[Senate Hearing 109-558]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 109-558

                          INDIAN YOUTH SUICIDE

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

        OVERSIGHT HEARING ON THE TRAGEDY OF INDIAN YOUTH SUICIDE

                               __________

                              MAY 17, 2006
                             WASHINGTON, DC



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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:
    Ashley, Norine, director, Apache Behavorial Health Services, 
      White Mountain Apache Tribe................................    17
    Curie, Charles G., administrator, Substance Abuse and Mental 
      Health Services Administration.............................     8
    Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice 
      chairman, Committee on Indian Affairs......................     1
    Eagleman, Chet, acting chief, Division of Human Services.....     4
    Gidner, Jerry, deputy director for tribal services, 
      Department of the Interior.................................     4
    Grim, Charles W., director, IHS, Department of Health and 
      Humane Services............................................     6
    Hubbard, Frederick L., associate director, Community 
      Relations, White Mountain Tribe............................    17
    Kauffman, Jo Ann, project director, Native Aspirations 
      Project....................................................    22
    Martin, William E., chairman, Alaska State Suicide Prevention 
      Council, first vice president, Central Council of the 
      Tlingit and Haida Tribes of Alaska.........................    19
    Maybee, Peter, assistant to the deputy bureau director, Law 
      Enforcement Services.......................................     4
    Murkowski, Hon. Lisa, U.S. Senato from Alaska................     2
    Perez, Jon, director, IHS, Division of Behavorial Health.....     6
    Skenandore, Kevin, acting director, Office of Indian 
      Education Programs.........................................     4
    Vigil, Donna, director, Division of Health Programs, White 
      Mountain Apache tribe......................................    17
    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...........................    30
    American Academy of Pediatrics...............................    37
    Bullard, Loretta, president, Kawerak Inc., Nome, AK..........    40
    Curie, Charles G.............................................    40
    Gidner, Jerry................................................    42
    Grim, Charles W..............................................    45
    Kauffman, Jo Ann.............................................    55
    Martin, William E. (with attachment).........................    65
    McCain, Hon. John, U.S. Senator from Arizona chairman, 
      Committee on Indian Affairs................................    29
    Vigil, Donna.................................................   164
    Walker, R. Dale..............................................   166
Additional material submitted for the record:
    Archambault, Donna, Home School Coordinator, McLaughlin, SD 
      (letter)...................................................   173
    Schmeichel, Patricia, McLaughlin, SD (letter)................   175

 
                          INDIAN YOUTH SUICIDE

                              ----------                              


                        WEDNESDAY, MAY 17, 2006


                                       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. John McCain (chairman of the 
committee) presiding.
    Present: Senators McCain, Dorgan, and Murkowski.

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

    Senator Dorgan. Senator McCain is delayed this morning and 
has asked that I convene the hearing. He will be here, however, 
shortly.
    I want to say good morning to everyone and thank all of you 
for being here. This is the cOMMITTEE ON Indian Affairs third 
hearing on the tragedy of Indian youth suicide. It is a 
sensitive subject, one that some perhaps would prefer we not 
even discuss, but one I think that we simply cannot ignore.
    Today, the committee will hear testimony about what kind of 
suicide prevention programs are currently available in Indian 
country; what programs exist that may not yet be available to 
certain areas in our country; whether there are recommendations 
to apply and tailor additional programs or resources to address 
the problem of Indian youth suicide on reservations and Alaska 
Native village communities.
    I want to acknowledge the presence of the Indian Health 
Service. Dr. Grim is with us and Mr. Perez, and that of the 
Substance Abuse and Mental Health Services Administrator, Mr. 
Curie, is with us today. You and your staff have been very 
helpful to this committee as we have reflected on a good many 
recommendations on these issues.
    Others of our witnesses have also provided valuable 
experience and insight. This is the third hearing that we will 
have held on this subject. Last week, during what was called 
Health Week in the United States Senate, the full Senate 
approved legislation that I had authored with my colleagues, 
Senator McCain, Senator Murkowski, and others, dealing with 
telemental health, one avenue to try to deal with this issue of 
teen suicide on Indian reservations.
    I am very pleased that the Senate has moved that 
legislation. I thank Senator McCain, Senator Murkowski, and 
others of my colleagues for working with me to put a piece of 
legislation together. It was very helpful.
    The legislation I think is a positive step, but there is so 
much more yet to be done, and that is the purpose of holding 
this hearing.
    We have a number of witnesses today. The first panel is a 
panel that is composed of Jerry Gidner, the deputy director for 
tribal services at the Bureau of Indian Affairs, U.S. 
Department of the Interior. Mr. Gidner is accompanied by Chet 
Eagleman, acting chief, Division of Human Services; Kevin 
Skenandore, acting director, Office of Indian Education 
Programs; and Peter Maybee, aAssistant to the deputy bureau 
director, of the Law Enforcement Services.
    We have Dr. Charles Grim, the director of the Indian Health 
Service, Department of HHS, accompanied by Jon Perez, the 
director of Indian Health Services Division of Behavior Health; 
and Charles Curie, administrator of substance abuse, Mental 
Health Services Administration.
    So we want to thank everyone who has changed their schedule 
to be with us this morning. Mr. Curie, I understand that you 
were scheduled to be elsewhere, but have changed your schedule 
to be with us. Thank you very much.
    Why don't we begin? I would like to call on Senator 
Murkowski if she has opening comments, and then we will begin 
to hear from the first panel.

   STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman.
    I appreciate your attention, as well as that of Chairman 
McCain, to this very important issue. As you have pointed out, 
it is an issue that we don't like to talk about. It is 
sensitive. It is personal, but it is very, very real.
    I am pleased to welcome to the committee this morning First 
Vice President, Bill Martin. Bill is Tlingit and Haida. He is 
with us today. He is a tribal leader and the chair of Alaska's 
Suicide Prevention Council. He has a big job in that role and 
we certainly appreciate all the work that he does.
    In August 2003, the Centers for Disease Control reported 
that the Alaska region of the Indian Health Service had a 
higher rate of suicide among Native youth under age 19 for the 
period of 1989 to 1998, so a 10-year period, higher than any 
other IHS region in the country. Ours was 23.8 per 100,000 
population. You can compare that to the next highest, the 
Aberdeen region in the plains, they were second at 19.1 per 
100,000.
    These are statistics that are terrible. These are 
statistics that should concern us all. Death by suicide in 
Alaska rose 4 percent in 2005 over the previous year. We know. 
We don't need to continue to listen to the stories about how 
they affect the communities, the families, but it is important 
to hear those stories and understand the devastation that the 
suicide is causing in too many of our Native villages in our 
communities on our reservations.
    Mr. Chairman, I want to commend you for your efforts and 
all that you have done to bring attention to this issue. The 
passage of the Indian Youth Telemental Health bill now pending 
in the House of Representatives, I think that is something that 
we all want to continue to encourage to make positive steps in 
the direction that that legislation leads us.
    We have some issues in Alaska that present great 
challenges, our distance, our geography, but we share many 
characteristics with Indian country in the lower 48. We are 
isolated in terms of our road infrastructure. In many cases, 
our telecommunications infrastructure needs improvement. We 
have serious needs for medical professionals in the areas, 
particularly in the behavioral health area. It is tough to get 
professionals to move out there to provide the services that we 
so desperately need.
    We recognize that for the rural telemedicine project, we 
can help bridge this gap that is so necessary. The Native 
health system in the State I think has proven to be a pretty 
innovative. This has been helpful to us, training the community 
members as behavioral health aids providing this bridge between 
the Native people needing the services and the professionals in 
the cities.
    So we are making serious headway there, but we recognize 
that we have so very hard to go. So I appreciate the good works 
of most of you at the table, those of you in the room, that are 
focusing on this, and the focus that this committee has placed 
on this issue that is such a concern.
    With that, Mr. Chairman, I just want to welcome everyone 
and look forward to their testimony.
    Senator Dorgan. Senator Murkowski, thank you very much.
    At a recent hearing dealing with methamphetamine addiction, 
we had a tribal chair come to this committee and describe the 
devastation of addiction to methamphetamine, but also the 
number of attempted suicides on her reservation. As a tribal 
chair, she described it in some detail, and it was startling, 
absolutely startling. What got me interested in this issue was 
a rash of suicide or a cluster of teen suicides on the Standing 
Rock Sioux Reservation in North Dakota. Even prior to that, I 
have used on the floor of the Senate, with the consent of 
relatives, the name of a young woman. I understand it is 
sensitive, and that is why I asked the relatives if I could do 
it, but a young woman, 14 years old, named Avis Little Wind. 
Avis Little Wind killed herself. She was 14. Her sister had 
killed herself, taken her own life 2 years before.
    At age 14, she had missed 90 days of school, lay in her bed 
in a fetal position, with obviously serious emotional issues, 
and somehow no one caught it. This young girl lay in her bed 
for 3 months, not going to school, at age 14, and it didn't 
raise any red flags anywhere, apparently.
    And so I went to meet with the school administrators, with 
the tribal council. I met with the classmates of this young 
women. And then just recently I went to the Standing Rock 
Reservation and had a meeting with Indian kids, high school 
kids, just us, nobody else was around, just myself and about 1 
dozen or 1\1/2\ dozen Indian kids, just talking for about 1 
hour about their lives, about what they see in their school, 
about the issue of teen suicide, teen pregnancy, 
methamphetamine.
    What is happening is pretty unbelievable in many areas. 
This issue of suicide is so tragic, particularly with respect 
to youth. It is young people I think feeling that their life is 
hopeless; that they are helpless. They decide that the only way 
out is to take their own life. Some young kids have told me 
that some of their acquaintances who took their lives really 
didn't want to die, they just wanted attention, and they were 
trying to get attention, to scream out and beg for attention.
    I think as a result of all of this, in our region Indian 
teens are 10 times more likely to take their lives than in the 
population as a whole. I think my colleague just described the 
circumstance in Alaska.
    So the purpose of this is not to exploit or to be 
sensational. The purpose of this is to see if we can find some 
way that is going to save some lives; that is going to say to 
these kids that things are not hopeless and there are people 
that want to help. That is the purpose of having these 
discussions and trying to think through what are the policy 
choices for us to address what is a very serious issue.
    Let me begin the first panel. Jerry Gidner is the deputy 
director for tribal services at the BIA. Mr. Gidner, your 
entire statement will be part of the record. You may proceed 
with your testimony.

