[Senate Hearing 111-36]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 111-36



                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE


                             FIRST SESSION


                           FEBRUARY 26, 2009


         Printed for the use of the Committee on Indian Affairs


47-726                    WASHINGTON : 2009
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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman
                 JOHN BARRASSO, Wyoming, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            LISA MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii              TOM COBURN, M.D., Oklahoma
TIM JOHNSON, South Dakota            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           MIKE JOHANNS, Nebraska
TOM UDALL, New Mexico
_____, _____
      Allison C. Binney, Majority Staff Director and Chief Counsel
     David A. Mullon Jr., Minority Staff Director and Chief Counsel

                            C O N T E N T S

Hearing held on February 26, 2009................................     1
Statement of Senator Barrasso....................................     6
Statement of Senator Dorgan......................................     1
    Prepared statement...........................................     2
Statement of Senator Johanns.....................................    60
Statement of Senator Murkowski...................................    52
Statement of Senator Udall.......................................    54


Broderick, Eric B., D.D.S., M.P.H., Acting Administrator, 
  Substance Abuse and Mental Health Services Administration, U.S. 
  Department of Health and Human Services........................    68
    Prepared statement...........................................    70
Jetty, Dana Lee, Student, Minnewaukan Public School; Member of 
  Spirit Lake Dakotah Nation.....................................    14
    Prepared statement...........................................    16
LaFromboise, Teresa D. , Ph.D., Associate Professor of Counseling 
  Psychology and Chair of Native American Studies, Stanford 
  University.....................................................    47
    Prepared statement...........................................    49
Lewis, Hayes A., Director, Center for Lifelong Education, 
  Institute of American Indian Arts..............................    37
    Prepared statement...........................................    40
McSwain, Hon. Robert G., Director, Indian Health Service, U.S. 
  Department of Health and Human Services........................    61
    Prepared statement...........................................    63
Moore, Hon. Robert, Member, Great Plains Tribal Chairmen's 
  Association and Aberdeen Area Tribal Chairmen's Health Board; 
  Council Member, Rosebud Sioux Tribe............................    18
    Prepared statement...........................................    20
Reid, Hon. Harry, U.S. Senator from Nevada.......................     7
    Prepared statement...........................................    11
Walker, R. Dale, M.D., Director, One Sky Center, Oregon Health 
  and Science University.........................................    24
    Prepared statement with attachments..........................    26


Bordeaux, Rodney, President, Rosebud Sioux Tribe, prepared 
  statement......................................................   117
Flynn, Laurie, Executive Director, TeenScreen National Center for 
  Mental Health Checkups, Columbia University, prepared statement   112
Gallanos, James, LCSW Project Coordinator, Office of Prevention 
  and Early Intervention Services, Division of Behavioral Health, 
  prepared statement with attachments............................   129
Gray, Jacqueline S., Ph.D., Assistant Professor, Center for Rural 
  Health, University of North Dakota School of Medicine and 
  Health Sciences, prepared statement with attachment............    79
Hawkins, Jessica, Prevention Program Manager, Oklahoma Department 
  of Mental Health and Substance Abuse Services, prepared 
  statement with attachment......................................    90
Kauffman, Jo Ann, President, Kauffman & Associates, Inc., 
  prepared statement with attachment.............................   102
Lewis, Hayes A., Director, Center for Lifelong Education, 
  Institute of American Indian Arts, prepared statement..........   122
Not Afraid, Leroy M., Member, Great Crow Nation, prepared 
  statement......................................................   120
Oglala Sioux Tribe, prepared statement...........................   115
Patterson, Brian, President, United South and Eastern Tribes, 
  Inc., prepared statement.......................................   117
Response to Written Questions Submitted to Eric B. Broderick, 
  D.D.S., M.P.H. by:
    Hon. John Barrasso...........................................   206
    Hon. Maria Cantwell..........................................   207
    Hon. Byron L. Dorgan.........................................   202
Response to Written Questions Submitted to Hon. Robert G. McSwain 
    Hon. John Barrasso...........................................   346
    Hon. Maria Cantwell..........................................   348
    Hon. Tom Coburn..............................................   349
    Hon. Byron L. Dorgan.........................................   343
Rios, Emilio, Member, Three Affiliated Tribes, prepared statement   196
Whiteman Tiger, Cora, prepared statement with attachments........    86
Written Questions Submitted to:
    Teresa D. LaFromboise, Ph.D..................................   354
    Hayes A. Lewis...............................................   352
    Hon. Robert Moore............................................   349
    R. Dale Walker, M.D..........................................   350
Supplementary information submitted for the record:
    A College Suicide Model for American Indian Students.........   230
    Article, entitled, Durkheim's Suicide Theory and Its 
      Applicability to Contemporary American Indians and Alaska 
      Natives....................................................   273
    Article, entitled, Suicide and Self-Destruction Among 
      American Indian Youths.....................................   285
    Article, entitled, Youth Suicide in New Mexico: A 26-Year 
      Retrospective Review.......................................   329
    Articles from the Argus Leader...............................   303
    North Dakota suicide trend charts............................   334
    Letter submitted to Secretary Mike Leavitt by Hon. Tim 
      Johnson....................................................   229
    Letter submitted to Hon. Byron L. Dorgan and Hon. John 
      Barrasso by Stephanie Hall and Whitney Osceola.............   227
    Mindstreet letter with Psychiatric Times article.............   224
    Presentation on Native American Prevention Initiatives in New 
      Mexico.....................................................   337
    Sources of Strength Program information......................   210
    Study paper, entitled, Adolescent Suicide at an Indian 
      Reservation................................................   254
    Study paper, entitled, An Update on American Indian Suicide 
      in New Mexico, 1980-1987...................................   261



                      THURSDAY, FEBRUARY 26, 2009

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 o'clock a.m. 
in room 628, Dirksen Senate Office Building, Hon. Byron L. 
Dorgan, Chairman of the Committee, presiding.


    The Chairman. I will call the hearing to order. This is a 
hearing of the Indian Affairs Committee of the United States 
Senate. The subject of the hearing today is an oversight 
hearing on youth suicide in Indian Country.
    I have an opening statement. I think I will just simply 
make a couple of comments and then call on Vice Chairman 
Barrasso for a couple of opening comments. Our Senate Majority 
Leader is here as our first witness, and I want to get right to 
    I want to make just a couple of brief comments about this 
subject. It is a very sensitive subject. I have held a couple 
of hearings on it, one in North Dakota where we had a cluster 
of teen suicides on the Standing Rock Sioux Tribe Reservation. 
I held a hearing here in Washington, D.C. on it. I acknowledged 
when I held the hearing that this is a very sensitive subject, 
a very difficult subject.
    I have told the story on the floor of the United States 
Senate, with the consent of the relatives, of a young woman 
named Avis Little Wind. Avis was 14 when she died. Avis Little 
Wind apparently felt hopeless and helpless and took her own 
life. She laid in a bed at home for some 90 days in a fetal 
position and nobody asked about her. Somehow she was never 
missed. Her sister had committed suicide. Her mother was a drug 
abuser. Her father had taken his own life. And somehow she just 
fell through the cracks.
    Avis Little Wind was just a 14 year old girl who ended her 
life very early. I went to that reservation. I met with the 
tribal council. I met with school officials. I met with her 
classmates. I was just trying to understand what is happening 
and why. What causes this?
    Following that, and following discussions at the Standing 
Rock Reservation where I went and met just myself with a good 
number of high school students to talk to them about their 
lives, we put together some legislation to try to make mental 
health treatment and counseling more widely and readily 
available to young people on Indian reservations, to try to, as 
one response, address some of the issue of teen suicides.
    Today, we will hear about what those efforts have resulted 
in. We are going to hear from a good number of witnesses. We 
are going to hear from Dana Lee Jetty, who is a student at 
Minnewaukan Public School and a member of the Spirit Lake 
Dakotah Nation. Dana's sister took her life. Her parents are 
with us today.
    We want to hear testimony from a number of members of other 
tribes. We are going to hear testimony from the Director of the 
Indian Health Service and the Acting Administrator of the 
Substance Abuse and Mental Health Services over at the 
Department of Health and Human Services.
    I want to mention we have a vote that will occur at 10:30 
a.m., so we will recess for the vote today. After I call on 
Vice Chairman Barrasso for a couple of comments, I am going to 
call on our Majority Leader. We are enormously honored that he 
has joined us today to be the lead-off witness on this very 
important subject.

