because this is a problem that can be 
addressed and successfully if done in a timely way.
    There is nothing worse in life than life without hope. Some 
people of our citizenry are unable to find hope in living 
because of the makeup of their brains, of their chemistry and 
there is help that can be found to help them to do that.
    So I think my only message this morning, Mr. Chairman, is, 
I think Senator Dorgan is on the Appropriations Committee, the 
Garrett Lee Smith Memorial Act authorized $82 million for 3 
years. The first $10 million was appropriated in the last 
Congress, and $27 million is what is required to stay on 
course. I would just simply ask all of our appropriators to 
make sure we get $27 million.
    If we are truly serious about being pro-life, I can think 
of few appropriations that could do more to help our Native 
American children and all of America's children who suffer from 
bipolar afflictions, manic-depression, schizophrenia or 
whatever the cause, to find the way to get the help they need 
to contribute to our great Nation the way that they can, even 
with mental disorders.
    So with that, Mr. Chairman, I will just include my 
statement in the record.
    [Prepared Statement of Senator Smith appears in appendix.]
    Senator Dorgan. Senator, thank you very much. Certainly as 
one appropriator, I am pledging to do everything we can to 
fully fund this requirement. It seems to me you cannot 
understand this problem and decide to do less than is humanly 
possible to deal with it. I hope our colleagues will agree on 
the Appropriations Committee.
    Dr. Carmona, I quoted Dr. Grim that this does not arise 
from one cause. I mentioned, for example, the one young woman 
who was dealing with these children's issues on one reservation 
who broke down and sobbed because she just had no resources. 
With the resources that are available at this point, do you 
have some confidence that ultimately on these reservations 
there will be adequate mental health services staffing for the 
psychologists, social workers, psychiatrists and others to be 
able to respond to these needs?
    Mr. Carmona. Sir; I am happy to address that. My answer 
maybe predates me being Surgeon General because I have had the 
privilege and opportunity to live and work in Indian country 
for a couple of decades in Arizona, and have gained a great 
appreciation and fondness for the culture, for the people, for 
their passion and also for the deficiencies in the communities.
    I think we are on the right road to remedy this very 
longstanding situation, which as you mentioned and as my 
colleague Admiral Grim has mentioned, is multi-factorial. It is 
people who have been robbed of their culture. It is people who 
are living a different life than their ancestors are used to. 
It is being disconnected from their families. It is being 
disconnected from mainstream America.
    It is so many variables, but we understand many of the 
variables because many of our people in the Public Health 
Service live among Indian country. Many of the programs that 
are in place now and growing based on funding that you have 
mentioned and the National Strategy for Suicide Prevention are 
working in the right direction.
    It is not all about clinicians. It is really about 
improving health literacy; that the people understand the 
genesis, the cause of the problems; that we who have the 
privilege to serve them understand the uniqueness of the 
culture; that we work hand in hand with our Indian partners to 
develop strategies that will address many of the issues.
    And not just in response to, but to prevent, to change 
culture, to change environments so that people do not feel that 
despondent in the environment; that they see hope where there 
was otherwise despair. That is not just psychologists or 
psychiatrists, but it is community health workers. It is faith 
healers within the community and so on.
    So I think we are developing robust programs. We are 
heading down the right path, but we should not forget that it 
has taken us, well, a couple of centuries to get where we are 
today. We are working as quickly as we can with great passion 
to remedy this problem. I do not think there is a better leader 
for the Indian Health Service than Admiral Grim, who I do not 
think a week goes by that we are not discussing ways to move 
these strategies forward for the general public health, as well 
as mental health in Indian communities.
    Senator Dorgan. Dr. Carmona, I have some additional 
questions, but my colleague, Senator Johnson, has just arrived. 
It is my understanding that he has to leave for another 
committee. He shares in his State a portion of the Standing 
Rock Reservation which I described earlier. Let me call on 
Senator Johnson for his comments.