STATEMENT OF JERRY GIDNER, DEPUTY DIRECTOR FOR TRIBAL SERVICES, 
   DEPARTMENT OF THE INTERIOR, ACCOMPANIED BY CHET EAGLEMAN, 
  ACTING CHIEF, DIVISION OF HUMAN SERVICES; KEVIN SKENANDORE, 
ACTING DIRECTOR, OFFICE OF INDIAN EDUCATION PROGRAMS; AND PETER 
     MAYBEE, ASSISTANT TO THE DEPUTY BUREAU DIRECTOR, LAW 
                      ENFORCEMENT SERVICES

    Mr. Gidner. Thank you, Mr. Chairman, Mr. Vice Chairman, 
members of the committee. With your permission, I will put the 
testimony in the record and just give a brief statement.
    My name is Jerry Gidner. I am the deputy bureau director 
for tribal services at the BIA. You mentioned my colleagues who 
are here today with me. I did want to mention that Bureau 
Director, Pat Ragsdale, is here today in the audience because 
of his interest in the topic.
    As the committee knows, Mr. Chairman, teen suicide is a 
serious problem in Indian country. The suicide rate is 2.5 
times greater than the nationwide rate. IHS statistics show 
that it is the third leading cause of death in Indian children 
5 to 14 years old and the second leading cause of death among 
teens and young adults 15 to 24 years old.
    Every 2 years, our Office of Indian Education Programs does 
a youth risk behavior survey, and that survey shows some fairly 
startling results. The last survey results that are available 
are those from 2003. Those results show that one-third of 
Indian children and teens feel sad or hopeless at some point in 
a given year, and that of course is a beginning stage in those 
children who might commit suicide.
    In high school, the surveys show that 21 percent seriously 
considered suicide in the last year and 18 percent actually 
attempted, made some attempt in the past year. I invite you to 
think about that for just 1 minute. That is a very stunning 
statistic. It means that nearly one-fifth of students in BIA 
schools or BIA-funded schools made some attempt at suicide.
    Senator Dorgan. Mr. Gidner, tell us again where that data 
comes from?
    Mr. Gidner. That comes from a survey conducted by our BIA's 
Office of Indian Education Programs, which is conducted every 2 
years in high schools and middle schools. As I said, that data 
is from 2003 and I understand the survey was conducted again in 
2005. That data is not yet available. In middle school, the 
younger children, 26 percent seriously considered suicide and 
15 percent actually attempted it. Mr. Chairman, as you pointed 
out, the youth of Indian country are crying out for help.
    Research shows that many social factors such as poverty, 
alcohol, and substance abuse can lead to suicidal behavior and 
these social factors as we all know are present in Indian 
country. So the question you are rightfully asking is what can 
be done about this. Our colleagues here at the table from HHS 
provide most of the suicide prevention and treatment behaviors.
    The role of the BIA is somewhat less than that. We do work 
on some of those societal factors. We help tribes develop the 
infrastructure of government, the infrastructure of schools and 
law enforcement, where that does not otherwise exist. We 
participate in several multiagency efforts. For example, in the 
Rocky Mountain region, there is a Native American youth suicide 
prevention initiative where we partner with IHS and others in 
that effort.
    Our law enforcement office, where they have jurisdiction, 
are very often the first responders to suicides and investigate 
the suicide. We also train our detention center staff, 
particularly for the youth detention facilities, in suicide 
prevention efforts.
    Our Office of Indian Education programs again receives 
funding. All bureau-funded schools receive funding through the 
Department of Education to operate safe and drug free school 
programs, and those are used to prevent violence and substance 
and alcohol abuse, which of course can be precursors to suicide 
attempts.
    In 2004, our education program launched a suicide 
prevention initiative using the question, persuade and respond 
model, where people are trained to question students that may 
be harboring ideas about suicide, persuade them to get help, 
and refer them to the appropriate help if they will go. All 184 
BIA-funded schools and dormitories received this training, and 
the administrators were instructed to ensure that all of their 
staff had that training as well.
    With that, I will conclude my statement. I will be happy to 
take your questions.
    [Prepared statement of Mr. Gidner appears in appendix.]
    Senator Dorgan. Mr. Gidner, thank you very much for your 
testimony.
    Next, we will hear from Dr. Charles Grim, the director of 
the Indian Health Service at the Department of Health and Human 
Services. Dr. Grim, thank you for joining us again.

STATEMENT OF CHARLES W. GRIM, DIRECTOR, INDIAN HEALTH SERVICES, 
  DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY JON 
  PEREZ, DIRECTOR, INDIAN HEALTH SERVICE DIVISION OF BEHAVIOR 
                             HEALTH

    Mr. Grim. Thank you, Mr. Vice Chairman, and Senator 
Murkowski. I continue to appreciate working with this committee 
and your willingness to raise issues like this that we in 
Indian Health deal with on a daily basis. This is a very 
important issue, and we are very appreciative that you have 
chosen to hold another hearing about it. I applaud you for 
getting the bill that you all introduced passed. I think 
telehealth is one of the ways that we are going to be able to 
get into some of the most rural parts of the country the kind 
of care that you receive in urban areas.
    Today, I am accompanied by Dr. Jon Perez, our national 
behavioral health consultant, who has been before you as well 
today. I am honored to be able to testify on behalf of 
Secretary Leavitt on suicide prevention programs in Indian 
country.
    I am also honored to testify alongside Charlie Curie, a 
strong supporter of addressing substance abuse and mental 
health issues in Indian country, something that I personally 
witnessed and watched him do during his tenure at SAMHSA. It is 
also always a privilege for me to testify alongside my 
colleagues at the BIA, today Jerry Gidner, because our two 
agencies play such a large role in Indian country.
    I would ask that my written testimony be made a part of the 
record. In it, you will find a much more detailed analysis of 
the statistics and some of the partnerships and things going on 
in Indian country. Today, I am just going to summarize a few 
things in my oral comments.
    Suicide in Indian country, as I have said before, in 
contrast to most of the rest of the United States, is 
characterized by higher rates for younger people, and affecting 
entire communities because suicide, much like an infectious 
disease, often spreads rapidly among families and peer groups 
in what you and others have called suicide clusters in Indian 
country.
    The latest information that we have, which has been cited 
by yourself, Senator Murkowski and the BIA, I won't go through 
all those statistics, but suffice it to say they are startling. 
I am glad that we, that the Senate, that the tribal leadership 
have brought this issue to the forefront and talked about it.
    I am also appreciative that the Surgeon General was here at 
the last hearing held here in Washington to raise the issue not 
only in the Nation, but the high rates in Indian country.
    The most important thing to remember is that suicide is not 
a single problem. It is a single response to multiple problems. 
Neither is it strictly a clinical or an individual problem, but 
one that is affected by the entire community. I think the panel 
that you have put here today is going to bring all those 
perspectives into play.
    Let me quote from the Institute of Medicine's landmark 2002 
publication called ``Reducing Suicide.'' They stated that 
suicide may have a basis in depression or substance abuse, but 
it simultaneously may relate to social factors like community 
breakdown, loss of key social relations, economic depressions, 
or political violence, much of which we know occurs in many of 
our Indian communities.
    To address it appropriately, we have worked on both public 
health and community interventions as much as we have the 
direct clinical ones. As you know, much of the Indian Health 
Service budget in alcohol and substance abuse and in mental 
health goes directly to clinical care.
    In late September 2003, I announced the Indian Health 
Service National Suicide Prevention Initiative. It was designed 
directly to support our Indian Health Service tribal and urban 
programs in three major areas associated with suicide in our 
communities: First, to mobilize tribes and tribal programs to 
address suicide in a systematic evidence-based manner; second, 
to expand and enrich research and program bases around suicide 
in Indian country, something that is lacking; and third, to 
support and promote programmatic collaboration on suicide 
prevention.
    While we have made progress in developing plans and 
delivering programs to Indian country, we all realize that this 
is only the beginning of a long-term concerted and coordinated 
effort among not only the Federal programs here at the table, 
but tribal communities, states, and other local and county 
community efforts around the country that we need to address 
the crisis.
    The initiative that we put together, along with tribal 
leadership and tribal providers, addressed all 11 goals around 
HHS's national strategy for suicide prevention. That work 
represented the combined work of advocates, clinicians, 
researchers and survivors of suicide and their families all 
around the Nation. It lays out a framework of action to help 
prevent suicide and also guide us in the development of an 
array of services that we are developing.
    In our headquarters office right now, we are currently 
working with the areas, tribes and communities, as well as 
States, to establish area-wide suicide surveillance and 
prevention systems, in collaboration with the BIA and States to 
collect information from law enforcement and medical examiner 
databases. We are also establishing partnerships between IHS 
and BIA to increase access to health and mental health care for 
children attending BIA-funded schools, and strengthening 
partnerships between State and Federal agencies in the area of 
suicide prevention.
    We have also been working closely over the last several 
years in collaboration with SAMHSA and other HHS agencies and 
nongovernmental organizations and States to address and reduce 
suicide. We continue to train community members in the QPR 
model that was mentioned by Mr. Gidner, to involve American 
Indian and Alaska Native youth in suicide prevention efforts 
primarily through school products and Boys and Girls Clubs. We 
have been utilizing tribal colleges to provide suicide 
prevention training and programs that are culturally 
appropriate to our population.
    For the first time, we have far more accurate data that is 
being gathered and shared from our clinicians in our 
communities, and those national policymakers and programs, all 
of which are extremely important to discuss the prevalence and 
the effects of suicide in Indian communities. No longer are we 
extrapolating data or estimating data, because we have data now 
that we feel is representative of Indian country and the 
communities affected.
    We are continuing to upgrade those systems. For the first 
time, our electronic health record that we have had for many 
years is going to be fully integrated with the behavioral 
health documentation that many communities keep on suicide and 
other behavioral health issues.
    Mr. Chairman, I will conclude my statement now by noting 
that, as I said earlier, my written statement goes into much 
more detail about the efforts that we have done. I want to 
thank you and this Committee again for continuing to raise this 
issue. I will be happy to discuss any of these issues that we 
have brought up today with you during the question and answer.
    Thank you.
    [Prepared statement of Dr. Grim appears in appendix.]
    Senator Dorgan. Dr. Grim, thank you very much.
    Finally, we will hear in this panel from Charles Curie. He 
is the administrator of the Substance Abuse and Mental Health 
Services Administration. Mr. Curie, thank you again for being 
here.