              Prepared Statement of Hon. Byron L. Dorgan, 
                     U.S. Senator from North Dakota
    Today, we will hold an oversight hearing on Youth Suicide in Indian 
Country. The purpose of today's hearing is to examine the effectiveness 
of the current prevention programs in Indian Country.
    The issue of suicide is of great importance both to this Committee 
and to me personally. As someone who has felt the crushing blow of 
suicide by a friend and co-worker, I am aware of the tremendous effect 
suicide has on surviving family members, friends and a community.
    Indian Country suffers from many health and economic disparities 
that have been linked to a higher risk of suicide: alcohol and 
substance abuse, depression and mental illness, unemployment, and 
domestic violence.
    The broken health care system in Indian Country adds to the risk of 
suicide in American Indian communities.
    The unfortunate result is that the rate of suicide among American 
Indian and Alaska Natives is 70 percent higher than the general U.S. 
    Today, we are focused on our young people in Indian Country and 
sadly they are not spared from these trends. [Chart 1] In this chart, 
we have listed on the left the 10 states with the highest percentage of 
Indians and on the right the 10 states with the highest rates of youth 
suicide. As you can see, the correlation is very troublesome.

    [Chart 2] This next chart shows the rates of suicide for ages 10 to 
24 across numerous racial groups. As you can see, American Indian and 
Alaska Native youth have the highest rate of suicide for both males and 
females. Young American Indian men have a suicide rate 2 to 4 times 
higher than adolescent males and 11 times higher than same-age females 
in other racial groups.

    In the last decade, Indian Reservations have seen youth suicide 
rates reach epidemic levels. In 2005, there were youth suicide clusters 
on the Standing Rock, Crow Creek and Cheyenne River Reservations. This 
is a crisis that we must address.
    I want to show a chart [Chart 3] which depicts the disparity in 
youth suicide rates from my home state. The top line shows the rate of 
suicide for American Indians, ages 10 to 24. The bottom line shows the 
same for Caucasians. Again, the rate for American Indians is incredibly 
high, but it also shows a decline over the past two years.

    In response to the epidemic in 2005, the issue of youth suicide in 
Indian Country gained National attention. Agencies, like the Substance 
Abuse and Mental Health Services Administration and the Indian Health 
Service, began specific initiatives to deal with the crisis. New grant 
funding, like the Garrett Lee Smith grants, were available for youth 
suicide prevention and many Tribal communities have received funding 
for their own programs.
    This Committee held three hearings on youth suicide in 2005 and 
2006. Part of what we are doing today is to follow-up on youth suicide 
prevention efforts that have occurred since our last hearing.
    We will receive an update from the federal agencies responsible for 
administering youth suicide programs, experts on the issue and Tribal 
leaders who see the impact of youth suicide every day. We will also be 
hearing from a longtime advocate for suicide prevention, the honorable 
Majority Leader Reid.
    I want to end my statement by saying, one youth suicide is one 
tragedy too many. This issue is about more than numbers, it is about 
the families and communities left behind and the young lives we have 
lost. [Chart 4] I want to show you see the face of a beautiful young 
woman, Jami, from the Spirit Lake Nation in my home state of North 
Dakota. Last November, Jami felt hopeless and decided to take her own 
life. Today, her sister, Dana will tell us, on a personal level, what 
youth suicide really means for Indian Country. We all need to work to 
address this crisis.

    I want to thank all the witnesses for being here today and look 
forward to your testimony.

    Senator Barrasso?

                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Well, thank you, Mr. Chairman. Like you, 
I have an opening statement, and it is an honor to have Senator 
Reid here, so I will submit my opening statement to the record.
    But I just want to say that no community is, or ever will 
be, immune from the tragedy of suicide. We have to make sure 
that the trauma of suicide and its aftermath does not paralyze 
the community. With that, I would like for just a few seconds, 
Mr. Chairman, to talk about the Wind River Indian Reservation 
in Wyoming, home of the Eastern Shoshone and the Northern 
Arapaho Tribes. It serves as an example.
    You talked about how serious and how sensitive this issue 
is. In two short months a number of years ago, nine young 
Native American men between the ages of 15 and 25 committed 
suicide, with another 88 verifiable suicide attempts occurring 
on the reservation within that time frame.
    Mr. Chairman, the Wind River Indian community mobilized to 
address this crisis, creating a team that included that Bureau 
of Indian Affairs, the Indian Health Service personnel, as well 
as the traditional and tribal leaders. Mr. Chairman, the 
suicides and the suicide attempts soon subsided. Since that 
time, the number of youth suicides has been decreasing on the 
    So I am particularly pleased that the Northern Arapaho 
suicide prevention team works well with the Fremont County 
Suicide Prevention Task Force and know that there are solutions 
and we can find them. Working together, we can improve our 
efforts even more.
    So with that, Mr. Chairman, let me just submit my statement 
to the record and welcome along with you, and say what an honor 
it is, for all of us to have Senator Reid with us this morning.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    I did not mention that the rate of suicide among American 
Indian and Alaska Natives is 70 percent higher than the general 
U.S. population. We have seen very troubling clusters of 
suicides, especially among Indian teens. That is what this 
hearing is about today.
    Senator Reid, we are pleased that you are here. The 
presence of the Majority Leader is always an honor. I know that 
this issue is something that is very personal to you and that 
you have spent significant time working on it as well.
    Thank you for being here, and you may proceed.