 STATEMENT OF HON. TIM JOHNSON, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Johnson. Thank you, Senator Dorgan and Senator 
McCain for holding what I think is a critically important 
hearing on just a tragic, tragic issue that affects young 
people in general, but particularly impacts Native American 
young people.
    I do have another obligation that I am going to have to 
leave soon to attend, but I do want to acknowledge that 
participating in the hearing today and making just enormously 
positive contributions to our circumstances in South Dakota are 
Julie Garreau, who is Director of the Main. She will be sharing 
her thoughts on what is going on in the Cheyenne River 
Reservation relative to activities for young people and how 
they are trying to address that terrible issue there.
    Twila Rough Surface of the Standing Rock Sioux Tribe is 
here as well. She has been very much involved in these issues. 
Betsy Mitchell is President of the Cheyenne River Sioux Youth 
Project. We also have with us representatives from the 
Project's partner organization, Running Strong for American 
Indian Youth.
    The South Dakota Health Department's statistics on suicide 
for 2004 list suicide as the second-leading cause of death for 
South Dakotans aged 15 to 24. On average in our small State, 
750,000 people, we lose 23 young people in that age group to 
suicide each year, a rate of one almost every 2 weeks. The 
suicide rate among Native American males in particular runs two 
to three times higher than the general rate in the United 
States as a whole.
    There are many factors that go into this tragic 
circumstance, but it is important that we on this Committee and 
in Congress in general provide the resources that those who are 
in the front line of combating this awful circumstance need to 
have. I know that Senator McCain, Senator Dorgan and the 
members of this Committee, Senator Smith as well, take this 
issue very much to heart. I look forward to working in a 
bipartisan fashion with the IHS and with our tribal leadership 
in our respective States to address this issue.
    Thank you.
    Senator Dorgan. Senator Johnson, thank you very much.
    Dr. Carmona, I mentioned that in the Northern Great Plains 
the rate of teen suicide on reservations is 10 times, according 
to the statistics we have seen, 10 times the national average. 
We also find clusters. I mentioned that on the Standing Rock 
Reservation, there have been 12 suicides in the last 6 months. 
Can you or Dr. Grim tell me, when you begin to identify a 
cluster of teen suicides, do you have teams that are sent out? 
What kinds of teams? What are those resources?
    Mr. Carmona. I would be happy to start, then I will pass it 
to my colleague, Admiral Grim.
    We do. U.S. Public Health Service officers, our 
Commissioned Corps readiness force, can be deployed at a 
moment's notice to any unmet health need, and not just mental 
health. We do it all over the world, but we are especially 
sensitive to the needs of the Indian Health Service and the 
tribal leadership who are experiencing these problems.
    One of the things that we really want to do is, rather than 
just always respond to clusters, but be able to build capacity 
within the tribal leadership and leadership within any tribe to 
be able to look forward and be able to have some predictive 
ability when they see children who may be developing that type 
of ideation.
    Certainly, we need to respond to these tragedies, but we 
feel it is much better to develop capacitance within the tribal 
leadership to be able to identify those risk factors and be 
able to prevent those things from happening. So we are looking 
at both sides, but certainly prevention, we want to spend a lot 
of time on, too.
    I will ask Admiral Grim to please comment.
    Mr. Grim. I would just say that the Surgeon General 
adequately described the ability of the Commissioned Corps of 
the Public Health Service to respond. We have called on the 
readiness force on multiple occasions when we have had suicide 
clusters within Indian communities. We bring in mental health 
professionals, social services professionals, logistics folks 
to help get all the people in and out.
    We work with tribal leadership. We wait until they ask. It 
is not something we thrust upon them. We work closely with 
tribal leadership and their councils. We work closely with them 
as they try to overcome those issues. Whenever we feel that we 
have addressed the immediate surge capacity need that that 
community has, we step out with the larger number of people.
    We try to leave some capacity there as well. When that many 
mental health and social services people have come in, they 
oftentimes bring in new programs, new sorts of treatments that 
perhaps the community did not have before. They help the local 
staff there in the local Indian Health Service or tribal 
program to just raise the capacity at that time.
    After the surge capacity leaves, we continue to keep an eye 
on that. We have developed a behavioral health management 
information system over the last several years that we have 
begun to deploy that now allows us to spot suicide clusters at 
a much earlier stage as we look at ideations and attempts.
    Senator Dorgan. Let me ask both of you, if you would, to 
submit for us following this hearing any evaluation you might 
have of what we might contribute to the Indian Health Care 
Improvement Act as we reauthorize it that might address this 
issue, recognizing we passed legislation previously on the 
issue of suicide prevention. But if there are things that you 
think we could do, particularly addressing the Indian issue, 
but not exclusively that, we would appreciate it.
    The fact is, most of us have in some way or another become 
acquainted with this issue. It is always a tragedy. When I was 
in my twenties, I walked into a room and found a friend who had 
taken his life. It took me a long while to just get over that, 
the tragedy of it. But when I see and hear about these young 
children who take their lives, it just breaks your heart. I 
think there must be ways for us to devote more time, more 
attention, more resources to try to intervene and intervene at 
the right time to be helpful.
    I think Senator Smith said it right. We tend to take a look 
at people who have an acute medical problem such as something 
that you can see, a huge wound bleeding, broken limbs. That is 
obvious, and we will immediately bring all of our medical 
resources to address something that is obvious and visual. But 
there are many in this country who live with afflictions that 
are not quite so visual and not quite so obvious. We spend less 
attention, less time trying to heal them.
    So at any rate, I appreciate very much your being here. I 
am going to call on my colleagues for questions as well.
    Senator McCain.
    The Chairman. Thank you very much, Senator Dorgan.
    Dr. Carmona, Senator Dorgan just mentioned that the suicide 
rate on Indian reservations is 10 times that of the non-Indian 
population. Do you accept that?
    Mr. Carmona. Senator, depending on which reservation you 
are speaking of, but certainly it is multiples of the U.S. 
incidence, depending on where you are looking.
    The Chairman. In the Northern Plains, as Senator Dorgan 
pointed out. As you mentioned in response to a previous 
question by Senator Dorgan, there are multiple reasons which 
you listed. What I do not understand, and you as the Surgeon 
General of the United States may have a view of this, is that I 
understand all those conditions that exist which lead to this 
terrible crisis that we are discussing, but don't those 
conditions also prevail, say, in inner-cities in America? Don't 
they prevail in other parts of America where there are pockets 
of poverty, crime, et cetera, and yet you do not see that level 
of teen suicide?
    How do you rationalize that? What is the difference that 
would make this such a serious problem in one area of poverty, 
deprivation, breakdown of families, et cetera, and not prevail 
in other areas of similar conditions?
    Mr. Carmona. Senator, it is a great question and one that 
confounds all of us. We have a good deal of information about 
urban problems, and where we see suicide clusters or suicide 
ideation in youngsters because of despondency, because of 
economics, because of social status, because of being 
ostracized from their communities.
    We do not have enough information yet, and we require more 
research on the uniqueness of Indian country and the tribal 
problems, because they are unique. Geographically they are 
unique. Culturally they are unique. The history is quite unique 
because it goes back centuries where they have been 
disenfranchised in some cases from their own cultures. It is a 
struggle every day for these young men and women growing up in 
a bicultural or multi-cultural society where elders may be 
attempting to retain their own culture.
    So my colleagues who are quite expert in this recognize 
that there are variables that are very unique to Indian country 
that need to be studied further before we could actually answer 
definitively your question.
    However, we are able to say that the rates are higher, the 
situation is much more complex, and because of that we have put 
more resources into research through CDC tracking with 
epidemiologists and surveillance programs; through our NIH and 
SAMHSA doing basic science and clinical research in those 
areas; working with tribal leadership to ferret out the 
specific variables, risk factors that are unique to Indian 
country.
    Admiral Grim.
    Mr. Grim. I would just add, too, that one of the three 
primary things that we are working on is to expand and enrich 
the data research around Indian country, not only the risk 
factors, but the protective factors, why some tribal 
communities do not have this problem and why others do. We are 
working with SAMHSA. We are working with NIMH. We are also 
working with Canada and their indigenous population and their 
professionals.
    The conference that the Surgeon General mentioned that is 
scheduled to occur in September in New Mexico is going to bring 
together people from all these organizations to start to 
develop a research agenda for the indigenous population of our 
country. We hope with a long-term approach to it and putting 
money into it immediately that we are going to start better 
understanding.
    We know the things that you can just state about it. It 
occurs in younger people. It occurs with some impulsivity 
instead of planning. We know things like that, but we do not 
know a lot of the multi-factorial causes that are both risks 
and protections.
    I want to publicly thank Senator Smith for getting a bill 
through in the Senate, for unanimously passing it to make more 
money available for this particular thing that particularly 
affects Indian country. I think, Senator Dorgan, at a hearing 
that you held in Bismarck, it was very telling when you asked 
how many people have been touched by suicide. It was in a room 
much larger than this that was also filled almost to capacity, 
and you asked how many people have been touched by suicide, 
either someone you knew or a family member, and almost every 
single person in that room raised their hand.
    So it is one of our three major focus areas to expand that 
research base to be able to answer those questions, Senator 
McCain.
    The Chairman. I hesitate to speculate, but if you have 
conditions, say, in an inner-city in America, of poverty, 
despair, alcohol, drugs, et cetera, and the American 
reservation has the same conditions, and yet the suicide rate 
on the reservation is far higher than that of the inner-city, I 
do not know how you can draw any other conclusion that it has 
something to do with the history of Native Americans and their 
exploitation and placement in American society which leads to 
greater despair.
     I do not indulge in psycho-babble here, but it seems to me 
that the only real difference is the history of Native 
Americans in America. Does that make any sense, Dr. Carmona?
    Mr. Carmona. Senator, it definitely does make sense. There 
is no question that there has been marginalization. There has 
been discrimination. There has been tribal America that has 
been ostracized. That manifests itself in a number of different 
ways.
    We today, the leadership today are feeling the burden of 
centuries of these problems that are now being clinically 
manifest in one manner with the suicides and suicide clusters 
in youth. So we are desperately seeking to identify 
scientifically the specific variables.
    I agree with the intuitive approach. I feel the same way 
from my experience living among and working with my colleagues 
in Indian country. But yet we have to take it to a higher level 
and actually put the scientific scrutiny to it to be able to 
specifically identify variables that we can then address to be 
able to develop programs that we can actually measure success 
with over time.
    So I am absolutely in agreement with you and share the same 
sentiments intuitively.
    The Chairman. Thank you very much, Senator Dorgan.
    I thank the witnesses.
    Senator Dorgan. Senator Smith.
    Senator Smith. I think Senator McCain has really hit on the 
real dilemma we have. Is suicide nature or nurture? I think the 
point I was making earlier is that many mental illnesses are 
clearly nature. I think Senator McCain's point is it is 
possible, maybe even probable, that the rate is higher among 
Native Americans because of the environmental factors in which 
they live.
    I would be surprised if mental illnesses are any more 
prevalent among Native Americans than other Americans, unless 
you have evidence to the contrary. In other words, a Caucasian 
or an African American child is probably numbered in the same 
percentages that would have bipolar illnesses or manic-
depression. Does the evidence suggest that?
    Mr. Carmona. I think the point you made, Senator, regarding 
nature and nurture is appropriate. I know of no evidence that 
would suggest that there is inherently a difference of 
incidence, bipolar, schizophrenia or any others. However, 
again, we all understand that the environment has huge 
ramifications in this problem and we are trying to identify the 
specific environmental factors that lead to this dysfunction, 
to this psychological instability in our tribal America.
    Senator Smith. I suppose my point is, to Senator McCain's, 
is that in addition to the medical intervention, the testing, 
the programs of interdiction, we have the added responsibility 
of making sure they have decent schools; that they have the 
potential for upward mobility; that they have an environment in 
which to live in which hope abounds instead of the depressive 
kinds of circumstances that many Native Americans feel.
    That is our challenge as a Nation to do better here, 
because this is a shameful thing in our country, that this rate 
is higher among Native Americans than other Americans.
    Mr. Carmona. Senator, I truly thank you for bringing out 
what to us is the obvious. I would say you are preaching to the 
choir because we see that every day. There is no question that 
these youngsters as you go through the reservation, where the 
high school dropout rates are terrible, the disease burden is 
astronomical even at a young age, alcoholism, drugs. Life 
expectancy is much less. Opportunity is much less. When they 
look out on the horizon of life, it should not be surprising 
that what they see is despair and not hope.
    I appreciate your pointing out that what we really need to 
do, as Admiral Grim and President Bush have directed, that we 
approach this in a multi-factorial way. We have to appreciate 
the environment. We have to appreciate the schools, the homes, 
the family situation, access to care. All of those things 
contribute ultimately to the health and growth and development 
of our youngsters on the reservation.
    Senator Smith. I think obviously these are larger issues we 
need to work on. But isn't it also true that suicide is higher 
in Native American communities because of their access to care? 
They do not have psychiatrists. They may not have the 
counselors in place to be helpful early enough.
    Mr. Carmona. Certainly intuitively people have said that. I 
do not know of any literature that would suggest that there is 
a link because of that, but those are some of the variables 
that we need to look into.
    We are doing everything we can now to increase the amount 
of health professionals and paraprofessionals, especially 
community health workers and healers in the tribal communities 
working with the tribal leadership, because often the opinion 
leaders in the community who may not have true medical 
professional degrees, but yet they have inherent credibility in 
their own communities. They are a stabilizing factor in those 
communities, whether it is a faith healer or a medicine man.
    But with increased health literacy, knowledge that the 
problem exists and us helping to give the tools to the 
leadership to be able to recognize these problems and try and 
correct them before the problem develops, I think this is where 
we are spending a lot of our time now, in partnership with the 
tribal leadership.
    Senator Smith. Doctor, do you know of any research, and in 
asking this question I think I know the answer because I do not 
think records were kept, but is there any research or 
historical evidence that prior to the westward movement of the 
European peoples into America and the conflicts between them 
and Native Americans, was their incidence of suicide in any way 
documented prior to that time among Native Americans?
    Mr. Carmona. I am aware of no such records, sir.
    Senator Smith. Thank you.
    Senator Dorgan. Senator Smith, thank you very much.
    A vote has just begun in the Senate, so we will take a 15-
minute recess. The Committee will reconvene at 10:30 a.m.
    Let me thank Dr. Carmona and Dr. Grim. Thank you very much. 
Would you please submit for the committee your evaluations of 
things that we might consider for the Indian Health Care 
Improvement Act dealing with this issue.
    Thank you very much. The committee is in recess.
    [Recess.]
    Senator Dorgan. The committee will come to order.
    The second panel of witnesses at today's hearing will be 
Twila Rough Surface, a member of the Standing Rock Sioux Tribe 
who lost a family member to suicide and who is also an employee 
of the tribe's Family Protective Service.
    As I call their names, if they would please come forward. 
We would appreciate their attendance: Joseph B. Stone, a member 
of the Blackfeet Tribe of Northern Montana, who is a practicing 
psychologist in Oregon and Washington; Julie Garreau, a member 
of the Cheyenne River Sioux Tribe and director of the Billy 
Mills Youth Center, the Main, in Eagle Butte, SD; R. Dale 
Walker, a Cherokee from Oklahoma and director of One Sky 
Center, which is a national resource center focusing on mental 
health prevention and treatment for Indians; and Clark Flatt, 
president and CEO of The Jason Foundation, named for his son 
who committed suicide at the age of 16 in 1997, from 
Hendersonville, TN, which is working with the Bureau of Indian 
Affairs on suicide education and prevention programs.
    Let me say to all of you how appreciative I am of the fact 
that you are willing to come today and to present public 
testimony. As I have indicated at the start of this hearing, 
perhaps for you as well, this is a hearing that you would 
sooner not attend and a subject you would sooner not discuss, 
but in many ways you are more qualified and in a better 
position to discuss publicly these issues with us in order to 
help develop some responses to them than almost anybody else in 
the country, so we appreciate your willingness to do that.
    We will begin with Twila Rough Surface, a member of the 
Standing Rock Sioux Tribe. Twila, thank you for traveling to 
Washington to be with us. We welcome you.
    All of the statements will be made part of the permanent 
record. You may summarize your statements. Second, the hearing 
record will be kept open for a period of time, 2 weeks 
following this hearing. If there are those in attendance at the 
hearing that would wish to submit additional testimony to be a 
part of the formal hearing record of the Committee on Indian 
Affairs, I would invite you to do that and send it to us here 
in Washington, DC, to the committee. We will make your 
testimony a part of the permanent record as well.
    Again, Ms. Rough Surface, your entire statement will be 
made a part of the record and you may proceed.