 STATEMENT OF CHARLES G. CURIE, ADMINISTRATOR, SUBSTANCE ABUSE 
           AND MENTAL HEALTH SERVICES ADMINISTRATION

    Mr. Curie. Thank you, Mr. Chairman and Senator Murkowski. 
Good morning. I am Charles Curie, the administrator of SAMHSA, 
the Substance Abuse and Mental Health Services Administration 
within the Department of Health and Human Services. I am 
pleased to be here today to describe how SAMHSA is working to 
address the issue of suicide among American Indians and Alaska 
Natives.
    Senator Dorgan, as you kindly mentioned earlier, I was 
scheduled to speak at a suicide prevention conference actually 
in Casper, WY today, but I am so personally concerned about 
suicide rates, especially in Indian country, and the work that 
we must continue to do there, that I wanted to provide this 
testimony myself.
    It is a privilege also to testify with my friend and 
colleague, Dr. Charles Grim, director of the Indian Health 
Service [IHS]. SAMHSA and IHS have developed a strong 
partnership and a lot of collaborations that we are working on. 
It is reflected in our current interagency agreement to work 
efficiently and effectively together to help meet the public 
health needs of American Indians and Alaska Natives.
    It is also a privilege to be here with Jerry Gidner, deputy 
bureau director for tribal services at the Bureau of Indian 
Affairs [BIA].
    Suicide is not only a serious public health challenge, but 
it is a tragedy that is only now receiving the attention and 
degree of national priority it deserves. As you indicated, 
Senator, many people have difficulty discussing this issue and 
many times it is easier to put it out of the realm of 
consciousness. Many Americans are unaware of suicide's toll and 
its global impact.
    Suicide makes up 49.1 percent of all violent deaths 
worldwide. It surpasses homicide as the leading cause of 
violent deaths. In the United States, suicide claims 
approximately 30,000 lives each year. When faced with the fact 
that the annual number of suicides in our country now outnumber 
homicides by 3 to 2, approximately 30,000 and 18,000 
respectively, the relevance of our work becomes very clear. 
When we know, based on SAMHSA's household survey for 2003, that 
approximately 900,000 youth have made a plan to commit suicide 
during their worst or most recent episode of major depression, 
and an estimated 712,000 attempted suicide during such an 
episode of depression, it is time to intensify activity to 
prevent further suicides.
    The household survey data, the countless personal stories 
of loss and tragedy, are why we have made suicide prevention a 
priority at SAMHSA.
    Last year, as you mentioned, a suicide cluster occurred on 
the Standing Rock Reservation in North Dakota; 10 young people 
took their own lives, and dozens more attempted to do so. The 
Red Lake Indian Tribe in Minnesota is experiencing high suicide 
rates following the deaths of 9 individuals at the hand of a 
16-year old high school junior. Tragically, many other 
reservations have similar stories to tell. Suicide is the 
second leading cause of death for American Indian and Alaska 
Native youth ages 15-24. In 2003, the suicide rate for this 
population was between 2 and 2\1/2\ times the national average, 
and the highest among all ethnic groups in the United States, 
with a rate of 18 suicides per 100,000 individuals.
    SAMHSA's policy is to level the playing field and to ensure 
that tribal entities are eligible for all competitive grants 
for which States are eligible, unless there is a compelling 
reason to the contrary. Currently, SAMHSA consistently is 
funding around $34 million of grants to award tribal behavioral 
health issues.
    In 2005, we made the first cohort of awards, 14 in all, 
including a grant to Arizona under the Garrett Lee Smith 
Memorial Act. These funds are available to help States and 
tribes implement effective suicide prevention networks. One of 
those first grants went to the Native American Rehabilitation 
Association in Oregon. Today, I am announcing almost $9.6 
million in funding for eight new grants, each for approximately 
$400,000 per year for 3 years under this program to support 
national suicide prevention efforts.
    Grants have been awarded to programs in Oregon, 
Connecticut, Utah, Wisconsin, and Idaho. In addition, grants 
specifically geared to American Indians and Alaska Natives have 
been awarded to the Manniilaq Association of Alaska, the United 
Indian Involvement, Inc., and the Montana-Wyoming Tribal 
Leaders Council. An announcement for a third cohort of grants 
under this program closed yesterday. SAMHSA again invited all 
tribes to apply and provided technical assistance to tribal 
organizations to encourage more applicants.
    The Garrett Lee Smith Memorial Act also authorized a 
National Suicide Prevention Resource Center. We are requiring 
the center to address how they would expand the current youth 
suicide prevention technical assistance to go toward tribes and 
tribal organizations.
    SAMHSA has long supported a national suicide hotline, 1-
800-273-TALK. Funding for the current hotline grantee was 
increased by $369,000 in fiscal year 2006, and the grantee has 
been asked to submit an application that indicates how they 
will expand their access to tribes.
    In the Administration's request for the fiscal year 2007 
budget, the one currently in front of Congress, SAMHSA is 
asking for nearly $3 million for a new American Indian-Alaska 
Native Initiative to provide evidence-based programming to 
prevent suicide and reduce the risk factors that contribute to 
youth suicide and violence.
    SAMHSA has also transferred $200,000 to IHS to support 
programming and service contracts, technical assistance, and 
related services for suicide cluster response and suicide 
prevention. One example is the development of a community 
suicide prevention tool kit. This tool kit includes information 
on suicide prevention, which can be made readily available via 
the web.
    SAMHSA also has issued emergency response grants in the 
aftermath of suicides, both on the Standing Rock Reservation as 
well as at Red Lake. Those dollars are still available to those 
two entities and we are still working in close collaboration to 
ensure those dollars are used in the best way possible.
    SAMHSA is proud of what we have done, while knowing that 
this is not nearly enough. There is much more to do. The 
problems confronting American Indian and Alaska Native youth 
are taking their toll on the future of tribal communities.
    I ask also that my written testimony be made part of the 
record, which does go into much more detail. I want to thank 
you again for the opportunity to appear today and I would be 
pleased to answer any questions you may have.
    [Prepared statement of Mr. Curie appears in appendix.]
    Senator Dorgan. Mr. Curie, thank you very much.
    The Senate now has a vote in progress. I understand there 
are about 6 minutes remaining, so I think we will have no 
choice but to have a brief recess. We do want to ask some 
questions, and I believe Senator McCain will be joining us as 
well. But I think in the interest of time here, we will take 
about a 10-minute recess, and we will reconvene, we expect, at 
10:15.
    [Recess.]
    Senator Dorgan. The hearing will come to order again.
    Let me thank the panel for their testimony, and let me ask 
a few questions, if I might.
    The hearings that I have held and the discussions that I 
have had paint a pretty dismal picture in most areas and with 
most reservations. The resources available, for example, when I 
went to the Spirit Lake Nation Tribe and talked to the school 
administrators, the tribal council, parents, students, and 
others, what I discovered with respect to the death of Avis 
Little Wind and others who had committed suicide is that they 
had very few resources. Mental health resources were virtually 
nonexistent. To the extent that they were accessible, they were 
accessible only with great difficulty, only then if you were 
able to borrow a vehicle from someone, if someone would loan 
you a vehicle that you could use, then the transport. It was 
unbelievable to me to see how few resources area available.
    Now, Mr. Curie, today you have described grants and I 
appreciate your announcement today of those grants. I think it 
is going to be helpful. But I would like all three of you to 
tell me, you know, you have told us what is happening; tell us 
what isn't happening that has to happen in order for us to 
fully address this.
    Let me describe why I say that. Dr. Grim, you talked about 
the resources that are important in rural areas to address 
this. But you know, the President's budget recommends zeroing 
out the Indian Urban Health Centers in urban areas, zero them 
out. So even in urban areas, we have problems with the 
resources.
    So I appreciate all that you say that you are doing. Tell 
me, as professionals, and as people who visit reservations and 
understand these issues, what is not being done that has to be 
done in order to really address this issue? Mr. Curie, would 
you go first?
    Mr. Curie. Yes; I will. Senator, I couldn't agree with you 
more that the issue around resources and accessibility to care 
is really part of the fundamental problem that we are seeing 
here. In fact, when we take a look at suicide rates, whether it 
is in Indian country or in general, untreated depression, lack 
of intervention many times is the root cause.
    I think when we look at Indian country, we look at the 
remoteness of many of the reservations we see especially in 
Alaska with the Alaska Native villages, and this is an ongoing 
problem. We need to be thinking in terms of how to have the 
resources available to people where they live. There are models 
that are now being developed.
    One, I would point out, is at the University of Alaska in 
which individuals who are from the tribe, young people in 
particular who are looking for a potential career, are trained 
as behavioral health, mental health, substance abuse aides and 
have the supervision, then, of a graduate degree professional 
that they would be connected with. We think this offers a 
pathway that we need to examine and see how we can expand and 
bring that to some sort of systemic level. Because again, when 
you have virtually hundreds of miles to go before you find a 
professional, it is unlikely that the interventions are going 
to be timely and appropriate.
    This is tied, I think, to the greater workforce development 
issue that is facing the field as a whole, both in mental 
health and substance abuse, attracting people, keeping people 
in the field. Then again it is compounded even further when you 
are talking about rural frontier remote areas, and we are 
talking about Indian country.
    So we need to be thinking in terms of how individuals 
themselves can be engaged and get the training and support they 
need.
    I think it is also very critical for us to do what we can 
in collaboration with agencies that work not only on the 
treatment end of things, but in helping the young people in 
those villages find both an anchor, and I was discussing this 
with Senator Murkowski earlier, and a line of sight of where 
they are going to end up being someday.
    I think those villages where we have seen a real focus on 
getting a sense of their cultural heritage, having strong youth 
initiatives to give them a sense of family, heritage, 
tradition, and helping them see what their future can hold, are 
establishing clear protective factors that can help address 
these risk factors. So we believe a public health model in 
identifying risk factors and increasing protective factors also 
will be critical in this process.
    Senator Dorgan. Thank you.
    Dr. Grim.
    Mr. Grim. I would agree with everything Charlie said. Let 
me just start out by saying that. Second, since we focus on 
direct clinical and preventive, as well as public health care 
in our settings, we need to continue to do that. We need to 
have those sorts of services available. I think the expansion 
of, and we are doing this in telehealth, the expansion of tele-
mental health capabilities. We don't have that across all of 
our areas yet. I think that will also lead to some increase in 
services.
    We face the same thing that Charlie said at a national 
level, you know, the recruitment and retention of the right 
types of health care professionals. But also I think I want to 
play up the partnership issue a lot. I don't think any one 
agency right now has the full answer to this, nor has all the 
money that they need to address it. But I think we are seeing a 
lot of partnerships emerge around this issue.
    A lot of it is coming from the Administration, asking the 
Indian Health Service and SAMHSA and BIA to work together. A 
lot of it is coming from the Congress in stimulating activity 
through funding or through bills like you all just passed. I 
think the partnerships that we have with SAMHSA, with BIA right 
now, are critically important partnerships.
    We have also worked with Canada. My counterpart from 
Canada, the Director for First Nations and Inuit Health Branch, 
they have a very similar problem up there. We had a recent 
meeting in Albuquerque, New Mexico where their National 
Institute of Health Research, our National Institute of Mental 
Health, people from Indian Health Service, and First Nations 
and Inuit Health Branch, the Wisdom Keepers and traditional 
healers from communities, all got together.
    We partnered to come up with a research agenda in Indian 
country over the next 5 or so years. We know there is a lack of 
information about, as Charlie said, some of the risk factors, 
as well as the protective factors. Ever since Charlie and I 
have been in our positions, we have held a joint meeting 
between the State block grant coordinators, the Indian 
programs, and the Indian Health Service and SAMHSA staff. That 
meeting has continued to grow in both importance, as well as in 
attendance. We are even having people from other countries come 
now. There is a part that spins off on that about suicide to a 
work group.
    So I think partnerships with others beyond just the ones I 
mentioned, because the socially complex factors of housing, 
education, safety in the communities, all those are part of it. 
It is just such a complex issue that we have to have more 
partnerships, I believe.
    Senator Dorgan. Mr. Gidner.
    Mr. Gidner. Thank you. I would agree with Dr. Grim and Mr. 
Curie as well. From the BIA perspective, on the micro level, I 
would say there are not enough trained people on the ground to 
observe and work with the youth, to identify those who may be 
thinking about suicide, and to get them into the appropriate 
health model to prevent that. BIA does have a cadre of social 
workers throughout the country. They are spread very thin and 
spend most of their time working with child abuse and 
adoptions, foster care, things of that nature.
    On the macro level, though, I would suggest that what needs 
to happen is there has to be a way to give these children hope 
that there is some better future for them. That would involve 
more job creation, better law enforcement, other things that 
are going to improve the health of their community so that they 
know there is something waiting for them, and that they have a 
reason to live.
    Senator Dorgan. Mr. Chairman, welcome. We are just 
finishing up the first panel. Senator Murkowski has not yet 
asked questions.
    I have to be down at an Appropriations hearing in a few 
minutes with the Defense Secretary to question him. I just 
wanted to make a point at the end of this panel. I think these 
partnerships are important. I especially appreciate the fact 
that you are all providing focus to this. I also think that we 
have to provide funding as well.
    For example, we have an Indians in Psychology Program 
trying to encourage Indians into psychology in colleges. That 
gets zeroed out every year by the Administration and they are 
zeroing out the Urban Indian Health Centers. So we do have to 
provide funding. We need youth centers. We need trained mental 
health professionals and so on.
    I have been sensitive to this issue of suicide for a long, 
long time. I walked in one morning and found a very close 
friend of mine had taken his life, a co-worker. I found him at 
his desk at 8 o'clock in the morning. With him, as it is, you 
say, with Indian youth, it is the single act in response to 
multiple causes, almost always the case regardless of age.
    But especially with respect to Indian youth, there is a 
very serious problem, and I appreciate the partnerships. We 
need the funding. We need strategies. I appreciate Chairman 
McCain also providing focus to this issue with this committee, 
and Senator Murkowski's attention and interest in it as well. I 
look forward to continuing to work with you and exchanging 
views with you and developing strategies with you to address 
it.
    Mr. Chairman, thank you very much.
    The Chairman. Thank you very much, Senator Dorgan. Thank 
you for your leadership. Thank you for your attention and your 
continued commitment to this issue.
    I know that a lot has been covered. I just wanted to ask, 
Mr. Curie, I keep hearing from Indian country that 
methamphetamine is having a significant effect on this issue, 
not just suicide, but on a whole lot of other aspects of Indian 
country. Can you comment specifically on the epidemic of 
methamphetamine and how it has affected this specific issue?
    Mr. Curie. Yes, Mr. Chairman; Methamphetamine is 
undoubtedly from what we have seen the most dangerous drug that 
has been on the street and available. In terms of its addictive 
quality, one use and addiction can occur. In terms of the 
devastating impact it has on the individual, in terms of their 
brain. Their whole life begins to get focused on one thing, and 
that is the desire to have more methamphetamine.
    The challenge and why it is in many parts of the country, 
while national prevalence data shows that actually opiates and 
painkillers are growing at a faster rate overall nationally, 
there are places in the country, in Indian country and rural 
and frontier areas in Western and Midwestern States where 
methamphetamine is the number one problem. That is because of 
the accessibility of the ingredients to make meth. It is 
available, of course, readily available in hardware stores, in 
various retail outlets, and there are recipes, of course, 
available through the Internet today.
    The Chairman. And some of it is coming across our Indian 
reservations from Mexico?
    Mr. Curie. Yes; and that is also another factor. 
Absolutely. So there is accessibility to it. And there is an 
undeniable link between substance abuse, especially when we 
talk about how dangerous meth is, and suicide. A high 
percentage of suicides are linked to drug and alcohol use.
    So to approach this, we believe that it has to be a 
multifaceted approach to the suicide problem, that we have to 
consider our substance abuse treatment and prevention efforts 
to be part of the suicide prevention efforts. We need to be 
working specifically with tribes in the context of their 
culture and the context of what their needs are to identify 
those risk factors that continue to contribute to the substance 
abuse problem, and to develop protective factors. We are 
finding many of them are the same that relate directly to the 
suicide problem and issue. So they do go hand in hand.
    We are looking very closely now in California, where the 
tribal organization, the California Rural Indian Health Board, 
received one of our access to recovery grants in which vouchers 
are being used and to expand their capacity for substance abuse 
treatment. We are going to be looking very much at the link 
there in terms of the impact that additional resource is having 
in helping address this issue.
    The Chairman. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Mr. Gidner, you mentioned in your testimony this high 
school, middle school youth risk behavior survey, where you 
have gotten some pretty compelling data about what our young 
people are contemplating. What do you do with that data once 
you receive it? I understand how these surveys work and the 
confidentiality aspect of the survey, but if you have 
statistics coming out of a middle school that show a 
disproportionate number of our young people are contemplating 
suicide, is there any opportunity through the BIA or for the 
school itself to have some kind of an intervention with a group 
of young people that are clearly at risk because they have 
indicated to you, they are asking for help. What do you do with 
the information?
    Mr. Gidner. What we have done, Senator, is launch, I 
believe I mentioned, the question-persuade-response model, 
where all the bureau-funded schools are trained, the 
administrators and staff, to intervene on behalf of individual 
students when they observe problems and to try to talk to those 
students and persuade them to get help and to refer them to the 
appropriate place to get that help.
    Senator Murkowski. But you are dealing with, again, you are 
not able to pinpoint who your students are. You just have a 
recognition that in this particular school we have an issue. 
With these surveys, you have a lag time between the time the 
students respond and the data is compiled and the results then 
get back. Are these surveys helping us do something? Or are 
they just an indicator of how bad the situation may be getting?
    Mr. Gidner. I actually don't know the answer to that 
question. I will have to make inquiries and find out exactly 
what we do do with that information.
    Senator Murkowski. I think when we ask our kids how they 
are feeling and how they are thinking, we need to be in a 
position to then respond and not respond eight or nine months 
after the fact in some generic way. These surveys have value, 
but we do want to know that we are able to get to the kids, 
particularly when you have statistics coming back that say one-
fifth of our high schoolers have contemplated suicide at some 
point in time.
    Mr. Curie, you mentioned a grant to Manniilaq Association, 
which we greatly appreciate. Can you tell me the terms of that 
grant, what we are talking about, and exactly how you 
anticipate that we will be able to utilize that to stem the 
suicide rate?
    Mr. Curie. Absolutely, Senator. It is a total of $1.2 
million over a 3-year period, $400,000 per year. It is to be 
utilized to begin to implement evidence-based suicide 
prevention strategies that are community-wide types of 
strategies. Again, more clearly identifying what risk factors 
are contributing to the suicide issue, risk factors such as 
students not having enough activity, young people and families 
not being fully engaged. There are going to be a variety of 
those types of risk factors.
    And then developing strategies and begin to put into place 
evidence-based programs that reflect the protective factors 
that can begin to address those particular risk factors, and of 
course a required evaluation of that over the 3-year period as 
to how effective it is working.
    Again, it is to put in a prevention framework and have it 
be community-based engaging all elements of the community.
    Senator Murkowski. Which is the appropriate response, the 
appropriate way to proceed in my opinion. We had an opportunity 
to speak a little bit during the break about, it is a societal 
issue. It is an economic issue. There are so many things that 
come into it.
    When I have asked young Alaskans out in the villages, are 
you happy, what would make your life better, it is some very 
simple responses. They are bored; we are looking for something 
to do; we have no community meeting place.
    And yet when we try to address that by providing for a Boys 
and Girls Club or some form of a community center, that doesn't 
necessarily fit your model in terms of where grant funding 
goes. We need it to be in some form of a service, and yet we 
need the flexibility to work with the communities.
    Manniilaq has, I was out there over the Easter break, and 
they have an incredible program out in the remote area where 
literally the whole family is taken out to be treated for 
substance abuse and other issues. But the family as a whole is 
addressed, not just the one individual that is suffering from 
the addiction or the depression. I don't know if we are set up 
to deal with a response in this broad a manner, but when we are 
looking at statistics like we are seeing now, it seems to me we 
have to do something different. The Manniilaq approach 
hopefully will shed some light there.
    Mr. Curie. I think that type of model has a lot of merit 
and applicability. In fact, I think one of the challenges and 
barriers that we have found in Alaska in particular is the fact 
that when treatment is offered that someone is taken out of a 
village, around 200, 300, or 400 miles to residential treatment 
centers, spends a period of maybe a few months there even, but 
goes right back. There has been very little intervention for 
the family or the community. The results are not good.
    Senator Murkowski. The results are predictable.
    Mr. Curie. Exactly. So what we need to do is find resources 
within the community and have the supports put in place so that 
people have an anchor to rely on. They need, again, to be 
community-based. It should be no surprise to us. We believe in 
community-based care throughout this Nation in what we are 
doing. We find that those give the best results. The same would 
be true in Indian country.
    Senator Murkowski. One question for you, Dr. Grim, and then 
you can comment here. As far as Alaska's behavioral health aid 
program, it is something that has been working in the State. Do 
you see this perhaps as a model to be used in other areas of 
Indian country? And if you would comment on what Mr. Curie and 
I were talking about.
    Mr. Grim. If you would permit me, Senator Murkowski, to 
respond to his question first. I wanted to say that I think the 
tack that SAMHSA is taking is a very appropriate on, too. One 
of the things I talked about in our partnerships together that 
we have with them. They are taking and asking communities to 
use evidence-based sorts of practices and try to put them in 
place in real life communities and see how they work.
    One of the things the Indian Health Service is doing with 
some of our resources is to go to the community level and ask 
them what needs to be done. We have been targeting communities 
that have some of the highest need. So we are doing basically 
what you said. SAMHSA is attacking it from one direction. We 
are using some of our resources to attack it from just the 
direction you said. We go into an individual community and say, 
okay, what is it you think you need; we have specialists that 
help; that can help guide the process. Then we try to tailor it 
for that community.
    So I think, again in combination with multiple agencies 
working together, we are trying to tackle it from different 
perspectives.
    To be more direct to your second question or your question 
to me, I have watched in awe and respect as Alaska has 
continued to push the frontier to try to deal with some of the 
issues that they have to deal with in their communities. I 
think the next step, the community behavioral health aid 
therapist that they are looking at is going to be another model 
program. As Charlie said, we are looking at shortages in many 
of the professional areas.
    He also noted, as I noted, that I think we have under-
diagnosed mental health issues, depression and others, in many 
of our communities, not just Indian communities around the 
country. Now that mental health care is becoming more 
acceptable, people are willing to seek it out. We are starting 
to see more chronic diseases that are being affected by some of 
the underlying mental health conditions people have. I think we 
are all becoming much more aware of it and the role that it is 
playing in not just mental health issues and suicide, but in 
chronic disease issues as well.
    Senator Murkowski. I appreciate your support.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    I thank the witnesses. I appreciate your prioritizing this 
very important issue. We look forward to working with you. 
Thank you.
    Our next panel is Donna Vigil, who is director of the 
Division of Health Programs at the White Mountain Apache Tribe, 
Whiteriver, AZ. She is accompanied by Dr. Norine Ashley, who is 
the director of the Apache Behavioral Health Services. William 
E. Martin is chairman of the Alaska State Suicide Prevention 
Council and First Vice President of the Central Council of the 
Tlingit and Haida Tribes of Alaska. Dr. Dale Walker is director 
of One Sky Center, Oregon Health and Science University. Jo 
Anne Kauffman is the project director of Native Aspirations 
Project in Spokane, WA.
    Welcome to our witnesses. Ms. Vigil, welcome. We are glad 
to see you. Please proceed with your statement.