                 STATEMENT OF HON. HARRY REID, 
                    U.S. SENATOR FROM NEVADA

    Senator Reid. Chairman Dorgan, Dr. Barrasso, it really is a 
pleasure for me to be here today. I appreciate your holding the 
    As Chairman Dorgan mentioned, this issue of suicide is very 
personal to me. More than a dozen years ago, I attended a 
Special Committee on Aging meeting chaired by Senator Bill 
Cohen from Maine. At the hearing, Mike Wallace talked about his 
emotional problems. This famous man, the anchor for 60 Minutes 
for so long, indicated that there were many times that he 
wanted to die. He would try to pick assignments hoping that 
maybe something would go wrong and he wouldn't be able to come 
    I was so impressed with his courage being there, his 
ability to speak publicly about a problem he had and the 
treatment he had received. Basically what he said was, ``I 
don't have that problem anymore. I take a little bit of 
medicine, talk to somebody once in a while, and I am fine.''
    At that time I commended him for his speaking out publicly 
about a condition that some associate with weakness, that some 
people, and many feel frankly, is a stigma. It was during this 
hearing that I came to the conclusion that my own personal 
experience in dealing with my dad, is something that I should 
talk about publicly. I and my family had kind of kept it to 
ourselves. Had we really failed? Why did my dad shoot himself 
in the head with a pistol? The whole family, we just kind of, I 
guess, pretended it hadn't happened.
    But at this hearing on Aging, I said that my dad had killed 
himself and that we should hold a hearing on senior suicide, 
and we did. I came to the realization that suicide was a 
national problem, not my problem, not my family's problem, not 
Nevada's problem, but a national problem. I came to the 
realization that there were people that needed to be advised 
that they were not the cause of someone having killed 
    The people who survive a suicide are many times the victim 
themselves. Feelings of guilt persist. So following these 
hearings that Chairman Cohen was willing to have, I was 
contacted by a married couple from Georgia. There name was 
Weyrauch, Georgia and Elsie Weyrauch. They had lost an adult 
daughter, who was a physician. They were so proud of her. She 
got out of medical school and had a good, successful practice, 
but she killed herself. These two wonderful people founded the 
Suicide Prevention Advocacy Network to raise awareness about 
the issue.
    So with their encouragement and that of a wonderful staff 
member of mine who became so involved in this, Jerry Reed, who 
since has left my office, and gone on to get a Ph.D. He has 
worked on suicide since those hearings that we had in the Aging 
Committee. He is here today, still working in suicide 
    With their support I proposed S. Res. 84, which declared 
suicide to be a national problem and sought to make suicide 
prevention a national priority. It passed the Senate. It passed 
the House. After Surgeon General David Satcher was confirmed, I 
invited him to approach suicide as a national public health 
issue, and he did. In 1998, he convened a conference in Reno, 
Nevada. The Reno conference brought together experts from all 
over the Country to address the problem of suicide. By the time 
they were finished, they had come up with a national strategy 
for suicide prevention.
    There are so many interesting things about suicide. Why are 
the leading States of suicide west of the Mississippi? For 
those of us in the West, where the air is so clear and the sun 
is so bright, and we don't have the dark winters, why is that? 
We are trying to figure it out. We don't know even now. But Dr. 
Satcher's convening the conference gave the issue some 
momentum. In 2001, a couple of years after that, the United 
States Department of Health and Human Services published its 
national strategy for suicide prevention, which provides a 
blueprint for suicide prevention in the United States. In 2002, 
a year later, the Institute of Medicine published its report, 
Reducing Suicide: A National Imperative.
    Now, Committee members, there had been nothing done about 
suicide prior to that. No money had been spent to try to figure 
out why there is more suicide in the West than the East. And 
now, there are studies going on. We need to make sure that they 
can continue and it is going to take a little bit of taxpayers 
money, but it is important. Because you see, more than 30,000 
people kill themselves every year. Now, those are the people 
that are reported suicides. There are a lot of suicides that 
are car wrecks, hunting accidents, and boating accidents who 
really aren't listed as suicides, but they are.
    As a result of these calls to action, we have suicide 
research centers, suicide hot lines, and the National Suicide 
Prevention Resource Center. This center is designed to provide 
States and communities with evidence-based strategies for 
suicide prevention. Importantly, the center collaborates with 
many organizations like the One Sky Center, represented today, 
and he will testify here, Dr. Walker, to promote widespread 
implementation of a national strategy.
    Here in the Senate, one of our members of our Senate 
family, Senator Gordon Smith, lost his 21 year old son to 
suicide. What a sad story. Garret Lee Smith was his name. And 
we all who served with Gordon heard about the love he and his 
wife have and had for their boy, who as a college student 
killed himself. The Garret Lee Smith Memorial Act became the 
first law to address youth suicide, so we are making progress.
    Many of us here today, including you, Mr. Chairman, 
Senators Akaka, Johnson and Murkowski, sponsored this 
legislation because of its potential to help communities and 
families save lives. During the last session of Congress, we 
made some steps forward. After many, many years of talking 
about it, we finally stuck into one of the must-pass bills, the 
Paul Wellstone and Pete Domenici Mental Health Parity and 
Addiction Act. We passed that legislation, and it was important 
that we did it.
    We have done some other good things. Under your leadership, 
Mr. Chairman, the Senate passed the Indian Health Care 
Improvements Act last year. It is so important we took care of 
that, but we still were unable to get it done, for a lot of 
reasons. I hope we try it again. It would have created an 
Indian Youth Health Program for suicide prevention, 
intervention and treatment efforts. I repeat, it is too bad it 
didn't pass.
    So I look forward to working with you and your colleagues 
to pass this legislation now, this year. If not this year, next 
    We have made some progress and that is important we talk 
about that, since the first hearing we had back in 1996. In 
fact, we have really come a long way. It is amazing what a few 
Congressional hearings can do to bring attention to such an 
important issue. We need to do more. We need to focus on 
populations that are particularly at risk, American Indians.
    We have 26 separate tribal communities in Nevada. I have 
worked hard to try to understand Indian Country. Mr. Chairman, 
you know that the suicide rate for Native Americans, who are 
between ages 15 and 34, as you have already indicated, is more 
than two times higher than the national average. Among this age 
group of Native Americans, 15- to 34-year-olds, it is the 
second leading cause of death. That is really staggering.
    In fact, the rate of suicide among youth on Indian 
reservations is three times greater than any other youth 
population. It has to be, for lack of a better description, a 
    The one thing that I have heard a number of you talk about, 
Mr. Chairman, you and Dr. Barrasso, is multiple suicides in a 
family. That is a study. This is not rare. It happens all the 
time. We have had instances of where a grandfather, a father 
and a son have committed suicide, in the same family. Nevada 
has one of the Nation's highest rates of suicide. In fact, I 
think we probably are the highest. The data suggests that our 
Native Americans in Nevada are even more likely than non-Native 
Americans to consider an attempt and to die from suicide, as we 
have already established. Outreach and awareness efforts on a 
number of Nevada's more remote reservations certainly make this 
    That is why I support efforts of Federal agencies, public-
private partnerships, tribes and others who develop and provide 
suicide prevention treatment programs are vitally important. 
The Indian Health Service has partnered with HHS and tribes to 
develop and implement a suicide prevention initiative. It is 
behind schedule.
    In recent years, SAMHSA's direct funding grants in 
partnership opportunities have generated research and supported 
programs in the field. A few Nevada tribes have received grant 
funds to promote prevention and provide treatment within their 
    Then there are programs in places like Boys and Girls 
Clubs, tribal community buildings, native language nests and 
language schools that build community, provide after-school 
programming, and strengthen the social fabric.
    Mr. Chairman, it doesn't take much. We learned in some of 
the hearings we held many years ago that mail carriers, people 
who deliver mail, can be trained, especially with certain 
populations like senior citizens, to see how patterns change, 
they don't pick up their mail, et cetera. In the State of 
Washington, they have had a number of programs like this which 
have been very successful in preventing people from killing 
    We have one Boys and Girls Club in Nevada, on the Walker 
River Paiute Reservation. We also have one youth treatment 
center on the Pyramid Lake Paiute Reservation. I suggest we 
need more to both successfully address the needs of young 
people and tribes.
    So Mr. Chairman, members of this Committee, I so appreciate 
your commitment and attention to this epidemic. Holding this 
hearing is so vitally important, and your dedication to 
improving and saving the lives of Native Americans, 
particularly our kids. And that is what they are. We have to 
understand why it is happening and what we can do to slow it 
down and ultimately prevent it.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Reid follows:]