  STATEMENT OF TWILA ROUGH SURFACE, REPRESENTING THE STANDING 
                        ROCK SIOUX TRIBE

    Ms. Rough Surface. Thank you. Good morning. I would like to 
thank Senator Dorgan for the invitation to state my concern for 
the young people of my tribe. My name is Twila Summers Rough 
Surface. I am an enrolled member of the Standing Rock Sioux 
Tribe. I have lived on the reservation my entire life. I am a 
mother, a grandmother, a wife, and I come from a family of 5 
brothers, 3 sisters, with 14 nieces and 20 nephews.
    I recently lost a niece to suicide on February 2, 2005. She 
was my sister's third child. The following events, I believe, 
contributed to the eventual death of my niece. On January 7 of 
this year, her brother, my nephew, was killed in a car 
accident. During the grieving period, her mother had nobody to 
come and talk to her regarding the death of her son. So I can 
only speculate that my niece saw all the hurt and could not 
handle the loss, so she decided to take her own life. My sister 
was overwhelmed by the deaths, and also tried to take her own 
life.
    Senator Dorgan. How old was your niece?
    Ms. Rough Surface. She was 23. And my sister was 
overwhelmed and she tried to take her own life. After the 
attempt, my sister related the following, that she thought that 
the only way to make the hurt go away was to take her life so 
she would not feel the pain and the hurt. Luckily, a family 
member found her in time.
    The loss of my nephew not only had an impact on our family, 
but on his friends as well. One of his good friends who had 
been selected to be a pallbearer at his funeral committed 
suicide the day my nephew was buried. His other best friend, he 
missed him very much and he was talking to my brother and he 
said he missed him a lot. On April 7, he also committed 
suicide.
    The effects of the deaths in my family have touched many 
and continues to be a concern. I must mention that at no point 
did any mental health professionals contact our family. I feel 
that if there had been intervention with grief counseling and 
support for my sister and her children, my niece may have had a 
chance to grow to be an elder of the community.
    The overall rate of suicide among our youth has increased. 
The rates remain unacceptably high. Adolescents and young 
adults often experience stress, confusion and depression from 
situations occurring in their families, schools, and 
communities. Such feelings can overwhelm young people and lead 
them to consider suicide as a solution.
    Few schools and communities have suicide prevention plans 
that include screening, referral, and crisis intervention 
programs for youth. Programs designed to assist children and 
families dealing with severe trauma are not readily available 
on Standing Rock. The families are economically disadvantaged 
and with a 40- to 75-mile trip to see counseling, it is 
virtually impossible to access these options.
    Transportation and access to a telephone is essential to 
regular therapy. However, this is not a luxury the majority of 
our families have. In our IHS Great Plains office, through the 
Indian Health Service, we only have one psychologist and he 
takes on about 3,000-some cases just for him. He travels to the 
South Dakota site and he only has 2 hours to spend down there. 
He cannot see as many people there either, to help.
    We do have two workers that have bachelor's degrees, but 
they are not trained to do assessments and things like that, so 
it is very hard for our tribe to get these resources. We do not 
have effective clinical care for the mental, physical and 
substance abuse disorders, and easy access to a variety of 
clinical interventions and support for help-seeking. We do not 
have support from ongoing medical and mental health care 
relationships, and we do not have grief counseling, and not 
enough police.
    I believe suicide is preventable. Most suicidal individuals 
desperately want to live. They are just unable to see 
alternatives to their problems. Most suicidal individuals give 
definite warnings of their suicide intentions, but others are 
either unaware of the significance of these warnings or do not 
know how to respond to them.
    Surviving family members suffer the trauma of losing a 
loved one to suicide and are at higher risk for suicide and 
emotional problems. We as a Nation need to be aware to learn 
the warning signs, get involved, become available, show 
interest and support, be willing to listen, be non-judgmental, 
offer empathy, offer hope that alternatives are available and 
outreach services, take action, remove means, and get help from 
individuals or agencies specializing in crisis intervention and 
suicide prevention.
    In conclusion, I would like to thank you for listening and 
request immediate assistance for the Standing Rock Sioux Tribe.
    [Prepared statement of Ms. Rough Surface appears in 
appendix.]
    Senator Dorgan. Ms. Rough Surface, thank you very much for 
being with us today and for your testimony. I will have some 
questions, but we will hear from the other panelists.
    Dr. Joseph Stone, a member of the Blackfeet Tribe of 
Northern Montana, is a practicing psychologist in Oregon and 
Washington. Dr. Stone, thank you for being with us.

    STATEMENT OF JOSEPH B. STONE, REPRESENTING THE AMERICAN 
                   PSYCHOLOGICAL ASSOCIATION

    Mr. Stone. Thank you, sir.
    I would like to thank the chairman, Ranking Member Dorgan 
and members of the committee for the opportunity to address 
this hearing today.
    I am Joseph Stone. I am an enrolled member of the Blackfeet 
Tribe of Northern Montana, and descendant of the Turtle 
Mountain Chippewa of North Dakota and the Lakota of South 
Dakota. I am an honorably discharged veteran of the U.S. Navy. 
My professional credentials include licensures as a 
psychologist in Washington State and Oregon; licensures as a 
mental health professional in Washington; and certification at 
level III as a chemical dependency professional.
    On behalf of the tribal members of the Confederated Tribes 
of Grand Ronde for whom I serve as the behavioral health 
program manager and clinical supervisor, the tribal council 
sends their greetings to the committee and thanks the committee 
for their attention and provision of resources to the issue of 
youth suicide prevention in native communities. The members and 
tribal council of the Confederated Tribes of Grand Ronde are 
committed to the health and well being of their youth and other 
native youth. They encourage the work of this committee.
    We have talked a lot about the statistical profile of what 
is occurring in the tribal communities, so I am not going to 
belabor that point too much. What I would like to do is speak 
briefly to some of the issues that were raised by the committee 
just a few moments ago.
    What we see is the outcome of a historical context, a 
context of historical trauma and what we have begun to consider 
post-colonial stress. Research in this area is new, but it is 
beginning to occur. Post-colonial stress it seems to have to do 
with the capacity of children to regulate their arousal and the 
ability of families and family members impacted by the chronic 
stress over the course of generations to help those children 
regulate their arousal.
    If a child grows up and they cannot regulate their arousal 
because their parents have been too impacted by chronic stress 
and thus too busy surviving, then that child has a compromised 
behavioral immunity or vulnerability then to further 
psychological or emotional or physical developmental insult, 
and therefore a lack of resilience to issues like suicide and 
other mental health disorders.
    In working with the tribal communities as a psychologist, I 
would like to present about 8 days worth of work that occurred 
at a tribe I worked at a few years ago. On Sunday evening, we 
had suicide number one, a male tribal member age 21 jumped off 
a bridge. He was never referred to my waiting list. I had 40 
active clients, 20 to 25 counseling sessions a week, and no 
time for community outreach to help reduce the stigma of 
seeking mental health services. He was not willing to seek 
referral to the community mental health center. The family 
perceived a lack of adequate culturally appropriate sensitivity 
and skill on that staff.
    He was not willing to discuss his issues with the medical 
providers because of the sense of shame and stigma that he 
felt. He reported to family members suicidal ideation, 
despondency, anxiety over fiscal matters, a severely depressed 
mood, ongoing suicidal ideation and substance abuse issues. He 
had recently been trained as a diver and had a chance to make 
some money. What happened is he stopped his car, went to the 
bridge, mounted the bridge as though is were the transom of a 
boat, and flipped over backwards as though a diver was going 
into the water to dive for sea cucumbers. We do not know if it 
was a genuine attempt to kill himself or if he was simply 
acting out of a substance abuse-induced haze. That does not 
matter.
    What happened then was by Wednesday, a second male tribal 
member in Canada had killed himself by self-inflicted hanging. 
This was hundreds of miles away, but he had heard about it. 
There was a lack of professional service for him, no community 
outreach, and the family did not know how to seek help or 
referral. They reported he was despondent and anxious over 
finances and over a failed romance. He had depressed mood. When 
he found out about the first suicide of his relative, he said 
he had found a way out of his pain.
    The psychological effects reverberated in our tribal 
community. There was fear, grief, a sense of foreboding. Who 
would be next? Feelings of powerlessness and helplessness. 
During that period of time, several of my regular clients 
reported increased suicidal ideation and intention. I had 
increased phone contact from community providers, tribal police 
and other tribal professionals about their concerns; monitored 
increased professional self-doubt about our capacity to help; 
sought outside intervention and support.
    We had a serious suicide attempt number three 1 day and 1 
week after the first suicide, a 17-year-old pregnant female, a 
close friend of the first tribal member killed herself with a 
massive overdose of Tylenol and other pills. She did not 
succeed; lost her child; killed most of her liver. During that 
week, I had three other attempts.
    No. 1, was a 17-year-old tribal member. He had issues of 
depression and substance abuse. He was arrested and reported to 
the county that he was suicidal. He attempted to kill himself 
by running into the wall at the jail and breaking his neck. 
There was no assessment or treatment through the community.
    No. 2, a 12-year-old tribal male had trouble at the school, 
hit his teacher, tore up his classroom. He came and saw me at 
my office. He said he was suicidal. I said, how would you kill 
yourself? He said, I would jump off a bridge. My words not his, 
the same bridge the first man had jumped off of. He had crossed 
it on a daily basis. No intervention from the community mental 
health program. I had him and his grandmother call me on an 
hourly basis.
    No. 3, 1 week and 3 days following the first suicide, I am 
going home from work. I get to a corner. There is a 9-year-old 
kid 40 feet up a tree. A police officer on duty and myself 
climbed into the lower branches of the tree so we could attempt 
to break his fall in case he actually jumped. We managed to 
talk him down. We did not have training to do that, but we just 
kept at it until he came down.
    What I would like to recommend is that we look very 
strongly at designating suicide prevention as the top 
preventive focus for the Indian Health Service; dedicated 
funding to support urban American Indian mental health and 
suicide prevention; establishing a national center of 
excellence for suicide prevention in tribal communities, 
operated and managed by Native American and American Indian 
experts and professionals; develop school-based mental health 
services to promote a positive school environment and help 
prevent youth suicide.
    Professional mental health providers should be able to make 
direct services to residential treatment for native children. 
We need to increase the collaboration between the county and 
the State system gatekeepers and tribal mental health providers 
to ensure adequate access. Exclusion of Native American clients 
who are suicidal from the system by State and county 
gatekeepers must be examined and that process must be changed.
    We need to increase the number of qualified mental health 
professionals in the field to a number proportionate in the 
general population. Funding for the American Indians in the 
psychology program should be doubled, with at least two 
additional university sites. We need to increase funding for 
training social workers and counselors.
    We need to provide an additional $170 million as 
recommended by the Friends of Indian Health to IHS to address 
the level of need for health and mental health care. We need to 
benchmark the funds available to the Indian Health Service 
versus those funds available to other publicly funded health 
care systems; ensure the number of IHS mental health providers 
meets the ratio of mental health and care providers for the 
general population and that each IHS area can subsequently 
ensure that there exists community-based mental health and 
suicide prevention programs.
    Thank you.
    [The prepared statement of Mr. Stone appears in appendix.]
    Senator Dorgan. Dr. Stone, thank you very much for your 
testimony.
    Next, we will hear from Julie Garreau, and I hope I am 
pronouncing your name correctly, Julie, a member of the 
Cheyenne River Sioux Tribe and director of the Billy Mills 
Youth Center, the Main, in Eagle Butte, SD. Welcome, and you 
may begin.