    STATEMENT OF DONNA VIGIL, DIRECTOR, DIVISION OF HEALTH 
 PROGRAMS, WHITE MOUNTAIN APACHE TRIBE, ACCOMPANIED BY NORINE 
   ASHLEY, DIRECTOR, APACHE BEHAVIORAL HEALTH SERVICES; AND 
 FREDERICK L. HUBBARD, ASSOCIATE DIRECTOR, COMMUNITY RELATIONS

    Ms. Vigil. Good morning, Mr. Chairman and members of the 
committee. My name is Donna Vigil. I represent the White 
Mountain Apache Tribe. I am the executive director of the 
Division of Health Programs. I have with me here Dr. Norine 
Ashley.
    The Chairman. Welcome
    Ms. Vigil. She is the director of the Apache Behavioral 
Health Center.
    The White Mountain Apache Tribe has 17,000 members with 
15,000 members living on the reservation. Before I go any 
further, I would like to say that Ronnie Lupe, chairman of the 
White Mountain Apache Tribe, sends his highest regards to all 
the members of the committee, especially to his friend, 
Chairman McCain. He considers all the members of the committee 
friends to the Apache people.
    The Chairman. Thank you.
    Ms. Vigil. Suicide is a great challenge to the White 
Mountain Apache Tribe, particularly among children and young 
adults. With very little outside funding, the White Mountain 
Apache Tribe has come together to address this issue. We 
started up in 2001 with a suicide task force established by the 
tribal council. It is headed by a community member who is an 
IHS employee and a member of the tribe. This committee, the 
suicide task force, has worked with Johns Hopkins University. 
It is working on research through the NARCH program, which 
stands for Native American Research Center for Health.
    Through that, the tribal council passed a resolution to 
begin a registry of suicides, and through the suicide registry 
our mental health center, Apache Behavioral Health Center, sees 
all the people who are suicidal, or who are at high risk. 
Within a 1-year period, there were 300 referrals from the task 
force. We have two tribal members who are working on the task 
force, assisting and helping with case management.
    Another committee we have formed is the High Risk Response 
Alliance through the Apache Behavioral Health Services. The 
Behavioral Health Alliance is really an effort to get community 
members involved in our efforts with suicide prevention.
    With that, we started a Ministers Alliance. You know, as 
Apache people, we are deeply spiritual, and we wanted to 
include spirituality in our suicide prevention program, so the 
Apache Behavioral Health Center did incorporate a component of 
spirituality. We have over 60 Christian denominations on our 
reservation. The ministers had a walk recently and had prayer 
services in a location where we had several suicides.
    Another part of the Alliance is the traditional part, our 
traditional healers. They formed a group and are planning a 
ceremony for the reservation.
    These are only some of our efforts. We have limited funds 
and are trying whatever we can to work on the suicide issue, 
but we have some barriers. I am going to mention them quickly 
because they are very important. One is that there are not 
enough professionals and paraprofessionals who can provide 
training or skills to respond to suicidal persons. Apache 
Behavioral Health Services is partly funded by Public Law 93-
638. It also receives funding from third-party billing, through 
Medicare [which is Medicaid of Arizona].
    But we fear that we may not be able to continue billing for 
our Native American counselors, those who are not doctors. They 
are good workers who go out into the community and help the 
people in crisis. Yet our Medicaid program is in jeopardy 
because of the certifications and degrees that are required. So 
we ask that this doesnt happen; that we are able to continue to 
bill for services provided by these non-professional people. 
This is very important for the continued success of our suicide 
prevention program.
    Another thing we need is a 24-hour response center. That 
would allow us to have a place where people can call any time.
    Underlying our challenge with suicide is the main problem 
of substance abuse. Without any culturally sensitive centers to 
which we can send our young Apache people, it is difficult to 
work on the problems that they have. So we are asking that we 
get funds for culturally sensitive substance abuse prevention 
centers, to provide this much-needed service for our youth.
    In conclusion, our needs are great, and our resources are 
few. Our suicide rate is among the highest in this country. So 
I am very happy and I am grateful that the Senate Committee on 
Indian Affairs has taken an interest in hearing about suicide 
in the hopes that you will help us to implement and fund 
suicide prevention programs.
    Thank you.
    ]Prepared statement of Ms. Vigil appears in appendix.]
    The Chairman. Thank you very much.
    Mr. Martin, welcome.