    Prepared Statement of Hon. Harry Reid, U.S. Senator from Nevada 

    The Chairman. Senator Reid, thank you so much for being 
with us.
    I want to put up one chart that amplifies something that 
you said that is so important for all of us to understand. You 
talked about the States with the highest youth suicide rates. 
You will see on these charts, it is very interesting that 
almost all of them are Midwest and Western States. You 
indicated that no one quite knows why that is the case, but 
that is a really interesting chart. It is something I had not 
known before I saw this chart yesterday.
    Does anyone have questions of Senator Reid?
    I know, Senator Reid, that it is intensely personal for you 
to speak about these issues, and yet I think your decision 
previously to speak out on these issues is enormously 
beneficial to our Country and to others who hear your 
testimony. I very much appreciate your willingness to come 
    Senator Reid. Byron, it has been good for my family. It has 
been good for the family to confront this issue and not be 
embarrassed. No one should be embarrassed about this. No one 
should feel it is their fault. There are organizations out 
there, lots of them now, who will help people work their way 
through this. Whenever I see someone where there is a suicide, 
I try to call them and give them organizations that can help.
    The Chairman. Well, thank you so much for being here today. 
I think it does provide an inspiration to others, so thank you 
for being with us.
    We have a list of witnesses today. I indicated that there 
will be a vote at about 10:30 a.m. We probably will break about 
20 minutes to 11 a.m., that is 20 minutes from now, to go vote 
and come back. We will have a brief recess.
    But I want to call on Ms. Dana Lee Jetty, who is a student 
at Minnewaukan Public School and a member of Spirit Lake 
Dakotah Nation, Fort Totten, North Dakota; the Honorable Robert 
Moore, Member of the Great Plains Tribal Chairmen's 
Association, and the Aberdeen Area Tribal Chairmen's Health 
Board; Dr. Dale Walker, Director of One Sky Center, Oregon 
Health and Science University in Portland, Oregon; Mr. Hayes 
Lewis, Director of the Center for Lifelong Education, Institute 
of American Indian Arts at Santa Fe, New Mexico; and Dr. Teresa 
LaFromboise, Associate Professor at Stanford University School 
of Education.
    I want to say to our colleagues, the Honorable Robert 
McSwain and Dr. Eric Broderick, that normally, I would call you 
first. I would like, with your permission, to call you after 
this panel so that you have a chance and an opportunity to 
listen to this panel, and then respond. So I appreciate your 
indulgence and thank you so much for that.
    Let me begin with Dana Lee Jetty. Dana Lee Jetty is here 
with her family. The circumstances of our inviting her here are 
very tragic circumstances. I know how difficult these things 
are. It is good of you to come. Dana Lee's sister took her 
life. Her sister's name was Jami Rose Jetty. It was just last 
November. She is a high-schooler in Minnewaukan, North Dakota, 
which is on the edge of the Spirit Lake Nation Reservation. She 
has agreed to come with her parents and visit with us today. I 
am going to begin with you, Dana Lee. You may proceed.


    Ms. Jetty. My name is Dana Jetty. I am 16 years old and I 
am an enrolled member of the Spirit Lake Tribe of North Dakota. 
Before I begin, I would like to thank the Committee for giving 
me the opportunity to talk to you about my family and, more 
importantly, about my sister Jami.
    Jami was 14 years old. She had a lot of friends and was 
mature for her age. Jami was open-minded and always asking 
questions about anything and everything. She was very caring, 
sweet, compassionate and never judged anyone. She saw the world 
in black and white, and found pleasure in simple things like 
listening to old stories from long ago. Jami was like any other 
teenage girl from a middle-class home surrounded by a family 
who loved her.
    November 3, 2008 started as a day like any other, but it 
ended as a day that I will never forget. November 3, 2008 is 
the day that my baby sister, Jami Rose Jetty, ended her own 
life. My sister and I were home that day and Jami woke me up 
about 9:30 in the morning to tell me that she felt sick and 
dizzy. I knew my sister had been having problems with 
depression, and I asked her if she had taken anything. She told 
me she had, so I immediately called my mom at her office. My 
mom came to the house right away, but Jami refused to tell her 
what she had taken and refused to go to the clinic.
    My mom told me to keep an eye on Jami while she went to 
make some calls to see what kind of help she could get for my 
sister. Of course, my sister was angry with me for calling my 
mom, but I talked to her for a while anyway. After Jami talked 
for a while, she asked me to leave her alone. I hesitated, but 
decided to give her some space.
    After I left her alone, I watched TV and made some food. I 
decided to clean up and called for Jami to come help me, but 
she did not respond. I walked towards the back of the house and 
saw that the bathroom door was closed, but the light was on. I 
opened it, but she was not in there. I looked towards Jami's 
bedroom and her door was also closed. I opened it, and I was 
instantly flooded with feelings of fear and shock. It was like 
a horrible dream that I cannot wake up from.
    I saw my sister with a belt fastened to the bunk bed and 
wrapped around her neck. Jami was sitting lifelessly, her body 
leaning against the wall. I ran to get my boyfriend and I tried 
to get the belt off her neck, but it was too tight. My 
boyfriend got a knife and cut her down. All I could do was 
yell, why, as I rocked her lifeless body in my arms.
    The next thing I recall is my mom and dad running into the 
house. I watched as my mom frantically called the police and my 
dad desperately tried to perform CPR. Within minutes, the 
police and paramedics arrived. Even though the paramedics did 
get a slight pulse, my sister, Jami Rose Jetty, was not alive 
when she arrived at Mercy Hospital in Devils Lake, North 
    On November 3, 2008, I lost my sister and my best friend. 
On November 3, 2008, my life and my family changed forever. 
Suicide has left me feeling lost, lonely and angry. I don't 
understand why my sister felt that she had to do this, and I 
don't know why she didn't ask me for help or tell me what she 
was thinking. Knowing my sister, she would not have wanted to 
burden others with her problems, but I wish she would have told 
    I, along with my family, have turned to our spirituality 
and our faith to guide us through this dark time. We have 
prayed. We have attended sweat ceremonies, and we have talked 
to whoever will listen to share our experience. In the 
aftermath of my sister's suicide and in the ceremonies we 
attended, we have come away with a message from Jami that we 
are now passing along to others: Tell the ones that are trying 
to end their lives this way, it is not the way to go.
    And so my sister's message has become a mission for my 
family. We have attended meetings in our community to tell 
anyone that is considering suicide that it is not the way to 
go, and that there are people who can help. In talking to our 
community, we have found that suicide is a much more common 
problem than we ever realized. People in our community have 
opened up to us and have shared their feelings of suicide and 
have expressed the shame that they feel for having those 
thoughts. I never imagined that so many people had these 
thoughts and kept them inside out of a sense of shame and 
    While I am surprised at how many people feel suicidal, I am 
not shocked at the hopelessness they feel. I know that my mom 
had concerns about my sister before her suicide. My mom did all 
the right things. She took her to the doctor. She talked to 
counselors and she was even evaluated by mental health 
professionals from Indian Health Services. The mental health 
providers dismissed my mom's concerns and diagnosed my sister 
as being a typical teenager. I know my mom is angry that these 
professional people did not provide the help she needed, and 
her strength and ability to forgive is amazing.
    Now, our mission has led us to Washington, D.C. Today, I, 
along with my family, ask you to support our efforts to prevent 
suicide by funding and developing quality programs and health 
services in our tribal communities. It is not enough to put a 
counselor in a community. We need trained professionals who 
really know how to help our communities. We can stop others 
from committing suicide if we talk openly in our communities 
and if we provide supportive places for people to go when they 
need help for themselves or for their family members.
    We need to make sure that our communities and our people 
know how to reach out for help if they need it, and we need to 
make sure that help is there when they ask. We need to share 
Jami's message: Tell the ones that are ending their lives this 
way that it is not the way to go.
    And so today, I am here on behalf of my sister Jami Rose 
Jetty to ask for your help. I ask that you support suicide 
prevention programs in our tribal communities, and I ask that 
when you have your discussions on the issue of suicide, you 
remember my sister. She was 14 years old. She was a beautiful, 
outgoing teenager with her whole life ahead of her. She was my 
sister, and she is what suicide looks like in Indian Country.
    Thank you for giving me the opportunity to share Jami's 
message with you today. Thank you.
    [The prepared statement of Ms. Jetty follows:]