STATEMENT OF JULIE GARREAU, EXECUTIVE DIRECTOR OF THE CHEYENNE 
        RIVER YOUTH PROJECT, CHEYENNE RIVER SIOUX TRIBE

    Ms. Garreau. Thank you. Good morning, Senator Dorgan and 
members of the committee. My name is Julie Garreau. I am a 
member of the Cheyenne River Sioux Tribe and executive director 
of the Cheyenne River Youth Project.
    On behalf of the Cheyenne River Youth Project and the young 
people of Cheyenne River, I would like to thank you for holding 
this series of hearings about youth suicide prevention in 
Indian country. We certainly appreciate the opportunity to 
share our thoughts and to participate.
    In addition, I would like to thank Senator Johnson, who 
helped to secure Federal funding for our teen center which is 
currently under construction.
    I understand that I was invited to participate in this 
hearing because the Cheyenne River Youth Project has an 
inspiring story to tell, a story that spans the course of 17 
years; that involves success, joy and heartbreak. But I was not 
sure what part of that story to tell because it has truly been 
an incredible journey. I have many stories that I can share 
with you, all of which are very personal, in fact so personal 
that I often become very emotional, especially when I think 
about those young people who have lost all hope and felt they 
had no other option but suicide.
    In 2002 and 2003, on Cheyenne River we lost 17 of our young 
people to suicide. In a community as small as ours, it is all 
very personal because they are our neighbors, our relatives. We 
know their mothers, their fathers, their grandmas and their 
grandpas. They are my nieces and my nephews.
    It truly is an indictment against all of us, our families, 
our communities and our tribes, when we lose our children to 
suicide and other tragedies. We are failing our children, but 
it does not have to be that way if we can make a combined 
effort to combine our resources and partners to make a 
difference.
    I believe the Cheyenne River Youth Project is an example of 
what a grassroots organization can do for its community. The 
key to preparing our kids to confront the challenges of youth 
lies within local initiatives. We all know the history of the 
reservation, when we were told what to wear, what to eat, how 
to dress, how to think, and even how and when to pray. Although 
that history is tragic, it is that reservation system that may 
now be our salvation because we are remotely located and come 
from close, small, close-knit communities.
    Our story is only inspiring because it is about people 
taking care of themselves, a local initiative, a personal 
solution. This is the story of a small group of people doing 
everything possible in their community to make a difference for 
their children. Once we had done all we could through our own 
resources, we sought partnerships with community organizations 
and eventually outside support.
    I would rather try to take it on ourselves, and we tried, 
but because we live in an impoverished economic condition and 
due to our rural location, we understand that it is impossible. 
In our history, we have encountered stumbling blocks, but 
instead of expending our energies deciding where to place the 
blame, we are finding solutions. We have succeeded because we 
have not deviated from our mission, which is to love and 
support the children and families of Cheyenne River. Quite 
honestly, I would rather not be here today. I would rather not 
leave my community to testify or to fund-raise, but the reality 
of our situation is that we need help. Our children need your 
help.
    I truly love my home, my work, and most of all the children 
and families that we are privileged to work with. I think the 
greatest example I can give you about why the Cheyenne River 
Youth Project is a success is the teen center we are currently 
constructing. The teen center is a reflection of listening to 
the children and building upon those ideas. When we decided 
that it was time to move forward in our plans to design and 
construct a teen center, we understood from years of experience 
that we needed to consult our teenagers. From that 
consultation, we have incorporated an internet cafe, a library, 
a computer lab, art and dance studio, and a counselor's office 
into the plan, because our children told us what they needed.
    We have made listening to our community an artwork. A teen 
center is not the only answer, nor is it the solution for every 
community. There are so many other needs, drug and alcohol 
counseling, better foster care and juvenile justice systems, 
and more mental health counselors. Nevertheless, our teenagers 
are excited about this new youth center. We have seen it in 
their faces and heard it in their voices. Even before it is 
built, it is giving them what they need most, which is hope. 
Now, when they look on the horizon of Cheyenne River, they see 
a teen center, which again represents hope.
    I thank you very much for your interest in our 
organization's efforts. I think that we are truly doing some 
amazing things on Cheyenne River and I think we are part of a 
really great future for our kids.
    Thank you.
    [Prepared statement of Ms. Garreau appears in appendix.]
    Senator Dorgan. Ms. Garreau, thank you very much for your 
testimony.
    Ms. Garreau. You are welcome.
    Senator Dorgan. We appreciate your work and your inspiring 
story. I will have some questions as well.
    Dr. Dale Walker is the director of One Sky Center. He is a 
Professor of Psychiatry and Public Health and Preventive 
Medicine, and director of the Center for American Indian 
Education and Research and Oregon Health and Sciences 
University. We very much appreciate your willingness to be with 
us, Dr. Walker, and you may proceed.

 STATEMENT OF R. DALE WALKER, DIRECTOR, ONE SKY CENTER, OREGON 
                 HEALTH AND SCIENCES UNIVERSITY

    Mr. Walker. Senator, thank you very much.
    I want to also add that your comments to open the meeting 
were remarkable. They were personal and we can tell you have 
been there. That is much appreciated. Sometimes we who testify 
have to do that work to make those voices heard. Your efforts 
to help bring this to the attention of the public is vital and 
greatly appreciated.
    I would add also that Senator Smith's opening conversation 
about suicide and difficulties of families in this country are 
landmark in importance.
    I am so happy and humbled to be here with you. I want to 
tell you a little bit about who we are and what we have done, 
and what we have found out about, and then some 
recommendations.
    The One Sky Center is 2 years old. We have been working 
with SAMHSA as a grant that is uniquely funded, actually, by 
two centers, both prevention and treatment centers within 
SAMHSA. It was the vision to have a national resource center to 
provide information and cultural competence and best practices 
for all Indian communities across the country. It has been a 
vision that I have had for my 28 years of work in this area, 
that we need to have a centralized body to gather this 
information.
    Until now, we have been unable. SAMHSA itself spends 
between $40 million and $50 million each year on American 
Indian projects. The ability to collect the information in a 
way that we learn and gather the data so that it is available 
to other Indian communities has not been there. We have now put 
that information in place. A major part of that information and 
our visits over the last two years, I have been out to over 100 
Indian communities to see what is happening, to provide 
technical assistance, to provide training, and also to explore 
consultation.
    The issues that have happened in the last 6 months are 
critical and extraordinary. The fact that there are suicide and 
violence issues in schools in Indian communities is something 
that we are vulnerable to across this country. All Indian 
communities have the symptoms and the risk factors that you 
have heard today and are vulnerable to the continuation of loss 
of life, incarceration and continued family and domestic 
destruction.
    There is no doubt in my mind after seeing all of the places 
that I visited, the intensity, severity and degree of 
difference in other communities that exists in Indian 
communities. Earlier today we were talking about why would that 
be. I think that indeed the historical relationship of 400 
years, and over 600 treaties that define access to care and 
education for Indian people and location of Indian people have 
been a part of the issues that we should all be concerned 
about.
    In addition, how people receive care has become quite 
visible, the access to care. I was asked to do a site visit 
with Standing Rock and provided the community assessment 
approach to doing that, which is a unique and very important 
way to do suicide prevention intervention work, where the 
community has its input and its ideas are forefront in 
resolving the problems and issues.
    If you look at Standing Rock and you see the size of the 
high schools and junior highs or middle schools and the grade 
schools, it is important to note some issues. If you just look 
at the facts for a moment, what you find out is that well over 
300 children have attempted suicide in their lifetime, 
attempted. Where does their treatment go after they have 
attempted? What access? You just heard that if indeed there was 
an attempt, what kind of follow-up, what kind of community and 
family interventions are made to support that attempt?
    If you look further and broader, you find out that 40 
percent of the children have talked about suicide as an outcome 
in their life. It is no doubt to me that the access to care is 
an issue. One of the recommendations that we talk about is 
strengthening the behavioral health care capacity. It has been 
said that the Indian Health Service can provide adequately 40 
percent of the need. If that is the case, what are we doing 
with the other 60 percent?
    I recommend that we pay attention to full funding for the 
Indian Health Service, and we also pay attention to full 
funding for mental health and addictions care within the Indian 
Health Service. Even at that level, Senator, we need more 
resources. An interagency collaboration led by Health and Human 
Services has been a remarkably important next step in cross-
agency support. I would think that if we could somehow from 
your point of view encourage this continued interaction of 
interagency cooperation, that that would be a vitally important 
step as well.
    I have been a part of that growth and development over 
these 2 years and think that is one of the most wonderful 
dedications of Federal services for support for Indian people 
that I have seen in my 28 years of work.
    A demonstration project, as Dr. Stone has suggested, a 
national center for suicide, is an important step as well. We 
have been providing the leadership to develop a community 
interface so that you can go to any of the communities and 
tribes and urban Indian centers to do this kind of evaluation 
from their point of view. That is critical, and we have to 
continue.
    We have also provided assistance for Standing Rock to seek 
funding under emergency funding for their services and if 
indeed that occurs, the One Sky Center will be there also to 
provide the care and the assistance and consultation to get 
that project moving along.
    The issue of a national evaluation of treatment must go 
hand in hand with any resources. Dr. Stone defined benchmarking 
of services. We need to get the information out to all 562 
recognized tribes and the 34 urban Indian health programs so 
that they all will be skilled and they will have the monies to 
support the access to care that is needed.
    I would like to thank the Committee and also this panel 
because it is an honor to be here with all of you as well. 
Thank you.
    [Prepared statement of Dr. Walker appears in appendix.]
    Senator Dorgan. Dr. Walker, thank you very much.
    Finally, the last witness will be Clark Flatt, president 
and CEO of the Jason Foundation. Mr. Flatt is the president and 
CEO of the Jason Foundation, a foundation begun after the 
suicide death of Mr. Flatt's youngest son Jason, aged 16, in 
1997. It has received national recognition for its community 
assistance resource line, a 24-hour, 7-day-a-week resource line 
staffed by a clinical specialist in partnership with the 
foundation.
    Mr. Flatt, we appreciate very much your willingness to be 
here and share your comments with us. You may proceed.