STATEMENT OF WILLIAM E. MARTIN, CHAIRMAN, ALASKA STATE SUICIDE 
 PREVENTION COUNCIL, AND FIRST VICE PRESIDENT, CENTRAL COUNCIL 
           OF THE TLINGIT AND HAIDA TRIBES OF ALASKA

    Mr. Martin. Chairman McCain, Senator Murkowski, other 
members of the committee, thank you for inviting me to testify 
at this hearing.
    My name is William Martin and I am chairman of the State 
Suicide Prevention Council in Alaska. I am also first vice 
president of Tlingit and Haida Indian Tribes of Alaska.
    The State Suicide Prevention Council serves in an advisory 
capacity to the Governor with respect to what actions can be 
taken to improve health and wellness; broaden the public's 
awareness of suicide; enhance suicide prevention services and 
programs; develop healthy communities; and develop and 
implement a statewide suicide prevention plans, copies of those 
plans I have brought with me and have distributed to your 
aides; and to strengthen existing and build new partnerships 
between public and private entities that will advance suicide 
prevention efforts in the State.
    Let me briefly outline the magnitude of our problem and 
then report on what seems to be working at preventing suicide. 
For the past decade, Alaska has had the second highest rate of 
suicide in the United States, twice the national average. 
Alaska Natives commit suicide two to three times that of non-
Natives in Alaska. In my written testimony is an even more 
startling statistic.
    Our Suicide Prevention Council has offered the workplans to 
prevent suicide. We distribute it within many diverse 
communities throughout the State. With no one answer that fits 
our many cultures, we believe there are tools that make suicide 
preventable. Our workplan combines analysis of the problem with 
words of wisdom from our Alaskan elders. It sets 13 prevention 
goals that a community can use to meet its specific suicide 
prevention needs.
    I submit with my written testimony a copy of our workplan 
and ask that it be included in the record of the hearing.
    The Chairman. Without objection, it will be made part of 
the record.
    Mr. Martin. Our Suicide Prevention Council has increased 
its suicide prevention and awareness efforts through a media 
campaign and through effective use of the Gatekeeper program. 
Gatekeeper programs reduce suicide rates by training first 
responders such as emergency personnel, public safety officers, 
clergy and others who may be approached in a suicidal crisis, 
but who typically lack specific suicide prevention experience.
    The Gatekeeper program results in much more effective 
crisis intervention. We could do far more Gatekeeper training 
if we could gain greater access to Federal funding for these 
programs. This cost-effective approach works and deserves more 
financial support.
    As an Alaska Native leader, I have become convinced that my 
people must go back to study the lessons of our ancestors. They 
lived in a time before alcohol was introduced to our 
communities. Suicide then was an unheard of event, typically in 
rare cases where one has grievously shamed his family or has 
caused despicable hurt upon others. Although my stance may not 
make me very popular, I am convinced that tribal leaders should 
set an example to our people by abstaining from alcohol. 
Whether or not alcohol is a problem for us as individuals, we 
leaders need to demonstrate to our people that alcohol is the 
cause of most of our social problems.
    Suicides in a community tend to go in streaks and I think I 
know why. I believe that there is a copycat effect that is 
encouraged by how we talk about people after they kill 
themselves. For example, at a funeral for someone, we never say 
bad things about a person who has died, but there may be a 
person listening in the audience, a young person who might 
think to himself that this is all I need to do to gain respect 
for my family and my friends and for my elders. So it starts a 
compounding effect.
    We need to talk to our young people before this happens. We 
need to praise their good qualities while we are living. 
Natives don't usually openly demonstrate day to day affection 
and love for our children because of some of our cultural ways. 
We just don't do that. We need to change this. Our Native 
cultures are living entities that need to be shaped by Natives 
alive today.
    To change this culture, to change our ways, we need to find 
funds from outside our own private communities to support 
suicide prevention programs that assist our elders and leaders 
in changing the attitudes of our people. Native communities 
simply cannot compete on the same playing field for funds from 
SAMHSA and from the Centers for Disease Control.
    One of our regions hit hard by suicide is the Yukon-
Kuskokwim Delta. Through the Association of Village Council 
Presidents, a plan has been organized which in Eskimo means 
``securing a future for our children.'' This mission is to 
create a well community in which all entities work together 
under the direction of elders to restore healthy communities, 
strong in culture and language.
    Like my own community in Juneau, the Tlingit and Haida 
community has developed a modest program that involves Native 
teachers in button-blanket making, weaving, and carving to pass 
on this knowledge to our youth. This has shown to be a great 
success in bringing back Native pride and Native values, the 
key defense mechanisms against hopelessness and depression that 
can lead to suicide.
    To fund a program such as this in the Juneau area requires 
funding of approximately $15,000 to $20,000. Funds like this 
should be made available to our smaller communities that could 
bid on plans and programs that we can use to discourage 
suicide.
    Mr. Chairman, my time has expired and I would be happy to 
answer questions and will be available for that.
    [Prepared statement of Mr. Martin appears in appendix.]
    The Chairman. Thank you very much, Mr. Martin.
    Dr. Walker.

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

    Mr. Walker. Thank you very much, Mr. Chairman. It is a 
pleasure to be here.
    Senator Murkowski, I also appreciate being here as a 
witness for you.
    My name is Dale Walker. I am a psychiatrist. I am also a 
Cherokee. I direct a program called the One Sky Center. The One 
Sky Center is the only national resource center for American 
Indian alcohol, drug and mental health in the country. In the 
last year, we have been at 59 different sites. We are a small 
group. We have partners across the country who work closely 
with us.
    We have heard a little bit about the discussion of 
interagency support and coordination, and I would tell you that 
the development of partnerships at the level of a resource 
center is a critical next step in trying to do these issues as 
well.
    We have been at many sites, first looking at alcohol and 
drug issues, but everywhere we went, it was the issue of family 
violence, suicide, disorganization, and disconnection with 
culture that were issues of great concern. You have heard 
already today the fact that these issues are interrelated, that 
indeed trying to wrestle with this issue in a pointed directive 
way is not as effective as working with the tribe and getting 
an overall plan on how to deal with the many circumstances that 
lead to the problems.
    You have heard some discussion also about indigenous 
knowledge or traditional knowledge about how to keep the family 
intact and about how to restore values. All of these are 
critical and quite important. Evidence-based work is also 
critical, but community-based treatment and management requires 
that the values within the community are a part of the care.
    We have been looking and working with areas also and 
finding out that you don't do a visit, a consult or technical 
assistance once; that when you visit, you stay. You work with 
the tribes continuously through the process.
    Sometimes, that is not in sync with the funding cycles of 
how programs work within the system, so we are very interested 
in if things are set up to help develop. By the way, I want to 
add, you already know that there is underfunding of mental 
health, addictions, and education. There are three reports, two 
from Congress, about the underfunding. You are aware of the 
disparities that exist in these areas.
    In order to address those, we know there needs to be more 
bottom-line funding to help with these problems. Then when you 
develop special programs with grants, you can actually advance 
the best practices for a community so that everybody can learn 
together.
    Our experience has been that if we can work with and train 
people, the behavioral health aide program in Alaska is a very 
good example, they are able, the community is empowered to 
select their people. They decide who gets the training for 
triage assessment and follow-up after-care in their programs. 
That empowers the community to be involved.
    They also have the trust and that kind of goes quickly with 
the process of care. We support that. I think it is a 
remarkable next step in training for IHS programs, as well as, 
frankly, third world programs that are in the same situation. 
These efforts are quite important.
    In the proposed bill, we took a serious look at the 
training issues and maintaining the expertise out in the field. 
How you get the care there, and how you maintain the care 
becomes critical. You have to maintain the care for licensure 
so that billing and work under the logical health care 
circumstances. That maintenance of license and certification to 
do the training is very difficult if you are in a remote area.
    We think that the telemedicine is not only for clinical 
care, but it is for training of the people who go out into the 
area. It would be wonderful to have in place modules for 
training in addictions and mental health and suicide so that 
people could take courses on Web sites and be able to do that. 
We are working with the tribal colleges and universities to 
help establish that kind of approach.
    The other position I would just mention is that the 
interagency task forces and partnerships work if the people 
understand that we have to look at the total funding across 
agencies and get together to figure out how to focus the 
dollars as a group. If you look at it as individual silos, that 
is what you get.
    We have much else to say in the discussion, but I am going 
to end the conversation here.
    Thank you very much.
    [Prepared statement of Dr. Walker appears in appendix.]
    The Chairman. Thank you very much, Dr. Walker.
    Ms. Kauffman, welcome.