   Prepared Statement of Dana Lee Jetty, Student, Minnewaukan Public 
              School; Member of Spirit Lake Dakotah Nation
    My name is Dana Jetty, I am 16 years old and I am an enrolled 
member of the Spirit Lake Tribe in North Dakota. Before I begin I would 
like to thank the Committee for giving me the opportunity to talk to 
you about my family and more importantly about my sister Jami.
    Jami Rose Jetty was 14 years old, she had a lot of friends, and was 
mature for her age. Jami was open minded and always asking questions 
about anything and everything. She was very caring, sweet, 
compassionate, and never judged anyone. She saw the world in black and 
white and found pleasure in simple things like listening to stories 
from long ago. Jami was like any other teenage girl from a middle class 
home surrounded by a family who loved her.
    November 3, 2008 started as a day like any other but it ended as a 
day that I will never forget. November 3, 2008 is the day that my baby 
sister, Jami Rose Jetty, ended her own life. My sister and I were home 
that day and Jami woke me up around 9:30 in the morning to tell me that 
she felt sick and dizzy. I knew my sister had been having problems with 
depression and I asked her if she had taken anything. She told me she 
had so I immediately called my mom at her office. My mom came to the 
house right away but Jami refused to tell her what she had taken and 
refused to go to the clinic. My mom told me to keep an eye on Jami 
while she went to make some calls to see what kind of help she could 
get for my sister. Of course my sister was angry with me for calling my 
mom but I talked to her for a while anyway. After Jami talked for a 
little while, she asked me to leave her alone. I hesitated but decided 
to give her some space.
    I left her alone and watched TV and made some food. I decided to 
clean up and called for Jami to come and help me, but there was no 
response. I walked towards the back of the house and saw that the 
bathroom door was closed but the light was on. I opened it but she was 
not in there. I looked towards Jami's bedroom and her door was also 
closed. I opened it and was instantly flooded with feelings of fear and 
shock. It was like a horrible dream that I could not wake up from. I 
saw my sister with a belt fastened to the bunk bed and wrapped around 
her neck. Jami was sitting lifelessly, her body leaning against the 
wall. I ran to get my boyfriend and I tried to get the belt off her 
neck but it was too tight. My boyfriend got a knife and cut her down. 
All I could do is yell ``Why?'' as I rocked her lifeless body in my 
arms. The next thing I recall is my mom and dad running into the house. 
I watched as my mom frantically called the police and my dad 
desperately tried to perform CPR. Within minutes the police and 
paramedics arrived. Even though the paramedics did get a slight pulse, 
Jami Rose Jetty, my baby sister, was not alive when she arrived at 
Mercy Hospital in Devils Lake, ND.
    On November 3, 2008 I lost my sister and my best friend. On 
November 3, 2008 my life and my family changed forever. Suicide has 
left me feeling lost, lonely and angry. I don't understand why my 
sister felt that she had to do this and I don't know why she didn't ask 
me for help or tell me what she was thinking. Knowing my sister she 
would not have wanted to burden others with her problems, but I wish 
she would have told me.
    I, along with my family have turned to our spirituality and our 
faith to guide us through this dark time. We have prayed, we have 
attended sweat ceremonies and we have talked to whoever will listen to 
share our experience. In the aftermath of my sister's suicide and in 
the ceremonies we attended we have come away with a message from Jami 
that we are now passing along to others ``. . . tell the ones that are 
trying to end their lives this way that it is not the way to go. . . 
    And so my sisters' message has become a mission for my family. We 
have attended meetings in our community to tell anyone that is 
considering suicide, that this is not the way to go and that there are 
people who can help. In talking to our community we have found that 
suicide is a much more common problem than we ever realized. People in 
our community have opened up to us and have shared their feelings of 
suicide and have expressed the shame that they feel for having those 
thoughts. I never imagined that so many people had these thoughts and 
kept them inside out of a sense of shame and hopelessness. While I am 
surprised at how many people feel suicidal, I am not shocked at the 
hopelessness they feel. I know that my mom had concerns about my sister 
before her suicide. My mom did all the right things. She took her to 
the doctor, she talked to counselors, and she even had her evaluated by 
mental health professionals from Indian Health Services. Those mental 
health providers dismissed my moms concerns and diagnosed my sister as 
being a ``typical teenager''. I know my mom is angry that these 
professional people did not provide the help when she needed it and her 
strength and ability to forgive is amazing.
    Now our mission has led us to Washington, D.C. and today I, along 
with my family, ask you to support our efforts to prevent suicide by 
funding and developing quality programs and health services in our 
Tribal communities. It is not enough to put a counselor in a community. 
We need trained professionals who really know how to help our 
communities. We can stop others from committing suicide if we talk 
openly in our communities and if we provide safe and supportive places 
for people to go when they need help for themselves or their family 
members. We need to make sure that our communities and our people know 
how to reach out for help if they need it and we need to make sure that 
the help is there when they ask. We need to share Jami's message: ``. . 
. tell the ones trying to end their lives this way, that it is not the 
way to go. . . ''.
    And so today, I am here on behalf of my sister, Jami Rose Jetty to 
ask for your help. I ask that you support suicide prevention programs 
in our tribal communities and I ask that when you have your discussions 
on the issue of suicide you remember my sister. She was 14 years old. 
She was a beautiful, outgoing teenager with her whole life ahead of 
her. She was my sister and she is what suicide looks like in Indian 
    Thank you for giving me the opportunity to share Jami's message 
with you today.

    The Chairman. Well, Dana, thank you very much. You have 
given all of us today an opportunity to remember your sister. 
My guess is that your little sister would be enormously proud 
of you.
    Ms. Jetty. Yes.
    The Chairman. The tragedy that has visited your family and 
the loss of your sister is intensely personal and intensely 
emotional to your family. And yet, for all of us to try to find 
lessons here that might help others who experience this tragedy 
is so important.
    I mentioned in the opening statement the death of Avis 
Little Wind on the same Indian reservation.
    Ms. Jetty. Yes.
    The Chairman. She, too, hung herself at age 14. I spent 
time going there, talking to everybody I could talk to to 
understand what happened there.
    Ms. Jetty. Yes.
    The Chairman. There are not obvious or easy answers. Often, 
it is very complicated. But the one thing that was clear to me 
and has always been clear to me, and is true on almost every 
Indian reservation, there is not readily accessible treatment 
by qualified professionals that are available. It is something 
we have to fix. I mean, this is a great tragedy.
    So we all appreciate very much your being willing to come 
and do something that I know is very, very difficult for you 
and your family to do, and that is speak publicly about it. You 
heard our colleague, Senator Reid, describe the inclination not 
to talk about these things.
    But I think your willingness to come to Washington, D.C. 
and to speak publicly about these things will help others. So 
we appreciate that.
    Ms. Jetty. Yes.
    The Chairman. What I am going to do, with the permission of 
my colleagues, is hear from the other witnesses, and then we 
all have a chance to ask Dana questions and other witnesses 
questions, if that is permissible. We likely will have to be 
interrupted by this recess for a vote.
    Let us start with the Honorable Robert Moore, who is a 
member of the Great Plains Tribal Chairmen's Association and, a 
Council Member of the Rosebud Sioux Tribe
    Mr. Moore?