    STATEMENT OF CLARK FLATT, PRESIDENT AND CEO, THE JASON 
                           FOUNDATION

    Mr. Flatt. Thank you, sir.
    Mr. Chairman and members of the committee, it is indeed an 
honor to be here. This is as much a fact-finding experience for 
me of being able to meet and talk with some of the people on 
the panel and some of the people in the audience that we have 
been wanting to talk with. You have really put together a good 
panel and a good resource here.
    My name is Clark Flatt, as you said, president and CEO of 
the Jason Foundation. I was asked to come here today to share 
my personal story about our organization, The Jason Foundation, 
specifically our funding strategy and our current work with the 
Bureau of Indian Affairs, specifically the Office of Law 
Enforcement Services, District Five.
    One month from tomorrow, July 16, will be the eighth 
anniversary of the tragic death of my youngest son Jason, to 
what I have even heard mentioned here, which we have been 
calling for years a terrible silent epidemic. In the general 
population, this silent epidemic is now the third leading cause 
of death for our young people aged 15 to 24. It is also the 
second leading cause of death for our college-age students.
    This silent epidemic as we call it has seen an over 300-
percent increase in the last 40 years among the general 
population of our youth. Even though it has been mentioned and 
sometimes touted that this trend has now leveled off and 
started to decline slightly, when we look at it, it is still 
almost 300 percent from where it was 40 years ago, which is a 
rate that nobody could say is acceptable in anyone's eyes.
    This silent epidemic that took my son's life, of course, is 
youth suicide. Nationally, the NHSDA reported in 2002 that in a 
study done in 2000 of the general population, there was an 
estimated daily average of over 2,700 suicide attempts each day 
in our Nation from young people age 12 to 17. From these stats 
and others that have been mentioned here today, specifically 
with the Indian nation, it was these types of stats that 
prompted us, my family and a small group of friends back in 
1997 to start The Jason Foundation in Hendersonville, 
Tennessee.
    The Jason Foundation literally began on, as they say, the 
kitchen table. A few months after my son's death, we decided to 
get together and brought some friends and some professionals 
together and decided that this silent epidemic of youth suicide 
that took my son, that Jason would become a silent statistic. 
We would begin to talk about how this impacted our family, how 
it impacted the community, and how it impacts even the extended 
community beyond just where we live.
    Our first mission was very simple. It was to do parent 
education seminars. I had gone to every seminar that I could go 
to, the PTO, PTA, community, church, to learn about drugs, HIV, 
homicide, school violence, anything that can make me a better 
parent to protect my children. No one in the 16 years of 
Jason's life ever discussed suicide as a problem that would 
face my problem and literally take my son's life.
    So we started a very, very aggressive local program to 
educate parents. This grew very quickly. Today, we offer 
specialized programs which is a school-based program that is to 
be built within the health and wellness curriculum of a school. 
It is not an extra program or after-school program. It is 
actually a curriculum.
    We also do staff training seminars which are used a great 
deal across the Nation in in-service training for educators for 
continuing education credits. Also, we still do the parent 
seminars, which is a big part.
    Our budget in 1997 was for two months, $2,700, which was a 
really aggressive thing for us at that time. Our budget for 
this year in 2005 is $9.7 million, so we have grown quite a bit 
over the last 7\1/2\ years. We now have a corporate office that 
from the kitchen table has grown to a little over 4,000 square 
feet in Hendersonville, TN. We have 25 regional offices across 
the Nation. We have contracted to open 24 more offices before 
the summer of 2006, covering 28 States that will have a Jason 
Foundation office literally within their States and serving a 
great deal more.
    One thing that as we talked and I was sharing with some of 
the people that we talked about was how we did some of these 
things. We very much believe in collaboration. Collaboration is 
the key. We have a national clinical affiliate which is one of 
the things that makes our program different, which is 
Psychiatric Solutions, Incorporated, out of Franklin, TN. They 
are now the largest provider of in-patient health care in the 
Nation. They have served as our national clinical affiliate and 
give us the basis for our programs that helps us in our 
development across the Nation.
    We also have the AFCA, which is the American Football 
Coaches Association. One of the things that was mentioned 
earlier is the stigma. When we decided to come out and talk 
about Jason, people did not talk about suicides that are 
happening. It was a personal tragedy and you went on. I have 
talked with Senator Smith about his. The situation to break 
this out, we needed to have a voice out there. The American 
Football Coaches Association has provided that voice. We have 
over 50 coaches across the Nation that do PSAs for us and help 
us as ambassadors across the Nation in opening doors and 
getting our programs presented to the right people in the 
States.
    Also, the USA Wrestling Organization does the same thing 
with their network. They have one of the best middle school and 
high school networks in the Nation. We then went on to have a 
national corporate affiliate which are proud to announce is 
Wal-Mart, which is doing a tremendous effort with us in 
awareness across the Nation. We also work with 31 attorneys 
general.
    I was asked today to specifically comment on JFI's funding 
strategy of how we do this. Of the $9.7 million budget this 
year, JFI has only one government grant, and that is for 
$77,500 that is a block grant from the Tennessee Department of 
Mental Health and Developmental Disabilities. It helps us with 
a specialized program within Tennessee where we provide our 
school-based programs and teacher in-service training for over 
700 schools. All other funding that we receive for The Jason 
Foundation is through corporate gifts, in-kind support, private 
and public grants, fund-raising activities and individual 
gifts.
    When I began The Jason Foundation, we spoke with several 
successful and some not so successful non-profits. I approached 
it as a business decision. The one thing that almost ran with 
every one of the ones that were not so successful, they had a 
small funding base and almost every one of them were tied 
entirely to State or Federal funding. They had failed. So we 
decided on our board of directors not to go that route. We have 
been able to, as I think JFI has demonstrated, that if 
corporate America can see a well-defined need and see how their 
involvement can make a difference, they will invest in an 
organization that is well run and that can show 
accomplishments.
    Last, I would like to comment on our collaboration which is 
part of this hearing here with the BIA Office of Law 
Enforcement Services, specifically with district 5. John 
Olivera, which is the National Child Abuse director for the 
BIA, heard me speak in Los Angeles and came up and asked me to 
consider doing a program in youth suicide prevention, which I 
discouraged him at that point, until he shared with me some of 
the stats, where it is 2\1/2\ times as bad as what we have 
shared here about the general population. It is 2\1/2\ times 
that on Indian reservations and in Indian country.
    So after talking and much prodding, we decided and signed 
an agreement of operation in January 2005. We started the basic 
information gathering by talking to tribal leaders and 
community workers, specifically in district five. Our plans are 
to take the JFI programs for the schools and for the teachers 
and staff training and parent seminars, and to take those and 
make them more ethnic and responsible to the community, and 
then provide those to the communities. Again, as we operate 
throughout the Nation, we never charge for any of our programs 
in our service areas that we do for schools, churches or youth 
organizations.
    As has been addressed and in closing here, one of the 
things that we have seen, and I really believe the challenge is 
not identifying the at-risk youth. That is not a challenge. We 
have the programs, not only The Jason Foundation, but other 
fine programs out there, have the programs that can be put in 
to and made ethnically responsible that will help identify 
these at-risk students. My concern is, and it has been echoed 
here, what do we do once we recognize those at-risk youths?
    The services we have seen there at this point are not 
adequate of being able to respond. Our fear is that if we start 
recognizing more youth that are at risk and we do not get them 
help, as was brought forth by Ms. Rough Surface as far as the 
things not coming in, that we will even make the problem worse.
    We are working on two programs, a tele-counseling program 
which is modeled after, I know you do some work in tele-
medicine. We have looked at that and worked with the people 
doing the cardiac care part. We really believe that even though 
it is not optimum, that we can do using experts in adolescent 
psychiatry to help locally train therapists to be able to 
provide services in these remote areas.
    Also mirroring some other programs, the mobile counseling 
centers, we have already gone to the point of outfitting it 
where they could go to different points of the reservation 4 
days a week and go back to the IHS hospital that we hope to 
collaborate with, where there would be referral sources and 
looking more in to the points of what we could do for extended 
care of some of the families they talk to.
    We are very much in the infancy range of all these 
programs, but we are excited about working with the other fine 
organizations here and we appreciate the opportunity to testify 
here. I would in closing say that the key lies, as we said 
here, I believe with the grassroots organizations throughout 
the communities. Those are the ones that make the difference. 
Those are the ones that are in tune with the communities. And 
those are the ones that we need to center upon.
    Thank you for this opportunity.
    [Prepared statement of Mr. Flatt appears in appendix.]
    Senator Dorgan. Mr. Flatt, thank you very much. I 
appreciate your testimony and your work on behalf of the memory 
of your son in ways that we hope will, and are convinced will 
save other lives.
    Dr. Walker, you used a term of 45 percent. I think you were 
talking about the Indian Health Service. Describe that term to 
me again.
    Mr. Walker. Yes; several years ago when the Indian Health 
Service was trying to develop its budget and projections, they 
tried to look at the need in the community. They went through 
an assessment process on all of the regions. If you 
collectively looked at it in an additive way, 45 percent of the 
services they were able to provide. It is not defendable, if 
you will. It really tells the problem in being true.
    If I could say an example of that I think is if you look at 
Standing Rock. Those kids that are in the schools, when the 
counselors are told that the kids are feeling suicidal, they 
are referred over to mental health for evaluation. There are 
only two mental health people, one in North Dakota and one in 
South Dakota, who line up the support and services. It is a 4-
month waiting list. Two people are not enough. So the services 
and the ability to get the number of people there is not 
adequate. The people who are doing the work are excellent.
    Senator Dorgan. Mr. Flatt described, once you have 
identified the person, a young person at risk, then what do you 
do with him. In the case of Standing Rock, for example, with 
the waiting list you have described, the inadequate services 
that Ms. Rough Surface described, to the extent that some child 
is sent someplace to get some help, in most cases they are sent 
to a hospital to a psychiatric unit about 70 miles or 80 miles 
away. Testimony from that tribe indicates that most of these 
children are back home within 1 day or two, with a little bit 
of medicine and no follow-up.
    So that describes the problem, Mr. Flatt, that you have 
alluded to, that if you have identified someone at risk, then 
you have to have the mental health services, the general health 
services available to treat it and deal with it.
    Ms. Rough Surface, you described the tragedy in your 
family. You said that there just are not enough mental health 
services, one psychiatrist, 3,000 cases. Did you mean 3,000 
people and one psychiatrist? At any rate, you just indicated 
that there is not the ability to have professional help because 
the help is not available.
    I think one of the other things that you had in your 
testimony, I think it was yours, just for example the lack of 
telephone service in a number of homes. A home that does not 
have a telephone is not a home that can easily reach out and go 
track somebody down. Can you describe that?
    Ms. Rough Surface. Yes; IHS is the primary mental health 
provider for the majority of families on the reservation. 
Accessing other services requires a drive of up to 75 miles or 
more. Families have little choice but to depend on the limited 
services of the IHS. There are several discrepancies of 
services in the area of mental health. One such gap includes 
the absence of an on-call mental health liaison mechanism to 
assist families during emergency situations involving a suicide 
episode. The lack of support services compounds the event with 
additional trauma to family members. The majority of incidents 
which require intervention occur after working hours.
    Dr. Kevin Furst at Standing Rock IHS, gives the following 
explanation for the policy that there are not enough qualified 
mental health providers to provide adequate coverage. We only 
have one doctoral-level professional. Dr. Furst also reports 
here on Standing Rock that there is one psychologist for every 
3,740 mentally ill persons.
    Senator Dorgan. Okay. That is the statistic I was looking 
for.
    Ms. Rough Surface. Yes; they have two bachelor-level staff, 
but they are not qualified to do suicide assessments, although 
they have done them in the past.
    Senator Dorgan. Thank you.
    Dr. Stone, you mentioned the need for school-based mental 
health services. What is the effectiveness of the school-based 
mental health services and how prevalent is that service?
    Mr. Stone. The prevalence rates I could not quote directly 
to you, but I will look that information up and get it and 
submit it to you.
    I think the critical element of school-based services, as 
Mr. Flatt had reported, accessing children in the schools is 
very important, but the critical element is not necessarily 
just school-based services, but collaborative school-based 
services, so that the school is collaborating.
    Senator Dorgan. Collaborative with what?
    Mr. Stone. Collaborating with the Indian Health Service, 
and then further collaborating with other agencies that have 