    STATEMENT OF JO ANN KAUFFMAN, PROJECT DIRECTOR, NATIVE 
                      ASPIRATIONS PROJECT

    Ms. Kauffman. Thank you, Mr. Chairman. I want to thank you 
and Vice Chairman Dorgan for your work on this issue, and also 
thank you, Senator Murkowski for your presence here and your 
interest in this very difficult topic.
    My name is Jo Ann Kauffman. I am a member of the Nez Perce 
Tribe. I have been involved in Indian health issues for the 
last 30 years. I have a master's in public health from the 
University of California at Berkeley.
    I was invited here to testify today as a contractor for 
SAMHSA and the work that we are doing currently on their behalf 
to bring evidence-based interventions to high risk communities 
in prevention mode.
    I must say, first of all, that this hearing is important 
and it was interesting coming on the heels of Mother's Day. I 
spent the weekend thinking about the importance of what can 
come out of this hearing and the work that you are doing to 
bring resources to communities, and my heart goes out to all of 
those parents for whom this issue is very personal.
    We were asked last year by the Substance Abuse Mental 
Health and Services Administration to consider an emergency 
contract. As a Federal contractor, we prepared a response for 
them, specifically to look at nine of the highest risk 
communities across the United States in Indian country for 
purposes of preventing some of the disasters that we saw last 
year with regard to youth violence in Minnesota and some of the 
suicide clusters across the Plains States.
    We pulled that together primarily as a prevention model to 
prevent youth violence, youth bullying and suicide. We targeted 
those communities most at risk through a quantitative 
assessment. We are engaging those nine communities in a 
grassroots, bottom up planning approach, and bringing the 
curriculum or the evidence-based interventions to those 
communities to implement according to their wishes over the 
remainder of this contract which runs until March 2007.
    The nine communities that were selected include, well first 
of all, in selecting the nine communities that was a 
quantitative analysis of mortality data related to violence for 
Indian youth in comparison with behavioral health funding and 
poverty rates. We looked at three areas primarily: The Aberdeen 
area, the Alaska area, and the Billings area. Then we did a 
series of interviews with professionals in each of those areas 
to identify three communities within each area to come up with 
the nine.
    In the Aberdeen area, we have agreements to work with the 
Cheyenne River Reservation, Crow Creek Reservation, and the 
Pine Ridge Reservation. In Alaska, we will be working with the 
Native Village of Alakanuk, the Noorvik Native community, and 
the Native village of Savoonga. In the Billings area, we will 
be working with Fort Belknap Indian Reservation, Fort Peck 
Indian Reservation, and the Wind River Reservation in Wyoming.
    Because youth violence is a complex historical, cultural 
and family issue that has economic and geographic and access to 
care kinds of issues overlaying that, our effort really is to 
reduce risks by promoting supportive and protective factors 
within each of those communities, and to allow each community 
to identify its own strategy.
    We did conduct a review of evidence-based interventions and 
I want to note that the National Registry of Evidence-Based 
Programs and Practices, known as NREPP, is provided through 
SAMHSA as a registry of evidence-based interventions. It 
contains only two Native American-focused evidence-based 
interventions that have received that seal of approval by 
NREPP.
    There are a host of other interventions that are called 
practice-based interventions. And then as you heard earlier, 
there are many cultural-based interventions that bring forward 
the traditions and values and ceremoneys of particular tribes 
and cultures as a way to protect Indian youth and to prevent 
violence.
    I am happy to report that last week, we conducted our first 
two community engagements. We worked with the communities at 
Pine Ridge and at Cheyenne River. Each of those communities 
conducted their own planning process. They learned about the 
evidence-based interventions. What emerged from that was their 
own very unique application of cultural knowledge and values 
and tradition and ceremony to come up with a plan for this next 
year for working within their school districts and their 
communities to prevent youth violence.
    All nine communities are very motivated. This effort is, as 
I described, is an emergency effort of a prevention mode to 
prevent further incidents like we heard of last year. But it is 
a short-term effort and each of the communities has been very 
active in seeking additional alternative resources through 
their States, through the Garrett Lee Smith opportunities for 
funding, and through other resources.
    So in closing, Mr. Chairman, I have a few recommendations. 
First, that the committee consider expanding support for tribal 
communities seeking assistance through SAMHSA or IHS. It is 
difficult for short-term demonstration efforts to have time to 
prove results. Second is that in looking the quantitative data, 
it is clear that many more communities require this type of 
preventive assistance through whatever channels are available.
    Third is that the NREPP process of sanctioning certain 
evidence-based interventions may inadvertently be leaving out 
many traditional tribal or practice-based interventions. That 
is important only because it seems that funding now is being 
tied closer and closer to that status of NREPP evidence-based 
interventions, including Medicaid reimbursement at the State 
level.
    So it would be important to provide whatever support to get 
more tribally based or culturally based interventions through 
that status.
    I support everything that has been said already with regard 
to workforce development in the paraprofessional field and 
increased access to services.
    In closing, Mr. Chairman, thank you very much for this 
time.
    [Prepared statement of Ms. Kauffman appears in appendix.]
    The Chairman. Thank you very much.
    I would like to ask the witnesses how serious in the 
overall issue of suicide is the issue of methamphetamine, the 
accompanying epidemic of methamphetamine. I will begin with 
you, Ms. Vigil.
    Ms. Vigil. Well, in the last year we have noticed a 30-
percent increase of methamphetamine use. When we recently 
tested our regular employees who work for the tribe there was a 
30-percent use.
    The Chairman. What percent?
    Ms. Vigil. Thirty percent. In the past, there was no 
methamphetamine abuse on the reservation; there was just 
alcohol. And now methamphetamine abuse is climbing even among 
the work force of the tribe. Methamphetamine abuse is related 
to alcohol abuse, and substance abuse is related to more than 
50 percent of the suicide cases.
    The Chairman. Mr. Martin.
    Mr. Martin. Mr. Chairman, it is a huge problem in Alaska 
because it is easily made. It can be made any place. Also, the 
effects of it are quicker in bringing down barriers in people, 
even more so than alcohol. It is a problem we are focusing hard 
on in villages, but without law enforcement in remote villages, 
it is very difficult. And besides, with the secrecy involved in 
each of those communities, it makes it very difficult to bring 
it out in the open and expose it to the law enforcement people.
    The Chairman. Dr. Walker.
    Mr. Walker. If suicidal intent and alcohol are a crisis, 
suicidal intent coupled with methamphetamine is a disaster. I 
say that in studying and working on suicide issues, 90 percent 
of the time substance use is a part of the suicide attempt, so 
it is a huge connection. The fact is that methamphetamine now 
is more and more available, and most kids use what is 
available. There is not a staggered way of doing it. They use 
what is available. Methamphetamine is everywhere in every 
Indian reservation. Therefore, it is used.
    The reason I say it is a disaster is that methamphetamine 
also causes psychosis. You actually lose control of your 
ability to use your own logical thinking.
    The Chairman. And there is a period of exhilaration and a 
period of depression.
    Mr. Walker. That's right. And so with all of that 
connected, the psychosis and the depression and the loss, all 
of those feelings are magnified, making risk for suicide much, 
much higher.
    The Chairman. Dr. Walker, before I leave you, is most of 
this in Indian County manufactured in Indian country? We know 
how easy it is to obtain the materials. Or is it like in the 
rest of the country, where you have really this flood of 
Mexican methamphetamine, which is even cheaper than making it 
yourself?
    Mr. Walker. What I hear across the country is the import, 
the bringing in from out of the country and out of the area. 
There are users, and many times by the way, the manufacturing 
is not by Indians out in isolated areas. It is by other people 
who know that is a good place to hide.
    The fact is, though, there is a huge problem with the 
movement of methamphetamine and other drugs into Indian country 
from out of this country.
    The Chairman. Now, we all know that the suicide rate is up, 
right?
    Mr. Walker. Yes.
    The Chairman. How much of that would you attribute to the 
methamphetamine problem?
    Mr. Walker. Difficult question. I would quickly tell you 
that we need to understand what is happening out in our Indian 
communities with methamphetamine. There is actually very little 
science. There are lots of facts and experience. But to answer 
your question, to make that relationship, I think it is a 
wonderful point that needs to be addressed. It reminds me that 
another recommendation we had is that perhaps in this bill some 
support from the National Institutes of Health might be useful 
to actually study these problems much, much more thoroughly.
    The Chairman. Maybe we can seek for that to happen. I think 
that is a very good recommendation.
    Ms. Kauffman.
    Ms. Kauffman. Thank you, Mr. Chairman.
    I think the only thing that I would add here with regard to 
methamphetamine is what we have heard is the difficulty in 
treatment of individuals who are addicted to methamphetamine, 
and that it is much more difficult and intense than I think the 
treatment programs that have evolved around alcohol addiction 
or even drug addiction. And so that we are hearing from drug 
treatment providers.
    The other thing that we have also heard is the difficulty 
in terms of law enforcement if there is ever jurisdictional 
ambiguities, I guess, that tend to work in favor of those who 
are hiding underneath the radar screen of law enforcement.
    The Chairman. Thank you very much. We are in agreement on 
lack of funding. We are in agreement there needs to be more 
interagency coordination and effort. What else do we agree on, 
Dr. Walker?
    Mr. Walker. Well, first of all, I think that the 
consistency of three hearings in 1 year is raising the 
visibility and the ability for communities to talk about the 
issues. If I could give a very, very direct comment, it would 
have to do with how we maintain connections with our 
communities when we do technical assistance and do the kinds of 
work in providing best practices in those communities. That 
connection is so critical to maintain. Letting the communities 
alone or letting them drift is not an effective way, and we 
know that.
    I think that the integration and support that we have seen 
from SAMHSA has been marvelous; the fact that we try to put, as 
you well know, if you talk about addictions and mental health, 
and prevention and treatment, those can also become isolated 
from each other. The fact that Mr. Curie states there is one 
SAMHSA is a wonderful message. The people are now starting to 
work together to move those things in partnership with the 
community.
    The partnership, by the way, starts with the leadership of 
the tribe. We need much, much more influence and ability to 
provide information so the tribal councils can actually make 
decisions about their own health care.
    The Chairman. Ms. Kauffinan.
    Ms. Kauffman. Thank you, Mr. Chairman.
    One of the points that Dale just made with regard to tribal 
leadership we use with our communities, it is called a 
community readiness model to assess where a community is before 
coming in with interventions or assistance. Across the board so 
far, it has been too little awareness on the issue, too vague 
awareness on the issue. I think that so much energy and 
resources are taken responding to tragedies and events, as they 
should be, but so much more needs to be done with regard to 
prevention and awareness and training at the local level.
    The Chairman. Mr. Martin.
    Mr. Martin. We agree that we need to get the programs into 
the villages, but more with the cooperation of the people in 
the villages. Sometimes there is a stigma involved where they 
feel that we are coming in and telling them how to do things, 
when in effect we should be able to be working with them, with 
the leaders of the villages, along with the elders. We already 
have the commitment from the elders, who are always standing by 
ready to assist in the youth programs, but we need to be able 
to work from the, like in our case, central council. Tlingit 
and Haida needs to work with the individual communities to be 
able to set up programs.
    The State Suicide Council is also willing to adapt its plan 
to any of the villages that would require assistance in setting 
up how to customize it for each individual village.
    The Chairman. Ms. Vigil.
    Ms. Vigil. I think we all agree that we need more 
paraprofessionals and professional Native Americans who can 
provide services. We need Medicaid of our State to continue to 
pay us for providing those services because that is one of the 
major sources of funding for us.
    Another thing we agree on is that treatment for Native 
Americans should be tailored specifically for them, to address 
all their issues.Thank you.
    The Chairman. I want to thank the witnesses. Senator Thune 
had some records that need to be included as part of the 
hearing record. The letters are from South Dakota Native 
Americans who have lost relatives to suicide, to be made part 
of the record.
    I want to thank the witnesses. I appreciate your commitment 
to trying to address this terrible and tragic issue. I am very 
grateful for the leadership and conunitment of Senator Dorgan 
and other members of this committee. We will not quit, nor will 
you, and hopefully we can make some progress over time and 
bring more attention to this ongoing national tragedy.
    Thank you. This hearing is adjourned.
    [Whereupon, at 11:25 a.m., the committee was adjourned, to 
reconvene at the call of the chair.]
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                            A P P E N D I X

                              ----------                              


              Additional Material Submitted for the Record

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


  Prepared Statement of Hon. John McCain, U.S. Senator from Arizona, 
                 Chairman, Committee on Indian Affairs

    This is the third hearing in the 109th Congress that this committee 
has held on youth suicide among Native Americans. At a field hearing 
Senator Dorgan chaired in North Dakota last year, and at a subsequent 
hearing here, we learned that the suicide rate for Native Americans 
continues to escalate and is many times the national average for other 
population groups. The tragedy of young people taking their own lives 
has particularly impacted various native communities around the country 
that have experienced ``clusters'' of suicides among their school-aged 
children.
    Legislation has been introduced to try to address the problem. 
Senator Dorgan introduced, and I co-sponsored, S. 2245, the Indian 
Youth Telemental Health Demonstration Project Act of 2006, which passed 
the Senate just last week. The bill authorizes a demonstration project 
to test the use of telemental health services in suicide prevention, 
intervention, and treatment of Indian youth. S. 1057, the Indian Health 
Care Improvement Act of 2006, which has been reported out of the 
committee but which has not yet passed the Senate, includes the 
development of a comprehensive behavioral health prevention and 
treatment program for Indian Behavioral Health Services; an assessment 
of the scope of the suicide problem; and a grant program to provide 
research on the multiple causes of Indian youth suicide.
    Today, the committee meets to examine how suicide prevention 
programs and resources that exist outside of Indian country might be 
applied to American Indians and Alaska Natives. To this end, committee 
staff has put together draft legislation to add a native component to 
existing Federal suicide prevention and related programs, and I welcome 
witnesses' comments today on these proposals.
    I am pleased that representatives from the White Mountain Apache 
Tribe could be here today. Last year, committee staff traveled to White 
Mountain to meet with Apache Behavioral Health Services, where they 
learned that, in the tribe of about 15,000 members, there had been over 
500 attempted suicides in 1 year. Even accounting for the different 
ways in which suicide attempts are counted, this number is both 
shocking and heart rending. I am pleased that the thoughtful and 
informed, if overwhelmed, people who helped to educate my staff in 
December are here today to again share their experience.
    Again, I commend the vice chairman for his leadership on this 
issue, and look forward to the testimony of the witnesses.
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     Prepared Statement of Loretta Bullard, President, Kawerak Inc.