                     HEALTH BOARD; COUNCIL 

    Mr. Moore. Thank you, Mr. Chairman. Thank you again. It is 
a pleasure to see you as well again.
    I am very honored and humbled to be here to represent the 
many tribes of the Great Plains, with which you are very 
familiar. You mentioned several of your own experiences out 
there in hearings and understanding, particularly at Standing 
Rock and others, like the story of Jami. There are hundreds of 
those stories in our area alone.
    In the Aberdeen area, as a matter of fact, when you look at 
some of the statistics, the national death rate from suicide is 
approximately 10 per 100,000, 17 per 100,000 in the IHS 
population and the service area, and in the Aberdeen area 
alone, it is over 22 per 100,000.
    At Rosebud, we have been sort of identified as the 
epicenter of suicide in Indian Country. Recently and just 
yesterday, Indian Health Services service unit at Rosebud 
released an alarming statistic. In our tribe alone, the suicide 
rate is 200 per 100,000 for males ages 15 to 24, which right 
now puts us as having the highest suicide rate in the world, in 
that little pink rectangle that Rand McNally calls the Rosebud 
Sioux Indian Reservation in your atlas.
    It is very alarming. There is not a single family member or 
tribal citizen at Rosebud that has not been directly impacted 
by the overwhelming number of suicides in our area. As a result 
of this, and as a result of the growing concern of elected 
tribal leadership and the entire community, we responded in a 
way that really organized and efficiently and effectively 
brought together tribal agencies to respond from all levels, 
including areas of law enforcement, alcohol and substance 
abuse, our tribal university and others.
    As you know, in Indian Country it is very important for us 
to have a very holistic approach to not just suicide, but to 
the overall wellness of all of our community, which includes 
those areas like law enforcement and education. And then we can 
be able to more directly address suicide.
    I have several recommendations that are, I think, important 
for us to talk about. One is we need improved collaboration, 
not only with what we currently have experienced, and I have to 
extend a great amount of appreciation to Mr. McSwain, Mr. 
Broderick and others who have really helped us and joined 
together as an overall HHS Department-wide response to our 
situation specifically at Rosebud. But we need improved 
collaboration, cooperation and data-sharing between IHS and 
tribes, and elevating suicide to a very reportable medical 
system of reporting so that the information is out there for 
tribes and IHS to be more response than they are and have been 
so far.
    IHS has to change its health care paradigm. Right now, IHS 
is really responsible for response to medical situations and to 
Medicaid. But in their own mission statement, they have 
identified health promotion and disease prevention as one of 
their leading missions. So we want to work with them to be able 
to shift that whole paradigm so that we are able to really 
provide a well and healthy community.
    Another area that we need to talk about is early childhood 
trauma. I have been asked to represent that point in that a lot 
of the suicides that have occurred, at least at Rosebud and in 
our area, can be directly identified to an incident that 
occurred in early childhood, but we don't have the resources 
and mechanisms in place to address that when it actually 
    However, in some of our programs, we have done very well at 
addressing the mental health needs of children. Our diabetes 
prevention program is one. We have had great success in 
addressing the mental health of our children who are showing 
early onset of Type 2 diabetes. In doing that, it has helped 
address and alleviate some of those mental health issues in 
those homes, but that is only just a small pocket in our 
    We also need the resources to really reach out and develop 
home-based, community-based response to suicide and to the 
behavioral and mental health issues in our tribal communities, 
where we have actual citizens engaged in response, actual 
citizens engaged in promoting and addressing the self-esteem of 
our children. One of the leading causes of suicide is lack of 
    So one of the things that we are doing in Rosebud is we 
have established the Wiconi Wakan Health and Healing Center. It 
means life is sacred. Our faith-based community and our 
traditional spiritual leaders have really joined together to 
invoke the spiritual life of our tribal citizens at Rosebud, 
particularly, as they have around the Country. It is a very 
spiritual issue for tribal citizens.
    Then finally, as we look at one of the issues that was 
mentioned in the earlier testimony from Jami's sister, is 
having the appropriate people in place at IHS and other Federal 
agencies or other systems of care in Indian Country. That means 
cultural competency. A lot of folks would say, oh, Jami's 
situation is that of just a typical teen, without fully 
understanding some of the cultural life that we have and having 
the competency to address that part of our lives in Indian 
    You have my written testimony. We will be glad to continue 
to work with you and the entire Committee and your staff as we 
join together in Indian Country to address this issue one on 
one. In fact, this Sunday we have our second Suicide Task Force 
meeting, which is conducted with the National Congress of 
American Indians. We had our first Suicide Task Force meeting 
this last fall in Phoenix. We are joining forces on a national 
level to address the situation and to provide resources and 
opportunities for tribes to respond.
    Thank you.
    [The prepared statement of Mr. Moore follows:]

 Prepared Statement of Hon. Robert Moore, Member, Great Plains Tribal 
   Chairmen's Association and Aberdeen Area Tribal Chairmen's Health 
               Board; Council Member, Rosebud Sioux Tribe
    Mr. Chairman and other Members of the Committee, thank you for your 
hard work to ensure that the appropriate authority and funding for 
health care services is available to meet the needs of the 17 Tribal 
Nations of the Great Plains, and thank you for the opportunity to 
provide this testimony on behalf of the Rosebud Sioux Tribe and all the 
Tribal Nations of the Great Plains Tribal Chairman's Association. I am 
Robert Moore, Elected Councilman of the Antelope Community, Rosebud 
Sioux Tribe of South Dakota. I am here today representing the Great 
Plains Tribal Chairman's Association (GPTCA), and the Aberdeen Area 
Tribal Chairmen's Health Board (AATCHB) -an Association of seventeen 
Sovereign Indian Tribes in the four-state region of SD, ND, NE and IA. 
The Great Plains Tribal Chairman's Association is founded on the 
principles of unity and cooperation to promote the common interests of 
the Sovereign Tribes and Nations of the Great Plains and their 
Great Plains Region
    The GPTCA stands on the Fort Laramie Treaty of 1868 (15 Stats. 635) 
Articles IV, V and IX that guarantees that the United States will 
provide health care services at the local level to our people and will 
reimburse the Tribes for any services lost. It was clearly understood 
by the Indian signers of that Treaty that necessary assistance would be 
provided to the signatory Tribes by the Indian agent and a local 
physician (or Superintendent or the Director of Indian Health Service 
in the modern era) and that sufficient resources would be made 
available to the physician to allow him to discharge the duties 
assigned to him. Indian health care fulfills a fundamental Treaty 
obligation and our Tribal people take this obligation very seriously. 
It is important to note that as Tribal members, we are the only 
population in the United States that is born with a legal right to 
health care. This right is based on treaties in which the Tribal 
Nations exchanged land and natural resources for several social 
services, including housing, education and health care.
    The Great Plains Region, aka Aberdeen Area Indian Health Service, 
has 21 I.H.S. and Tribally managed service units. We are the largest 
land based area served of all the Regions with land holdings of 
Reservation Trust Land of over 11 million acres. There are 17 Federally 
recognized Tribes with an estimated enrollment of close to 200,000 
tribal citizens. The Tribes of the Great Plains are greatly underserved 
by the I.H.S. and other federal agencies with the I.H.S. Budget 
decreasing in FY 2008 over the FY 2007 amount. This is in spite of 
increased population size and worsening health disparities. The GPTCA/
AATCHB is committed to strengthening direct health care systems and all 
Federal Programs in a comprehensive delivery to improve the lives of 
our enrolled members and in particular our Youth of the Seventh 
Generation. In the past few years, unfortunately, our Tribes have 
experienced an increase of Suicides.
Health Data and Overview
    As documented in many reports, the Tribes in the Great Plains 
region suffer from among the worst health disparities in the Nation, 
including several-fold greater rates of death from numerous causes, 
including diabetes, alcoholism, infant mortality and suicide. For 
example, the national infant mortality rate is about 6.9 per 1,000 live 
births, and it is over 14 per 1,000 live births in the Aberdeen Area of 
the Indian Health Service--more than double the national rate. The life 
expectancy for our Area is 66.8 years--more than 10 years less than the 
national life expectancy, and the lowest in the Indian Health Service 
population. Leading causes of death in our Area include heart disease, 
cancer, unintentional injuries, diabetes and liver disease. While the 
numbers are heart-breaking to us, as Tribal leaders, these causes of 
death are preventable in most cases. They, therefore, represent an 
opportunity to intervene and to improve the health of our people. 
Additional challenges we face, and which add to our health disparities, 
include high rates of poverty, lower levels of educational attainment, 
and high rates of unemployment. All of these social factors are 
embedded within a health care system that is severely underfunded. As 
you have heard before, per capita expenditures for health care under 
the Indian Health Service is significantly lower than other federally 
funded systems, including the health care provided to Federal 
Specifics on Suicide
    Unfortunately, youth suicide has had a severe and devastating 
impact on the Great Plains tribes. The national death rate from suicide 
is approximately 10 per 100,000 population, and it is 17 per 100,000 in 
the IHS population. In the Aberdeen Area IHS, the suicide rate is over 
22 per 100,000 population-more than double the national rate. Adding to 
these disheartening numbers is the fact that suicide is more common 
among American Indian and Alaska Native youth, whereas suicide rates 
tend to increase with advancing age among the general population. 
According to the Centers for Disease Control and Prevention (CDC), from 
1999-2005, among youth age 10-19 years nationally, the suicide death 
rate was 4.5 per 100,000 population.
    In South Dakota, where I am from, among American Indians during the 
same timeframe, the suicide rate was over 38 per 100,000 population--
more than eight times the national rate. The result is that not only do 
we have a higher percentage of people committing suicide, we have a 
higher percentage of young people killing themselves--resulting in an 
even greater number of years of potential life lost in our populations. 
In addition, the Great Plains region suffers from extreme disparities 
in health, educational opportunities, and poverty, and suicide among 
our young people is limiting the potential of future generations to 
overcome these challenges.
    Our young people live in great despair--witnessing the extreme 
emotional and social impact of high rates of infant deaths, living with 
poverty and often within abusive households, and watching other young 
people taking their own lives. The result is that we tend to see 
clusters of youth suicides in many of our communities, including my 
home in Rosebud, SD.
    Over the past several years, the lack of resources, funding and 
staffing has taken its toll on our Tribal communities. It takes a 
community to raise a healthy child, and when you have school systems 
that needs strengthening due to lack of funds, a law enforcement 
department that is not operating at full capacity, a health care system 
that is inadequate, lacking proper funding and adequate staffing (such 
as no mental health care) combined with poverty, substance abuse, lack 
of jobs and quality of life, our People suffer. And, our Children 
suffer most of all.
    The following are words directly from a teenager whose 14 year old 
sister committed suicide last November in North Dakota:

        Jami was in a sitting position against the wall on her bed with 
        a belt around her neck. The belt was tied to the bars of the 
        top of her bunk bed which was leaning against the wall. I ran 
        into the living room and told my boyfriend what Jami had done, 
        then I ran back into Jami's room and he followed. I tried to 
        take the belt off of her neck but it was too tight. Then my 
        boyfriend cut her down. After that, I called my Mom and Dad. I 
        sat there holding her till they came. I was crying 
        uncontrollably talking to her asking her, ``Why?''

        I couldn't comprehend what had just happened. Then I heard my 
        Mom and Dad come running in. My Dad started to do CPR on her, 
        and my Mom was on the phone calling the Police Department to 
        get the ambulance here. Then not even five minutes later they 
        were here. The paramedic worked on her with no response, they 
        did get a slight pulse at one time, and then they rushed her to 
        the hospital.

        She was already gone by the time they got there. The doctor at 
        the hospital said if she would've survived she would have been 
        brain dead.

        The experience of losing my sister, best friend, someone I 
        confided in, is very painful and hard to accept. I feel lost, 
        lonesome, alone, and sometimes angry because I don't know why 
        she did this while I was just in the other room. We always told 
        each other ``everything''. She didn't tell me how she felt. I 
        know she thought that I had enough of my own problems and 
        didn't want to burden me with hers, but she still could have 
        told me.

        It's been a few months now and I still feel lost, lonesome, and 
        alone, but what I have learned from this is; don't keep things 
        to yourself, talk to someone because there is always someone 
        there for you who is willing to listen and help you.

    Over the last several years in the Rosebud Sioux Tribe alone, we 
have witnessed dozens of suicides and hundreds of documented suicide 
attempts. The situation became so bad that in 2007 our Tribal President 
declared a State of Emergency in order to draw attention and resources 
to the problem. This year, 2009, there has already been 1 suicide and 
more than a dozen attempts in less than 2 months.
Rosebud Model
    Chairman and Members of the Senate Indian Affairs Committee, to 
lose one of our Youth hurts our entire Community and Tribe. Our Tribal 
Leaders and community health advocates have worked tirelessly to find 
out what the roots of the problem are, and to see how we can improve 
our situations and prevent more suicides. Several projects have begun 
to address the problem of youth suicide. For example, on Rosebud we 
have started or expanded several programs, including:

   Wiconi Wakan Health and Healing Program

   ``Safe Schools Project'' in collaboration with Todd County 

   Suicide Task Force

   White Buffalo Calf Pipe Women's Program

   Alcohol and Drug Treatment Program

   RST Tribal Health Program (including Tribal Education and 
        CHR Program), with the support of IHS's ``point man'' for 
        Suicide Prevention/Intervention, Austin Keith (just arrived 
        last week) will be able to physically follow up on every 
        suicide completion and attempt, and begin tracking every 
        suicide attempt with a Rapid Response Team approach.

   Suicide Prevention Grant

   Suicide Summits and Meetings with community members and 

    The response and efforts conducted in the Rosebud Sioux Tribe have 
been remarkable, and we are hoping to have an impact on reducing 
suicide permanently in our community. Unfortunately, these efforts were 
not started in time to save many of our young people, and in the 
sixteen other tribal nations in our region, not enough is being done to 
focus on suicide prevention. In addition, we need a well-coordinated 
data, surveillance and response plan to meet the needs of all our 
communities. Regrettably, most of our communities do not have access to 
Area-wide and community-specific data that is managed by the IHS. In 
our region, most medical services and datasets are managed by the IHS 
at the federal level, and most of our public health programs are 
managed by the tribes. We need improved collaboration, cooperation and 
data sharing between the IHS and the tribes. According to Dr. Donald 
Warne, Executive Director of AATCHB, the Health Board has no reports or 
data sets with Area level data specific to suicide. As we attempt to 
improve our system of epidemiology related to suicide and mental 
health, this is precisely the problem. Although the IHS collects and 
maintains administrative and clinical data on patients seen in IHS 
clinics, these data are not readily accessible nor useful for the 
traditional public health functions of population monitoring, 
investigation, program planning, and evaluating the effectiveness, 
accessibility and quality of health services.
    For suicide, we need to develop a public health care infrastructure 
that is capable of supporting a ``Rapid Response'' approach and follow 
up to suicide events attempts/gestures and completions in all of our 
communities. This implies creating a data collection and monitoring 
system that allows ready access to actionable data at a moment's 
notice. Such a system cannot rely on passive surveillance alone (i.e., 
voluntary), which is currently the case. Therefore, I would first 
recommend that suicidal behavior be elevated to the status of a 
reportable event throughout the Aberdeen Area. That means mandated 
reporting of all suicidal behavior in a timely manner by all providers 
(including first responders). Secondly, surveillance should apply to 
all levels of jurisdictional access (community, Tribal, Area) on a 
need-to-know basis. Suicidal contagion gives no credence to reservation 
boundaries. An electronic, integrated, surveillance system could 
accomplish these objectives. Finally, an active suicide surveillance 
system could serve as the starting point for the development of a more 
extensible infrastructure that supports focused, targeted interventions 
and coordination of care through automated analysis of factors relevant 
to crisis management and suicide prevention/intervention (i.e. who 
intervenes, when they intervene, with whom, and others).
    IHS must change its health care paradigm to one of ``Disease 
Prevention and Health Promotion'' rather than just treating medical and 
behavioral problems after they begin. Our People need wellness 
education programs, exercise and healthy foods that are closely 
integrated with our traditional belief systems. Our Children need 
improved self-esteem and a stronger sense of hope for the future if 
they are to live in a healthy way. To achieve these goals, we need more 
resources to develop healthy communities. The health of the community 
often determines the health of the families and the health of the 
children. Suicide is preventable, but we need resources in order to 
continue our community healing efforts.
Sufficient Resources
    What would it take to give the Indian Health Service (IHS) 
sufficient resources to address our health care needs? The current 
appropriation for IHS clinical services is about $3.4 billion. Our 
estimated funding percentage based on documented level of need is 
approximately 50-60 percent of that need. In order to bring IHS up to a 
more appropriate level of funding, an additional $2 billion for 
clinical service would be needed nationally making our annual Federal 
appropriation closer to $5.4 billion. This would be a major increase, 
but a small one relative to the $700 billion budget for the Department 
of Health and Human Services (DHHS). A significant portion of these 
additional resources need to be directed toward behavioral health, 
suicide prevention and holistic care that meets the needs of our young 
people and our future generations.
    In closing, we do not want to lose any more of our Youth. We seek 
to take on directly the terrible disparities that make our population's 
health status comparable to a third world country. As the nation takes 
on the ideas of health care reform, as President Obama noted in his 
address before Congress on Tuesday evening, February 24, 2009, please 
ensure that American Indian and Alaska Native communities and leaders 
are included its development. Also, please ensure that national efforts 
at health promotion take into account the unique needs and health 
disparities of our nation's first inhabitants. Thank you, again, for 
this opportunity and your attention to these vital matters.