responsibility for the mental health care of tribal people. 
That would include counties and State agencies also.
    So we really have to have a robust collaboration among 
professionals and an educational effort among professionals to 
understand the issue of suicide, to recognize the factors of 
suicide, to help identify the kids who are possibly suicidal, 
and also to provide preventive activities to those kids and 
families that may help them to deal with issues of alienation, 
with issues of self-esteem, with issues of depression, possibly 
before they get into the acting-out phase.
    So I think it is clear that interagency collaboration is 
very important.
    Senator Dorgan. All right. Thank you very much.
    Ms. Garreau, with respect to the Cheyenne River Youth 
Project, you are now building a teen center, but you have had 
the Cheyenne River Youth Project in operation for some while. 
Is that correct?
    Ms. Garreau. Yes; it has.
    Senator Dorgan. Have you seen a diminishment of suicide 
attempts? Tell me the impact that you have been able to see or 
experience with respect to youth as a result of this project.
    Ms. Garreau. Our organization was established in 1988. In 
1994, we created a suicide crisis referral hotline, which we 
operated from 1994 through 2000. At that point, we lost funding 
and so we were not able to do it anymore. In working with the 
tribal psychologist, within the first year he had estimated 
that we had affected the number of completions and attempts by 
38 percent.
    So we know that, and I think it worked because they were 
local people who manned the hotline. We had close connections 
to community organizations and agencies. We worked with the 
psychologist to where we could actually schedule somebody when 
they needed it. When they would call on the hotline, we had 
times when we could schedule them to go in and see a 
psychologist.
    So we did see an effect almost immediately. I think as far 
as the teen center, I think what we provide is a support system 
for our kids. I do not have any definitive numbers, but what I 
do know because I have been there since the beginning, actually 
being the founder of the organization, I can tell you how many 
kids that we have affected positively who have gone on to 
become, and most of our kids are at risk. All of them come from 
family situations where they struggle getting to school every 
day, focusing on their homework, where their meals are going to 
come from.
    What we try to do is we are a support system. So if they 
need help with homework, we are there for them. If they just 
need to talk, we are there for them. We provide them social 
opportunities. We also provide tutoring. With the new teen 
center, we have had a youth center for kids ages four to 
twelve, but we did not have a place for them to transition 
into. So hopefully in the spring of 2006 we will have the grand 
opening for our teen center so that our children will have, 
once they outgrow our first youth center, they will be able to 
move into the teen center and continue to have that positive 
influence.
    Senator Dorgan. Thank you for your work.
    Mr. Flatt, you heard Dr. Walker talk about 45 percent. I 
think this describes that when you look at the universe of 
health care need, 45 percent of it is covered with existing 
funding and 55 percent is not covered. That obviously means 
that people with all kinds of problems are not getting the 
health care, in some cases mental health care they need.
    Now, you have been enormously successful raising private 
sector funds for your foundation, and I commend you for that. I 
know how hard that must be. You have obviously reached out and 
found a network of private sector funding. Yet what you are 
doing is really important. I am really pleased you are 
connecting to Indian Health and so on.
    We still need full funding and we need to move toward full 
funding for the needs in the Indian Health Service. Dr. Grim, a 
man for whom I have great admiration, he has testified here a 
number of times and testified at the Bismarck meeting. He 
cannot answer the questions I ask, and I understand why he 
can't. He works for the Administration. I asked the question, 
Dr. Grim, how much money did the Indian Health Service ask for? 
Tell me what your request was of the Office of Management and 
Budget? That is the eye of the needle through which funding 
requests go. It goes from the Indian Health Service to the 
Office of Management and Budget, which is part of the White 
House, and then into the President's budget and back.
    So we know what the President's budget asks for with 
respect to the Indian Health Service, but Dr. Grim cannot 
answer the question: How much did you request? And so, because 
he works for them, and to do so would undercut the President's 
budget. So I formally asked him for it, but I do not ever 
expect to get it.
    The question is, however, do you agree that notwithstanding 
all the private sector initiatives, and especially yours, which 
I am so proud of what you have done, we really do need to focus 
on better funding through the Indian Health Service for a wide 
range of things, especially mental health.
    Mr. Flatt. Yes, sir; definitely. I think that it needs to 
be both. I think that you need to tie the private sector 
funding, which I am a big champion of. I believe that is the 
moneys that will be if it is built in a correct way, will be 
there year after year. It breaks my heart when I hear stories 
like she said of starting a program that is successful and 
because, especially on State levels where budgets are here 
today and gone tomorrow, where a great program is working and 
showing results has to shut down because their only funding 
source was that governmental source.
    The best scenario would be to have the private sector and 
the governmental funding together. Just with the money, I can 
tell in the short 6 or 7 months we have been working with BIA, 
the IHS could use a lot more money than they are asking for and 
still would have a lot to go. They are doing a noble job with 
the moneys that they are getting, but yes sir, it cannot be 
done on the private sector at that large scale.
    But I do think that they should be a collaboration. I agree 
with several of the people who talked here, and that is what we 
were talking with Dr. Perez earlier. We have been trying to get 
together for a couple of months now, of trying to get the 
private sector to work with IHS and to share together resources 
and to share together different things that we can do together.
    So yes, sir, I wholeheartedly, and we work very hard with 
the Garrett Lee Smith Memorial. In fact, Congressman Bart 
Gordon from Tennessee was the one who championed that on the 
House side, which we had spoken with him about getting 
involved. We are so proud that he was that member to do that.
    So yes, we need that funding. We need more than that 
funding. But I would like to see, so that we do not have 
stories like this, that we bring in the private sector, sell 
them on the idea of getting involved, especially on the local 
areas. There is a lot of the clinical support that can be done 
and would love to be done by local affiliates. And then you get 
a buy-in that goes on and on and on beyond possibly just a 
governmental grant.
    Senator Dorgan. Dr. Walker talked about access to care and 
location. I think you were describing, as we know especially in 
North Dakota, but in most parts of the country, the location in 
many cases of where Native Americans live is far from the 
hospitals, the primary centers of care.
    So because of that, we have in one reservation, for 
example, a dentist who performs dentistry out of a trailer 
house for 5,000 people. Well, is that dental health? Well, 
whoever is there is doing I am sure the best job they can, but 
the resources are not sufficient and the location of the 
reservation is often far from these other facilities. That, 
too, is a very significant problem. That is why the Indian 
Health Service has to be better funded.
    If we are only meeting one-half the need, and I do not know 
these statistics. I just asked our staff to dig into that some. 
But if we are only meeting one-half the need that exists, that 
means the other one-half are suffering, perhaps mental health 
issues; perhaps resulting in suicide; perhaps cardiac problems. 
The list is endless.
    So we just have to do better, in my judgment. Dr. Walker, 
you might want to expand on the access issue. I think that even 
if we have the will here, you have to have the will to 
identify, the will to understand who is at risk. You have to 
have access on an emergency basis when you need it, regular 
access to the services you need.
    Mr. Walker. I could not agree with you more. The issue of 
access and understanding how you get access are quite important 
in Indian communities. One level is to try to support the 
funding process to its requested level.
    I understand ``requested by whom'' is maybe a part of that 
question, but need has to be served. That is a treaty 
obligation. If it is not being served, I would question the 
treaty.
    The other part of that may be my more optimistic side, is 
that there are multiple agencies that do provide services, both 
State and Federal, that are not within the IHS, but could be 
potential resources. One of those is Medicaid and Medicaid 
reimbursement for care. We know that the rates and the ability 
to get access to care in the two States of North and South 
Dakota are different from one another in the way that they do 
their services, even in the timing that they have their 
services available.
    Wouldn't it be nice if we could encourage agencies that do 
provide social services and support, housing, criminal justice 
support, at multiple State levels and Federal level to begin to 
work on these problems and get together to provide a service of 
care.
    You know well, Senator, that there are different points of 
view and different very misunderstandings of Indian needs. Many 
States will say that is a Federal problem; we do not do that. 
There are 35 States that have Indian communities, Indian 
reservations. All of those States have to have an equal and 
balanced understanding of how they get access to care.
    Now, you are right in the isolation. Standing Rock is an 
interesting area because there are eight communities somewhat 
distant from one another in an area the size of one-half of New 
Jersey. You are trying to provide geographic care and 
assistance to eight communities. Somehow when you set up 
appointments in one area and you expect the patient to be 
there, but they are unable to communicate that they cannot be 
there. There are many broken-down appointments and follow-up 
just based upon the geography, as you say.
    I would add, though, that is actually true in the urban 
settings, too. We have a lot to learn in that area.
    If I might, I want to add one other extra point. That is 
that we have these emergencies of Standing Rock and Red Lake. 
If you look at think about over the year, there might be 10 of 
those a year that are extra-emergent; that stand up and say do 
something. The One Sky Center has tried to be the on-call 
center to be there. It is a commitment beyond what we were 
originally funded to do, but it is a moral commitment that we 
have to make to be there.
    We have worked closely with the Indian Health Service and 
SAMHSA to provide as much support as we can, but if we really 
want to develop a demonstration project to develop emergent 
care, and why would one want to do that? The example would be 
both at Standing Rock and Red Lake. When your health care 
providers are members of the community, it is their families 
who are committing suicide and suffering from homicide. It is 
not the time for them to be therapists. It is the time for them 
to be grieving family members.
    We have to provide a backup system and support to help that 
emergent care. While it is not a huge issue from point of view 
of happening every day, we cannot visit Standing Rock, do our 
evaluation, shake hands with them, and wish them well. We have 
a committed partnership and that lasting relationship has to be 
supported.
    Senator Dorgan. Dr. Walker, thank you very much.
    I want to thank all of the witnesses who have come from 
some distances to be with us today.
    Let me thank also Senator McCain. He had another hearing 
this morning, but I thank him for his cooperation and his work 
and his attention to this issue as well.
    I think that, as I said when I started, this is a very 
sensitive topic. There are some who have counseled me privately 
not to have public hearings on this because it diminishes some 
in the eyes of others. That is not my intent at all. I think 
that when asked what is the most important thing in your life, 
if you do not answer ``your children,'' there is something 
fundamentally wrong with you. I think everyone in this country 
answers ``their children.'' They will do anything for their 
children. We all want life better for our children. Whatever is 
in second place is a long ways behind. It is about our 
children.
    You have, Mr. Flatt and others, I, too, have lost a 
wonderful daughter to heart disease, not to suicide, but I can 
only imagine the added horror of having a child not only gone, 
but having a child that has taken his or her own life.
    In terms of responding to the needs of our children, I 
think the passion that has been demonstrated by the testimony 
today is really important. We are going to get this done, make 
progress. We are going to try to reach some goals here if 
people pull together and understand there is an urgency.
    I do not mean to suggest somehow that there is something 
different about Indian country. These are the first Americans. 
These are the people who greeted the immigrants. And yet in 
many cases, they live in third world conditions on too many 
reservations with full-blown crises in housing, health care and 
education, and with circumstances where those who are afflicted 
with problems cry out for help and do not find it.
    It seems to me you start with building blocks deciding the 
first thing we are going to do is make sure that we reach out 
to our children. When you find areas of the country where you 
have 2\1/2\ or 3 times the rate of teen suicides, or in the 
Northern Plains 10 times the rate of teen suicides of the rest 
of the country, there is an urgency and a crisis for us to 
understand what is happening and to begin to mobilize efforts 
to do something about it.
    All of you in your way are doing that and your travel to 
Washington, DC is important. I hope in the long term we will 
save lives of children in this country.
    I would encourage you to do the same as I did the previous 
panel, the Surgeon General. If you have some suggestions for 
Senator McCain and I of what you think we might add to the 
Indian Health Care Improvement Act as we consider introducing 
that and moving it forward now in this Congress, we are 
determined to get this done and get it signed by the President, 
please send us your recommendations as well following this 
hearing.
    In the meantime, I want to thank all of you for some very 
important testimony and I appreciate your participation.
    This hearing is adjourned.
    [Whereupon, at 11:40 a.m., the committee was adjourned, to 
reconvene at the call of the Chair.]