    Kawerak, Inc. is encouraging the Senate Indian Affairs Committee to 
introduce and support passage of language that would dedicate funds for 
tribal suicide prevention programs.
    Kawerak is a tribal consortium and non-profit in northwest Alaska. 
We provide services throughout the Bering Straits Region. Our region 
encompasses 26,000 square miles, has 16 distinct communities and 20 
federally recognized tribes. We have very few roads in the region, so 
most in-region travel is by small airplane, snow machine in winter, or 
small boats in the summer. We are authorized by resolution to provide 
BIA services to 18 of our tribes and 2 of our tribes compact 
independently. Our Board consists of the presidents of each of the 20 
tribal councils in the region, two elder representatives and the chair 
of Norton Sound Health Corporation, a tribally authorized health 
consortium.
    The incidence of suicide in the Bering Strait Region is staggering. 
The regional population is about 9,000 individuals of which 7,500 are 
Alaska Native. All suicides in the Bering Straits Region have been 
Alaska Native. The Bering Straits Region suicide rate is double the 
rate in Alaska and is six times the national rate. Suicide accounts for 
17 percent of all deaths in the Bering Straits Region. Our population 
is small, but our problem is large. In regions such as ours, we know 
the individuals that commit suicide. They are our relatives, our 
friends, our tribal members, our children and young adults. Because our 
population is small and we know each other, I believe the suicides have 
a cumulative impact on our young people. In the last 3 years [2003-05], 
20 people committed suicide in 11 of our 16 communities. The majority 
of individuals who committed suicide were between the ages of 15-29 
years old. At least 122 individuals took their own lives from 1979-2004 
[1991 statistics were not available]. 75 other individuals attempted 
suicide between 2003-05, and it is reported that 175 individuals talked 
about taking their own lives. [These are individuals who went through 
Norton Sound Health Corporation's Behavioral Health On Call system and 
do not include the number of attempts that went unreported or 
individuals who did not call for help.]
    Nome Public Schools conducted a Youth Risk Behavior Survey in 2005 
for ages 12-18 year old junior high and high school students and 
compared them to the same survey in 1999. To put this in perspective, 
there were only 203 students in the survey group. Fifty-three students 
[26 percent] who responded to the survey said they had seriously 
thought of killing themselves and 29 [14 percent] actually tried to 
kill themselves at one time.
    Behavioral health providers in many rural areas of Alaska are 
either in short supply or are less than optimally trained for their 
duties [or both]. There is also a high turnover. It is difficult to 
provide comprehensive services in so many communities. Training local 
service providers would be an effective solution but funds are needed 
to do so.
    Kawerak is recommending funds be set aside for tribal suicide 
prevention programs because of the epidemic proportions of suicide 
among our youth. Tribes and tribal consortiums currently compete with 
the States for SAMHSA's suicide prevention grant funds. When Kawerak 
talked to State Behavioral Health Services Division Suicide Prevention 
staff, we were encouraged not to apply for the SAMHSA grant because the 
State was going after the same grant funds. Statewide suicide 
prevention efforts tend to focus on broad planning and prevention 
activities that have had limited success in village Alaska. The State 
of Alaska has made funds available for some communities to hire village 
suicide prevention coordinators. This has been more successful.
    Suicide is a serious problem in our rural villages. It is going to 
take time and money to address. We would like to design and implement a 
grass roots, hands problem--in keeping with the unique cultures and 
conditions in northwest Alaska.
    We encourage this committee to make funds available such that we 
can begin to reduce the high rate of suicide among our youth.
    For further information, contact:
    Loretta Bullard, president, Kewerak Inc., PO Box 948 Nome, AK 
99762, Phone: 907-443-5231 Fax: 907-443-4452
                                 ______
                                 

Prepared Statement of Charles G. Curie, Administrator, Substance Abuse 
               and Mental Health Services Administration

    Mr. Chairman and members of the committee, good morning. I am 
Charles G. Curie, M.A., A.C.S.W., Administrator of the Substance Abuse 
And Mental Health Services Administration [SAMHSA] within the 
Department of Health and Human Services. I am very pleased to be here 
today to describe how SAMHSA is working to address suicide among 
American Indians and Alaskan Natives.
    I was scheduled to speak at a suicide prevention conference in 
Casper, WY today, but I am so personally concerned about suicide rates 
especially among American Indians and Alaskan Natives that I wanted to 
provide this testimony myself.
    It is a privilege to testify along with Dr. Charles Grim, director 
of the Indian Health Service [IHS] this morning. SAMHSA and IHS have 
developed a strong partnership reflected in our current Intra-Agency 
Agreement to work efficiently and effectively together to help meet the 
public health needs of American Indians and Alaska Natives. It is also 
a privilege to be with Jerry Gidner, Deputy Bureau Director for Tribal 
Services at the BIA.
    It was just over a year ago that Kathryn Power, Director of 
SAMHSA's Center for Mental Health Services, testified before this 
committee on my behalf, and Ulonda Shamwell, Director of Policy 
Coordination at SAMHSA, testified at a field hearing in North Dakota on 
suicide and violence among American Indians and Alaskan Natives. We 
have accomplished a great deal since then that I want to share this 
with you today.

Suicide

    Suicide is a serious public health challenge that is only now 
receiving the attention and degree of national priority it deserves. 
Many Americans are unaware of suicide's toll and its global impact. 
Suicides make up 49.1 percent of all violent deaths worldwide, making 
suicide the leading cause of violent deaths, outnumbering homicide. In 
the United States, suicide claims approximately 30,000 lives each year. 
When faced with the fact that the annual number of suicides in our 
country now outnumbers homicides by three to two--approximately 30,000 
and 18,000, respectively--the relevance of our work becomes clear. When 
we know, based on SAMHSA's National Survey on Drug Use and Health 
[NSDUH] for 2003, that approximately 900,000 youth had made a plan to 
commit suicide during their worst or most recent episode of major 
depression and an estimated 712,000 attempted suicide during such an 
episode of depression, it is time to intensify activity to prevent 
further suicides. The NSDUH data and the countless personal stories of 
loss and tragedy are why I have made suicide prevention a priority at 
SAMHSA.

Suicide Among American Indian and Alaska Native Youth

    Last year, a suicide cluster occurred on the Standing Rock 
Reservation in North Dakota and South Dakota. Ten young people took 
their own lives, and dozens more attempted to do so. The Red Lake 
Indian Tribe in Minnesota is experiencing high suicide rates following 
the deaths of nine individuals at the hand of a 16-year-old high school 
junior. Tragically, many other reservations have similar stories to 
tell. Suicide is now the second leading cause of death (behind 
unintentional injury and accidents) for American Indian and Alaska 
Native youth aged 15-24. In 2003, the suicide rate for this population 
was almost twice the national average. American Indian youth have the 
highest rate of suicide among all ethnic groups in the United States, 
with a rate of 18.01 per 100,000 as reported in 2003. What is sad to 
report is that more than one-half of all persons who commit suicide in 
the United States, and an even higher fraction in tribal communities, 
have never received treatment from mental health providers.

SAMHSA's Role in Better Serving American Indian and Alaska Native
    Populations

    SAMHSA focuses attention, programs, and funding on improving the 
lives of people with or at risk for mental or substance use disorders. 
Consistent with President Bush's New Freedom Initiative, SAMHSA's 
vision is ``a life in the community for everyone.'' The agency is 
achieving that vision through its mission ``building resilience and 
facilitating recovery.'' SAMHSA's direction in policy, program, and 
budget is guided by a matrix of priority programs and crosscutting 
principles that include the related issues of cultural competency and 
eliminating disparities.
    To achieve the agency's vision and mission for all Americans, 
SAMHSA supported services are provided within the most relevant and 
meaningful cultural, gender-sensitive, and age-appropriate context for 
the people being served. SAMHSA has put this understanding into action 
for the American Indian and Alaska Native communities it serves. 
SAMHSA's policy is to level the playing field in order to ensure that 
Tribal entities are eligible for all competitive grants for which 
States are eligible unless there is a compelling 4 reason to the 
contrary.
    Since CMHS Director Power testified before the committee last year, 
and as a result of the Garrett Lee Smith Memorial Act [Public Law 108-
355], SAMHSA is now working with State and local governments and 
community providers to stem the number of youth suicides in our 
country. In 2005, we awarded the first cohort of grants, 14 in all, 
including a grant to Arizona, under the Garrett Lee Smith Memorial Act 
State/Tribal Suicide Prevention program. These funds are available to 
help States/Tribes implement a Statewide/Tribe-wide suicide prevention 
network. One of those first set of grants went to the Native American 
Rehabilitation Association in Oregon.
    Today I am announcing almost $9.6 million in funding for 8 
additional new grants [each for approximately $400,000 per year for 3 
years] under this program to support national suicide prevention 
efforts. Grants have been awarded to programs in Oregon, Connecticut, 
Utah, Wisconsin, and Idaho, and grants specifically geared to American 
Indians and Alaskan Natives have been awarded to:

   \\\\\\Manniilaq Association of Alaska to provide a variety 
        of suicide 5 prevention approaches to a region that has one of 
        the highest youth suicide rates in the world;
   \\\\\\United Indian Involvement, Inc. to implement a Youth 
        Suicide Prevention and Early Intervention Project targeting 
        American Indian and Alaskan Native children and youth ages 10 
        to 24 in Los Angeles County; and
   \\\\\\Montana Wyoming Tribal Leaders Council to provide 
        suicide prevention efforts to six Montana and Wyoming American 
        Indian reservations, serving Blackfeet, Crow, Northern 
        Cheyenne, Fort Peck, Fort Belknap, and Wind River populations.

    An announcement for a third cohort of grants of $400,000 per year 
for 3 years under this program closed yesterday. SAMHSA again invited 
all American Indian and Native Alaskan tribes to apply for these 
grants. In an effort to increase the number of applicants from American 
Indian and Alaskan Native tribes, we provided technical assistance 
specifically for them.
    The Garrett Lee Smith Memorial Act also authorized a National 
Suicide Prevention Resource Center, and for fiscal year 2006 we 
received an additional $1 million in supplemental funds for the center. 
We recently requested an application from the existing center for use 
of these supplemental funds, requiring them to address how they would 
expand the current youth suicide prevention technical assistance to 
tribes and tribal organizations.
    Though not a part of the Garrett Lee Smith Memorial Act, SAMHSA has 
long supported a national suicide hotline--1-800 273-TALK. Funding to 
the current hotline grantee was increased by $369,000 in fiscal year 
2006, and the grantee has been requested to submit an application that 
indicates how they will expand access to American Indians and Alaskan 
Natives.
    The Administration's request for fiscal year 2007 for SAMHSA asks 
for nearly $3 million for a new American Indian/Alaska Native 
initiative, which provides evidence based programming on reservations 
and Alaskan Native villages to prevent suicide and reduce the risk 
factors that contribute to youth suicide and violence. We plan to 
continue our collaboration with IHS as we have done in the past in this 
initiative.
    SAMHSA has also transferred $200,000 to IHS to support programming 
and service contracts, technical assistance, and related services for 
suicide cluster response and suicide prevention among American Indians 
and Alaska Natives. One example is the development of a community 
suicide prevention toolkit. This tool-kit includes information on 
suicide prevention, education, screening, intervention, and community 
mobilization, which can be readily available to American Indian and 
Alaska Native communities via the Web and other digitally based media 
for ``off the shelf'' use.
    SAMHSA is proud of what we have done while knowing that this is not 
nearly enough. The problems confronting American Indian and Alaskan 
Native youth are taking their toll on the future of American Indian and 
Native Alaskan tribes.
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to appear today. I will be pleased to answer any questions 
you may have.
                                 ______
                                 

 Prepared Statement of Jerry Gidner, Deputy Bureau Director for Tribal 
               Services, BIA, Department of the Interior

    Mr. Chairman, Mr. Vice Chairman and members of the committee, my 
name is Jerry Gidner and I am the deputy bureau director for tribal 
services in the Bureau of Indian Affairs [BIA] at the Department of the 
Interior. I am pleased to be here today to provide the Department's 
testimony on suicide prevention programs and their application in 
Indian country. Several of my BIA colleagues accompanied me today. They 
are Chet Eagleman, acting chief, Division of Human Services; Kevin 
Skenandore, acting director, Office of Indian Education Programs 
[OIEP]; and Peter Maybee, assistant to the deputy bureau director, Law 
Enforcement Services [OLES]. Each is a member of a federally recognized 
tribe, is a senior BIA program manager, and has invaluable field 
experience.
    I would like to take the opportunity to share the BIA's concern 
about Indian teen suicide and the emotionally wrenching impact it has 
on Indian country.
    Teen suicide is a serious long-standing problem in Indian country. 
Research has shown that social factors such as poverty, alcoholism, 
gangs, and violence contribute in the manifestation of suicidal 
ideation, suicidal behavior and suicide attempts by Indian children and 
teenagers.
    The Indian Health Service [IHS] data document that suicide is the 
third leading cause of death in Indian children age 5-14, and the 
second leading cause of death in Indian teenagers and young adults age 
15-24. In addition, the IHS data indicate that Indian teenagers/young 
adults' suicide rate is 2.5 times greater than the nationwide U.S. 
rate. Young Indian men are more at risk to completed suicides, whereas 
young Indian women are more at risk to suicide ideation or thoughts.
    In addition, data from the biennial BIA High School and Middle 
School Youth Risk Behavior Surveys [YRBS] provide insight into the 
progression Indian children and teens go through from feeling sad or 
hopeless, to seriously considering suicide, to making a suicide plan, 
to actually attempting suicide, to incurring serious injury requiring 
treatment by a medical professional. The data demonstrate that 
approximately one-third of Indian children and teens feel sad or 
hopeless, in a given year, which is an early stage in a suicidal event. 
The most recent BIA YRBS data for Indian students enrolled in 2003 show 
that for Indian high school students:

   \\\\\\21 percent seriously considered attempting suicide in 
        the last year, and
   \\\\\\18 percent actually attempted suicide one or more 
        times in the last year.

    For Indian middle school students, the data show that:

   \\\\\\26 percent seriously considered attempting suicide, at 
        some time in their life, and
   \\\\\\15 percent had attempted suicide.

    Furthermore, statistics from the 2002 Annual Report of the Alaska 
Bureau of Vital Statistics show that between 1990 and 1999, Alaska 
Native teens committed suicide at a rate of 110 per 100,000 or over 5 
times greater than the rate of 20 per 100,000 non-Native teenagers in 
Alaska.
    Although national hard data are not available on Indian country 
residents, the professional literature strongly suggests a close 
association between parental alcohol and drug abuse, child abuse 
[whether emotional, physical, or sexual], domestic violence and suicide 
in children and teens. Often suicide may be the only way a child or 
teen sees of extricating him/herself from a hostile or threatening 
environment. However, the following can help prevent suicide in Indian 
country:

   \\\\\\Improved housing conditions.
   \\\\\\Increased prevention and treatment services.
   \\\\\\Increased identification of at-risk individuals and 
        families and referral to services.
   \\\\\\Enhanced community development and capacity building 
        through technical assistance and training for tribal leaders 
        and staff.

    BIA programs assist tribal communities to develop their natural and 
social-economic infrastructures [that is, tribal governments, tribal 
courts, cultural vitalization, community capabilities, et cetera] or 
provide services to fill infrastructure gaps [that is, education, law 
enforcement, social services, housing improvement, transportation, and 
so on]. For the BIA, suicidal events significantly impact law 
enforcement personnel since they are the most likely first responders 
and have a significant impact on BIA/tribal school teachers and 
students when the suicidal individual is a child or teenager.
    BIA's Law Enforcement, Education, and Tribal Services programs 
continually seek ways to collaborate and to support activities directed 
at suicide prevention and services coordination. An example of this 
type of coordination is the BIA Rocky Mountain Region [Montana and 
Wyoming] Native American Youth Suicide Prevention Health Initiative 
developed and presented by BIA, IHS, and Indian Development and 
Education Alliance [IDEA]. The region also hosted a workshop on Native 
American Youth Suicide Prevention Training of Trainers in 2005, which 
included ``natural healers'' to provide referral and support.
    Within the BIA's OIEP school system all Bureau-funded schools 
receive supplemental program funds, through the U.S. Department of 
Education, to operate a Safe and Drug-free School program. Schools use 
these funds to address a myriad of issues to make their schools safe 
places for students and staff. BIA schools receive about $92 per 
student enrolled and use these funds to address a myriad of issues to 
make their schools safe places for students and staff. Past initiatives 
included the Comprehensive School Health Program where OIEP partnered 
with IHS and the National Centers for Disease Control to assist schools 
in developing plans that brought together the involvement of their 
community partners such as local law enforcement, social services, and 
mental and physical health providers.
    OlEP is committed to ensuring a safe and secure environment for our 
students. Our focus is the implementation of suicide prevention 
strategies. The OIEP's Center of School Improvement launched a Suicide 
Prevention Initiative using the IHS endorsed scientifically researched 
based Question Persuade Respond [QPR] model. QPR is an aggressive 
intervention program focused on suicide prevention. An initial training 
in QPR was held in Denver, CO. in August 2004 and provided training on 
the QPR model to all 184 BIA funded schools and dormitories. 
Administrators at the school and dorm level were instructed to complete 
100 percent training in the QPR suicide prevention model for staff at 
their respective schools. Additional sets of training material have 
been distributed to the schools and dorms through the Education Line 
Offices on an annual basis. In 2004, OIEP provided training 
opportunities for schools to establish crisis intervention teams to 
address potential suicide incidents, using the QPR model.
    OIEP has provided training almost yearly on prevention of risky 
behaviors as well as preparation required to address almost any 
emergency situation. Most recently OIEP sponsored a nationwide event 
whereby students were dismissed for the afternoon while staff met to 
review their policies and procedures addressing emergency situations. 
Just last week, the majority of Bureau funded schools attended a 2-day 
``Safe Schools'' training in Denver, CO. The focus of the training was 
on emergency preparedness for any type of emergency situation that 
would include what to do in an attempted suicide or suicide incident.
    In summary, the BIA, IHS, Substance Abuse and Mental Health 
Services Administration, other Federal agencies, and Indian tribes must 
continue to work together to address all aspects of suicidal events--
both before and after the event happens. Because most Indian programs 
fall within the respective missions of the BIA or the IHS, it is 
essential that the programs, in each respective agency, that directly 
or indirectly relate to suicidal events are coordinated and function 
collaboratively. BIA invites other Federal, state and tribal 
organizations and agencies to contact BIA regarding programmatic 
information, to coordinate efforts and resources, and to collaborate in 
addressing suicidal Indian children, teens and young adults.
    This concludes my statement. I want to thank you for your concern 
for the wellbeing of Indian children, teens and young adults. My BIA 
colleagues and I will be happy to answer any questions you may have.
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  Prepared Statement of Donna Vigil, Executive Director, Division of 
     Health Programs, White Mountain Apache Tribe, Northern Arizona

    My name is Donna Vigil, I represent the White Mountain Apache Tribe 
in northern Arizona in my capacity as executive director of the 
Division of Health Programs. I am a member of the White Mountain Apache 
Tribe, being born and raised on the reservation. I have here with me 
Dr. Noreen Ashley, director of the Apache Behavioral Services. Our 
tribe has approximately 17,000 members, of which close to 15,000 live 
on the reservation.
    Before I go any further, I would like to say Ronnie Lupe, chairman 
of the White Mountain Apache Tribe sends his highest regards to all of 
you, especially to his close friend Senator McCain. He considers all 
the members of the U.S. Senate Committee on Indian Affairs as friends 
to the White Mountain Apache people.
    Suicide is one of the greatest challenges facing our people, 
particularly our children and young adults. Our rates of attempted and 
completed suicide are 17 times higher than those of all other races in 
the United States, and five [5] times higher than all other American 
Indian and Alaskan Native tribes. Attempts among our youth have 
increased 11 percent in 1 year. In 2001, our tribe experienced the loss 
of four young people to suicide in a very short time period. Each 
suicide attempt or completion sends a ripple through our small tribal 
community of incalculable suffering, grief and years of productive life 
lost. I often wonder what would happen if Falls Church, VA were to 
suddenly experience an unemployment rate of over 50 percent, a high 
school drop out rate of over 54 percent, a substance abuse rate 
reaching epidemic proportions, and a suicide rate over 17 times the 
national average. What kind of Federal and State support would be 
forthcoming?
    With little Federal support, our community has come together to 
address the issue of suicide on many fronts. Showing considerable 
foresight, the tribal council appointed a Suicide Task Force in 2001. 
The task force is headed by an employee of Indian Health Service who is 
a community member and a member of the tribe. The Suicide Task Force 
worked with Johns Hopkins University to obtain a NARCH grant to do 
research on suicide. Through the encouragement of the Task Force and 
NARCH the tribal council passed a resolution to establish a suicide 
registry. Those who have been identified as being at high risk are 
provided with referrals to our mental health facility for treatment and 
periodic case management. In a 1-year period, there have been over 300 
referrals to two full time workers, who are monitoring and providing 
assistance.
    In addition to the Suicide Task Force, a High Risk Response 
Alliance was established in October 2005 through the tribe's mental 
health clinic, Apache Behavioral Health Services. This was a grassroots 
effort to involve the community in responding to the suicides.
    Our mental health center has attempted to tap into the cultural and 
spiritual underpinnings of Apache life to suicidal people. They have 
sponsored a Minister's Alliance, a group of ministers and pastors from 
the 60 churches on our reservation. One recent activity organized by 
the Minister's Alliance was a community prayer walk that focused on 
visiting the places where people had successfully killed themselves. 
More recently, a Traditional Alliance has formed and is in the process 
of planning a reservation-wide ceremony to engage those Tribal members 
who adhere to traditional beliefs. As Apaches, we are deeply spiritual 
people all efforts to combat suicide must include spirituality to be 
successful. As you have-heard, we are taking steps to address our 
suicide problem. However, our efforts are limited due to several 
critical barriers.
    First, there are not enough professional and paraprofessional 
health care providers trained and skilled in suicide response that is 
also familiar with the Apache way of life and Native spirituality. Our 
desire is to train and employ more tribal members to meet this need. We 
need Apache speakers, people who know the culture and the community to 
work with our suicidal tribal members. Thus, we want to train more 
Apache people to reach out to our suicidal family members, friends and 
neighbors. Unlike the majority culture, we do not have a professional 
class to do this work. We must do it ourselves. Our mental health 
center, Apache Behavioral Health Services, is partially funded by a 
Public Law 638 contract agreement with Indian Health Service. It is 
also supported though third-party billing of Arizona's Medicaid 
programs. We are fearful that because of new professional and 
educational certification requirements in counseling and substance 
abuse treatment, our paraprofessional workers will eventually lose 
their ability to receive reimbursement for their good work. This must 
not happen. Even though he or she may not possess a doctorate in 
psychology, a well-trained Apache mental health outreach worker with a 
high school diploma who visits suicidal people in the field can often 
do more to decrease the risk of suicide of an Apache person than any 
doctor-degreed non-Apache person. Therefore, we must retain our ability 
to bill Medicaid programs for services provided by qualified, non-
degreed paraprofessional mental health workers.
    Second, we need to develop a 24-hour crisis response center whereby 
family members, friends and any concerned person can contact a trained 
crisis response professional or trained volunteer to provide immediate 
assistance. By necessity, this center would need to have satellite 
locations throughout the 1.7 million acre Fort Apache Reservation in 
order to be able to provide the rapid response needed when persons are 
considering suicide as a solution to their immediate problems.
    Third, substance abuse is a major underlying causal factor of 
suicide among our people. Data indicates that more than 30 percent of 
White Mountain Apache adults abuse drugs and more than 50 percent abuse 
alcohol. This is also related to the high morbidity and mortality rates 
among the WMAT people. Fundamentally, we need resources to expand 
outpatient and residential substance abuse treatment on our 
reservation. The current system for substance abuse treatment in the 
State of Arizona cannot meet the unique needs of White Mountain Apache 
adults and youth requiring services. In fact, it is nearly impossible 
to locate a culturally appropriate residential substance abuse center 
for Native American adults and teenagers in Arizona.
    In conclusion, our needs are great and our resources are few. Our 
suicide rates are among the nations' highest and continue to escalate. 
While we have made great strides in responding to suicide attempts, we 
lack the resources to implement wide-scale prevention. Specifically, we 
need Federal support to:
    1. Provide 24-hour culturally competent crisis intervention for 
youth and adults suffering with suicide ideation;
    2. Create community-based substance abuse prevention and early 
intervention initiatives;
    3. Establish a culturally competent substance abuse treatment 
facility on the reservation for adults and youth; and
    4. Ensure Medicaid reimbursement for qualified, non-degreed 
paraprofessionals working in suicide response.
    The White Mountain Apache Tribe and I are grateful that the U.S. 
Senate Committee on Indian Affairs has taken the time to investigate 
the needs of our people in the area of suicide prevention. It is our 
hope that this testimony has served to help define what measures must 
be enacted to assist us in reducing the number of suicide attempts and 
completions amongst Native American people.


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