=======================================================================


                            A P P E N D I X

                              ----------                              


              Additional Material Submitted for the Record

=======================================================================


   Prepared Statement of Hon. Gordon Smith, U.S. Senator from Oregon

    Mr. Chairman, I'd like to begin by thanking you for recognizing the 
serious problem of youth suicide among our Native American population, 
and for convening today's hearing to call attention to this issue and 
the steps that can be taken to prevent it from happening.
    Suicide is the second leading cause of death among Native American 
youth aged 10-24. And according to CDC, in 2002 there were 106 suicides 
in this age group, 80 percent of whom were male. In my home State of 
Oregon, 63 young people in this age group died by suicide in 2002, 5 
percent of whom were young Native Americans. Mr. Chairman, it is time 
for the Federal Government to respond to this alarming trend, as we 
cannot afford to wait any longer.
    Fortunately, there is hope. On October 21, 2004, President Bush 
signed the Nation's first youth suicide prevention bill into law--the 
Garrett Lee Smith Memorial Act, named in memory of my son who died by 
suicide in September 2003. Garrett's law recognizes that youth suicide 
is a public health crisis linked to underlying mental health problems, 
and specifically targeted funds to help enable Native American tribes 
to develop suicide prevention and early intervention programs.
    Garrett's law authorized $82 million dollars over the next 3 years 
for youth suicide prevention and early intervention programs including 
voluntary, confidential screening programs like TeenScreen, a program 
my wife Sharon and I have been enthusiastic supporters of in our 
hometown of Pendleton, OR.
    The Federal Substance Abuse and Mental Health Services 
Administration [SAMHSA] is charged with implementing Garrett's law and 
will be awarding grants shortly. These grants will be used to develop 
and implement State-sponsored statewide or tribal youth suicide early 
intervention and prevention strategies in schools, educational 
institutions, juvenile justice systems, substance abuse programs, 
mental health programs, foster care systems and other child and youth 
support organizations.
    Of the $10 million we appropriated for fiscal year 2005, $5.5 
million will find State and tribal youth suicide prevention efforts. 
According to SAMHSA, this money is expected to fund 14 awards, with a 
maximum award of $400,000 and at least one grant will be made to a 
Native American tribal organization. I'm pleased to report the first 
grant awards will be announced at the end of the summer.
    For fiscal year 2006, the Garrett Lee Smith Memorial Act is 
authorized to receive $27 million, as advocated by the suicide 
prevention community. Securing full funding through the appropriations 
process will be a major step forward in helping States and tribes make 
real progress in preventing youth suicides.
    However, enactment and securing full funding of the Garrett Lee 
Smith Memorial Act is just the beginning, a first step down a long road 
toward developing our Nation's mental health infrastructure.
    Mr. Chairman, mental illness is a treatable disease, especially if 
detected at an early stage. Full funding for Garrett's Law will improve 
early identification of young Americans with mental illness and help 
facilitate their access to treatment, especially among our Native 
American youths who are at particularly high risk. I am confident the 
Garrett Lee Smith Memorial Act will help save Native American children 
and families from experiencing the pain of suicide.
    I sincerely appreciate the efforts you and this committee are 
undertaking on behalf of our Native American population to highlight 
the importance of this issue, and we are fortunate to have such a 
distinguished group of witnesses with us today.
    I am especially pleased to welcome Joseph Stone, who is a member of 
the Black Feet Tribe and provides mental health services to tribes in 
Oregon; and Dale Walker, director of One Sky Center at the Oregon 
Health and Science University in Portland, OR, which helps tribes 
develop effective mental health and substance abuse treatment programs. 
It is a pleasure to have both of you here and I truly appreciate your 
sharing your experiences with us today.
    Mr. Chairman, in closing I would like to leave you and my 
colleagues with this final thought: Today, while we are discussing the 
broad spectrum of the possible approaches that can be taken to 
proactively help prevent these tragedies among our Nation's young 
people, we must not forget that mental illness and suicide are 
indiscriminate killers. Mental illness doesn't care if you're rich or 
poor, from a loving family or a broken home. The only thing that 
matters is diagnosing the problem early and getting treatment to those 
who need it in time to make a difference. This is an area I'm sure all 
my colleagues can agree upon, and I look forward to working with you 
Mr. Chairman to help young Native Americans and their families combat 
this terrible problem.
    Thank you.
                                 ______
                                 

Prepared Statement of Terrance Booth, Sr., Metlakatla Indian Community, 
                             Metlkatla, AK

    I am a former tribal council member, Metlakatia Indian Community, 
Metlakatia, Alaska. I served on the tribal council for 8 \1/2\ years 
and during my time served we in our community had youth suicide take 
place. More attention needs to be given to the Native American Youth. 
Primarily, poverty reductions steps need to be in place for all of the 
American Indian Reservations. Each year as the new USA Census report 
comes out one does not see the elimination of poverty among American 
Indians it remains about the same each time Census Report is issued. 
Eliminating poverty and improving the social and economic conditions of 
American Indians will greatly improve their tribal settings. As it is 
now with such poor state of tribal settings it is no wonder thoughts of 
suicide prevail among our youth.
    Terrance H. Booth, Sr. (Tsimshian Tribe)
                                 ______
                                 

  Prepared Statement of Twila Rough Surface, Standing Rock Sioux Tribe

    Good Morning, I would like to thank Senator Dorgan for the 
invitation to state my concern for the young people of my tribe.
    My name is Twila (Summers) Rough Surface, I am an enrolled member 
of the Standing Rock Sioux Tribe and lived on the reservation my entire 
life. I am a mother and a grandmother and come from a family of 5 
brothers, 3 sisters with 14 nieces and 20 nephews.
    I recently lost a niece to suicide on February 2, 2005. She was my 
sisters' third child. The following events, I believe contributed to 
the eventual death of my niece. January 7, 2005, her brother was killed 
in a car accident. During the grieving period, her mother had nobody to 
come and talk to her regarding the death of her son. I can only 
speculate that my niece saw all the hurt and couldn't handle the loss, 
so she decided to take her own life. My sister was overwhelmed by the 
deaths and also tried to take her own life. After the attempt my sister 
relayed the following ``She thought the only way to make the hurt go 
away was to take her life so she would not feel the hurt and pain.'' 
Luckily a family member found her in time.
    The loss of my nephew had a great impact on his friends. One of his 
friends who had been selected to be a pallbearer at his funeral 
committed suicide on the day my nephew was buried. His best friend also 
said he missed him very much and on April 7, 2005 he committed suicide 
The effect of the deaths in my family has touched many and continues to 
be a concern. I must mention that at no point did any mental health 
professionals contact our family. I feel if there had been intervention 
with grief counseling and support for my sister and her children, my 
niece may have had a chance to grow to be an elder of the community.
    The overall rate of suicide among our youth has increased. Rates 
remain unacceptably high. Adolescents and young adults often experience 
stress, confusion, and depression from situations occurring in their 
families, schools and communities. Such feelings can overwhelm young 
people and lead them to consider suicide as a ``solution.'' Few schools 
and communities have suicide prevention plans that include screening, 
referral, and crisis intervention programs for youth. Programs designed 
to assist children and families dealing with sever trauma are not 
readily available on Standing Rock.
    Families are economically disadvantaged and with the 40-75-mile 
trip to seek counseling it is virtually impossible to access these 
options. Transportation and access to a telephone is essential to 
regular therapy, however this is not a luxury the majority of our 
families have.
    We do not have:

   \\\\\\Effective clinical care for the mental, physical, and 
        substance abuse disorders.
   \\\\\\Easy access to a variety of clinical interventions and 
        support for help seeking.
   \\\\\\Family and community support.
   \\\\\\Support from ongoing medical and mental health care 
        relationships.
   \\\\\\Grievance counseling.
   \\\\\\Not enough police.

    Suicide is preventable. Most suicidal individuals desperately want 
to live; they are just unable to see alternatives to their problems. 
Most suicidal individuals give definite warnings of their suicidal 
intentions, but others are either unaware of the significance of these 
warnings or do not know how to respond to them. Surviving family 
members, suffer the trauma of losing a loved one to suicide, and are at 
higher risk for suicide and emotional problems. We as a nation need to 
be aware:

   \\\\\\Learn the warning signs.
   \\\\\\Get involved.
   \\\\\\Become available.
   \\\\\\Show interest and support.
   \\\\\\Be willing to listen.
   \\\\\\Be non-judgmental.
   \\\\\\Offer empathy.
   \\\\\\Offer hope that alternatives are available.
   \\\\\\Out reach services.

    Take action, Remove means and get help from individuals or agencies 
specializing in crisis intervention and suicide prevention.
    In conclusion, I would like to thank you for listening and request 
immediate assistance for the Standing Rock Sioux Tribe.

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  QUESTIONS OF Dr. CARMONA, SURGEON GENERAL, AND Dr. GRIM, DIRECTOR, 
                         INDIAN HEALTH SERVICE

    Question: What is the status of fiscal year 2005 funding through 
SAMHSA for two programs authorized under the Garrett Lee Smith Memorial 
Act?

    Answer: The request for applications for the State-sponsored Youth 
Suicide Prevention and Early Intervention grants and the Campus Suicide 
Prevention grants have been received and are currently undergoing peer 
review. SAMESA expects to make awards for these programs by September 
30.

    Question: In September, 2003, Dr. Grim created a National Suicide 
Initiative at IHS to provide national leadership on this tragic issue. 
One of the major areas of this initiative involves research. What is 
the status and results of this initiative with respect to data 
collection?

    Answer: Surveillance, data collection and data analysis are 
integral to data based research efforts, but just as importantly they 
are components to a comprehensive community or public health response 
to suicide. In support of data collection and analysis, and under the 
direction of the Indian Health Service Division of Behavioral Health 
(DBH), the Office of Information Technology (OIT) released a suicide 
surveillance tool in the Resource and Patient Management System (RPMS) 
Behavioral Health System (BHS) v3.0. This suicide surveillance tool, a 
21-item form, allows behavioral health providers to record suicide 
events. The suicide reporting form is also available in the graphical 
user interface to BHS v3.0, Patient Chart, which supports direct 
provider entry of clinical information. Direct provider entry of 
clinical information enhances both the accuracy and privacy of clinical 
data--two very important factors in the collection of suicide data.
    It is believed to be the most comprehensive tool and surveillance 
undertaking for suicide anywhere.
    Also, under the direction of the DBH, the Indian Health Performance 
Evaluation System (IHPES) Program developed a corresponding web-based 
suicide reporting form. The web-based suicide surveillance tool 
replicates the functionality and content of the RPMS-based tool. The 
web-based form allows non-RPMS users to: (1) access the tool via the 
DBH website; (2) complete documentation and data entry activities for 
suicide related events; and (3) submit the completed suicide activity 
to a central data base located at National Programs.
    DBH/OIT will release the RPMS suicide reporting form in the IHS 
Electronic Health Record by the end of fiscal year 2005. Deploying the 
form in the EHR will allow primary care providers to also record 
suicide events. This will provide more comprehensive data and 
facilitate baseline fiscal year 2006 suicide data for American Indian/
Alaska Native patients receiving care at IHS direct, tribal and urban 
facilities Suicide data (including data entered via the RPMS-or web-
based reporting tools) will be available via the DBH website. I/T/U 
behavioral health program managers will be able to view data specific 
to their Area (rates per 100,000) as well as data from other areas. All 
data will be in aggregate form and will not contain any patient 
identifiers. The system will contain three layers of security 
including: (1) IHS firewall and network security; (2) user id and 
password protection; and (3) Secure Socket Layer (SSL) security. SSL 
security is the same security used by financial institutions to allow 
``on-line'' banking activities. There are currently 250 sites using the 
current BH applications.

    Question: What sorts of partnerships have IHS and BIA formed to 
address the youth suicide issue on reservations? What kind of 
partnerships do you think would be useful?

    Answer: At the national level, IHS Division of Behavioral Health 
(DBH) representatives are collaborating with the BIA Office of Law 
Enforcement Services (OLES) representatives to develop a Memorandum of 
Understanding (MOU) to improve access to health and mental health care 
for American Indian and Alaska Natives (AI/AN) who are incarcerated in 
BIA and tribally contracted/compacted adult jails and juvenile 
detention centers. The intent of the MOU is to promote the 
establishment of local IHS, BIA and Tribal interagency agreements to 
coordinate services and establish Indian Country policy regarding 
screening (e.g., for suicide ideation), intake, assessment, medication 
management, and other health and mental health procedures (e.g., 
protocols for actively suicidal inmates) for incarcerated individuals. 
One issue in AI/AN communities is that tribal or IHS clinics are 
usually open 8-5, and an individual who is actively suicidal may need 
to be transported hundreds of miles to a regional hospital. In 
situations where local secure safe room are not available a suicidal 
youth may end up being incarcerated in the local adult jail for 
protection (which is against BIA OLES policy). Better IHS/BIA 
collaboration should create additional secure space for individuals who 
are actively suicidal.
    IHS Headquarters Office of Clinical and Preventive Services (OCPS) 
has established a multi-disciplinary School Health Committee, which is 
obtaining information concerning school health issues in Bureau of 
Indian Affairs Schools, Tribal Contracted/Compacted schools, and those 
State public schools whose student population is predominately American 
Indian. The overall goal is to assist those schools to promote healthy 
lifestyles for AI/AN students (e.g., reducing risk factors relating to 
suicide ideation) and to effectively provide an environment that is 
conducive to learning and encourages students to achieve. In the 
Billings Area, the IHS, BIA, tribal representatives and the Jason 
Foundation are collaborating to provide a culturally appropriate 
suicide prevention curriculum for school administrators and staff to 
recognize signs and symptoms of suicide and other suicide prevention 
services. This type of collaboration could be easily duplicated in 
other parts of Indian country. Another area that IHS and BIA 
partnerships could be developed is providing suicide prevention e.g., 
peer mentoring and life skills education in schools including Youth 
Regional Treatment Centers. Better collaboration at the local level 
would also lead to improved follow-up care plans and policies for 
suicidal individuals who have been hospitalized in State, regional, or 
private hospitals.
    Also, some of the IHS Area Offices behavioral health staff are 
involved in establishing an Area-wide suicide surveillance and 
prevention system in collaboration with the Bureau of Indian Affairs 
(BIA) and States.

    Question: At the committee's May 2 field hearing in Bismarck, Dr. 
Grim spoke of his experience at Red Lake High School. He told us that 
he saw the Red Lake Community drawing strength from not only mental 
health professionals but also tribal spiritual leaders. Please comment 
on the role of traditional health care practices in prevention and 
treatment of suicide and related mental health issues.

    Answer: It is the policy of the Indian Health Service [IHS] to 
facilitate the rights of American Indian and Alaska Native people to 
their beliefs and health practices as defined by the tribe's or 
village's traditional culture. The current IHS policy is meant to 
complement and support previously stated IHS policy for implementing 
the American Indian Religious Freedom Act of 1978 (Public Law 95-341, 
as amended). The IHS recognizes the value of traditional beliefs, 
ceremonies, and practices in the healing of body, mind, and spirit. The 
IHS encourages a climate of respect and acceptance in which traditional 
beliefs are honored as a healing and harmonizing force within 
individual lives, a vital support for purposeful living, and an 
integral component of the healing process.
    According the World Health Organization (WHO), the term 
``traditional medicine'' refers to ways of protecting and restoring 
health that existed before the arrival of modem medicine. In practice, 
the term ``traditional medicine'' refers to a number of components 
including mental healers and herbal medicines. A majority of native 
populations depend on traditional medicine for primary health care. The 
work force represented by practitioners of traditional medicine is a 
potentially important resource for the delivery of health care and 
medicinal plants are of great importance to the health of individuals 
and communities.
    The Director's Traditional Medicine Initiative emphasizes the 
alliance of traditional and western medicine practices between 
community traditional healers and IHS health care providers. Through 
this initiative, the agency seeks to foster formal relationships 
between local service units and traditional healers so that cultural 
values, beliefs, and traditional healing practices are respected and 
affirmed by the IHS as an integral component of the healing process.
    During 1995, 1996, and 2001, discussion circles were held in Indian 
Country to seek advice from traditional healers and tribal leaders on 
how to address traditional medicine. In response to concerns identified 
in the discussion circles, decisions regarding traditional healers are 
to be based upon what the local community considers appropriate. The 
IHS will honor the preferences of local communities in identifying 
traditional healers and determining how and if they should be 
incorporated into the medical model. It is the local community's 
responsibility to approach and orient local health care providers about 
tribal and/or community culture and traditions.

    Question: Please discuss IHS's efforts with SAMHSA to conduct 
training for tribal communities in suicide prevention and response.

    Answer: The IHS and the Center for Mental Health Services (CMHS/
SAMESA) Inter-Agency Agreement supports programming and service 
contracts, technical assistance and related services for suicide 
cluster response and suicide prevention for American Indian and Alaska 
Native tribal and urban populations. The Agreement involves two areas: 
(1) the development of a community suicide prevention ``tool kit'' 
website. The tool kit will include culturally appropriate information 
on suicide prevention, education, screening, intervention, and 
community mobilization which could be readily available in American 
Indian and Alaska Native communities via web and other digitally based 
media for ``off the shelf'' use and further development throughout the 
country. And, (2) The training and deploying of a network of at least 
12 behavioral health personnel (Tribal and/or Federal), one from each 
IHS Area, to serve in the CMHS/IHS national Suicide Prevention Network 
(NSPN). These individuals will be trained to provide onsite visits to 
communities in need of suicide prevention and/or intervention 
assistance. To date, prevention/intervention tools have been developed 
and a focus group was convened to review the materials at the annual 
IHS/SAMHSA Behavioral Health Conference in San Diego on June 28, 2005. 
Feedback from this meeting will aid in the refinement of the tool kit 
materials. It is the intention of the IHS to implement the toolkit in 
all their area offices by the end of the summer.
    In Albuquerque, NM, on June 13-17, 2005, a 5-day training was held 
to prepare over 20 participants to deliver onsite assistance to 
communities in crisis; those that are experiencing suicide clusters or 
need suicide prevention assistance. The training included: (1) Youth 
Suicide Prevention Initiative, which is based on the Center for 
Substance Abuse Prevention's (CSAP) Gathering of Native Americans 
(GONA) Model Program and also involved concepts of peer mentoring, 
facilitator training, and team and trust building; (2) Critical 
Incident Stress Management (CISM), which included concepts of defusing 
and debriefing; (3) QPR (Question, Persuade, and Refer)--a suicide 
prevention basic skills train the trainer technique; and (4) 
presentations on traditional healing ceremonies and resiliency. A 
second Youth Suicide Prevention Initiative training will be held in 
Billings, MT, on August 1-3, 2005, and will provide participants an 
opportunity to engage their facilitation skills in delivering suicide 
prevention models/processes to approximately 60 youth, with an 
estimated 8 adolescents attending from Standing Rock and Red Lake 
communities. IHS is collaborating with BIA at the local level to 
coordinate this training.
    Another suicide prevention effort that IHS and SAMHSA are 
collaborating on is the development of a Suicide Prevention Scan. The 
Indian Health Service and First Nations and Inuit Health Branch of 
Health Canada (FNM/HC) Memorandum Of Understanding (MOU) Suicide 
Prevention Working Group was developed to address concerns and share 
solutions regarding the disparity of suicide rates among the indigenous 
people of North America. It was a direct result of the MOU between the 
HHS and Health Canada, signed in Geneva, Switzerland, in 2002. The 
purpose of this MOU is to ``share knowledge through an agreed upon 
annual schedule of work which may include the exchange of information 
and personnel, the conducting of workshops, conferences, seminars and 
meetings.'' The Scan (a comprehensive directory) of promising and best 
suicide prevention practices, or programs, is currently being developed 
by One Sky (on behalf of the U.S. and funded by CMHS) in collaboration 
with FNIHB, Assembly of First Nations (AFN) and the Inuit Tapariit 
Kanataini (ITK) organizations.
    One area that IHS, SAMHSA, and BIA could collaborate on is the 
incorporation of suicide prevention programs (e.g., life skills 
education or peer mentoring programs) in schools with high AI/AN 
populations.

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