    The Chairman. Mr. Moore, thank you very much.
    I did not mention in the opening statement, because I 
truncated my remarks, that a lot of us have personal 
acquaintance with these issues. Mine was pretty profound, and 
had a huge impact on my career. I walked in the office of a 
friend and a boss in the State Capitol who had just been 
elected to a State-wide elected office. He had been a 38 year 
old Harvard-trained lawyer from a town of 80 people in North 
Dakota. That is some accomplishment, to leave a town of 80 
people and get a law degree from Harvard and be elected to a 
State-wide office. I walked in his office one day and found him 
dead. He had committed suicide.
    So I have, and all of us do, I suppose, in various ways 
very personal acquaintances with suicide. In this case, it was 
a very close friend that I found one morning in his office. I 
think it is a tragedy always, but magnified especially by young 
people who decide that things are hopeless and helpless and 
they must end their life at a very young age.
    What I would like to do is recess. The vote started 10 
minutes ago. We can vote and come back, and I would expect we 
will be back in 15 minutes and continue the hearing.
    Thank you very much. We are in recess.
    The Chairman. The hearing will come to order.
    Next, we are to hear from Dr. Dale Walker, M.D., Director 
of One Sky Center, the Oregon Health and Science University in 
Portland, Oregon.
    Dr. Walker, thank you for being with us.
    We apologize to all of you for the delay, but we must go 
vote when the rolls are called here in the Senate. We 
appreciate your indulgence.


    Dr. Walker. Senator, I am happy to hear that business goes 
on. That is always good to see.
    Indeed, it is an honor to be here with all of you and to 
hear the story, Dana, that you have shared with us. I think 
that makes us think especially about this problem, and I thank 
you for sharing.
    I want to first of all, identify the One Sky Center as a 
national resource center for American Indian alcohol, drug, and 
mental health. We provide an outreach to well over 100 
communities, tribes, Indian communities, urban programs, across 
the Country. That gives us incredible information and personal 
stories about what is happening in our communities.
    It is true that we have all personally had these 
experiences happen to our families and people in our community. 
But within an American Indian community, the loss of a life or 
the loss of a cluster of lives is a unique phenomena. In my 
view, it is defined very easily as a disaster for that 
community. If you have a small community of 3,000 in a 
reservation, if you have 8,000, and you have 17 lives that are 
lost, teenagers, early 20s, and how that impacts the community 
in the short term and the long term, carries with it a major 
burden of illness. That burden of illness is complicated by the 
multiple problems.
    Suicide is a chronic problem, a chronic illness, if you 
will, but it is additive. You know, all of the other things 
that we have heard about, the addictions problems, the housing 
problems, severe domestic violence, community violence, all of 
these things together create community moods and community 
problems. The feeling of hopelessness and helplessness that you 
mentioned within an individual is felt within the community.
    I still remember when I did my first evaluation at Standing 
Rock. One of the Elders said, we are tired of suffering. We can 
suffer and feel no more. We are numb to the losses. That is 
when I think of the phrase, disaster. That is when I think that 
we need to be really attentive to the problems when they happen 
at Rosebud and Wind River and Standing Rock and Alakanuk, and 
places that we all know well and we know the difficulties 
    The One Sky Center has worked in those areas providing 
technical assistance, consultation, and probably as important 
as anything we do, is gather information to put into tool kits 
and information packages that are unique and defined for the 
community. That is information they need to help recover from 
the problems that they have.
    Community mobilization is something that we will hear from 
SAMHSA and the Indian Health Service. I can only tell you that 
I think that is one of the critical elements of recovery within 
a community is for the community to open up, discuss and 
understand the difficulties, and begin to make decisions based 
upon who they are, the people they are, the culture they have. 
Those elements are critical.
    Now, the other piece that I don't want to understate is the 
need for good quality health care, medical services, mental 
health care and delivery within those communities. I have sat 
in front of this Committee and said before that not all of the 
Indian health need is performed and completed by the Indian 
Health Service.
    We don't expect that, but we expect the agencies across the 
Federal Government to gather together and garner resources in 
such a way that people can deal with these health care 
problems. We have 13 recommendations and they kind of fit in 
six areas. When we went through to think about this, we thought 
that the policy administration area was our most critical.
    We recommend that two particular items be addressed. I 
think that it would be useful that a standing committee or a 
task force be developed at the HHS level to help the 
collaboration, coordination and cooperation necessary across 
agencies to work with Indian people. Money comes at Indian 
communities in small silos. Each one has definitions and 
special purposes, but they don't work together. That actually 
divides the ability of the tribes to make decisions about their 
generalized health care because they have to address from 28 up 
to 37 grants for mental health care, each one with a project 
officer who hasn't been to their reservation.
    So we have the difficulty of trying to integrate those 
services, helping the tribal councils manage the health care 
needs of their communities. I think that is an area that we 
really need to think about how we can integrate those services 
    Another issue that can only be stated this year, and that 
is that we need to take a serious look at where health care 
reform is going nationally in this Country, and hook the stars 
of the Indian communities to that change. We need a blue ribbon 
task force and we need Indian involvement in health care reform 
in this Country. They need to be a part of that and a part of 
the reform that would happen.
    Now, I have gone through, and I have mentioned other pieces 
of information in regards to community competence, youth and 
family development, training and education, and clinical 
services, but I think if I can leave you with the point that we 
have a lot of work to do. We know a lot about the clinical care 
and services, but access to care, as someone mentioned here, is 
a critical point and a critical element for us to deal with.
    I hope that we can do the training and the education, the 
outreach and the community mobilization and make things happen. 
We need to continue the programs like Native Aspirations, like 
Project HOPE, and One Sky Center, so we can continue to do this 
work. We are working hard to maintain a permanent relationship 
with the health care field.
    I will stop now. I know we have so many things to say, but 
I always want to tell you that the One Sky Center is a resource 
center for the Indian communities, but it is also for you. I 
would welcome, and I thank your staff for the outreach and the 
wonderful work that you are doing.
    [The prepared statement of Dr. Walker follows:]

 Prepared Statement of R. Dale Walker, M.D., Director, One Sky Center, 
                  Oregon Health and Science University
    Mr. Chairman, Vice-Chairman, and members of the Committee, my name 
is R. Dale Walker, M.D.. I am the Director of the One Sky Center, the 
American Indian/Alaska Native (AI/AN) National Resource Center located 
at Oregon Health & Science University in Portland, Oregon. I am a 
Cherokee psychiatrist with over 30 years experience in the fields of 
substance abuse and mental health. I have worked with native people, 
veterans, health & medical professionals, and tribal communities. I am 
also a member and immediate past president of the Council of Advocacy 
and Public Policy for the American Psychiatric Association, in addition 
to being a long-time member of the Association of American Indian 
Physicians. Finally, I am a member of the Advisory Council of the 
National Institute of Drug Abuse (NIDA).
    I thank the Committee for inviting the One Sky Center to testify as 
an expert witness on suicide prevention in Indian Country and to 
comment on recent trends in youth suicide among American Indian and 
Alaska Natives.
    It was my great honor to testify in front of this Committee twice 
in the 109th Congress on Indian health and suicide prevention. I look 
forward to updating my earlier reports to you on the suicide prevention 
efforts of One Sky Center and some allied organizations. While suicide 
remains a devastating problem throughout much of Indian Country, many 
notable culturally appropriate initiatives are also underway.
Current Suicide Prevention Initiatives in the Pacific Northwest
    The One Sky Center is allied with other national, regional, and 
local entities working on suicide prevention in Indian Country. 
Following is an update on One Sky Center and some of the regional 
entities not appearing at this Senate Hearing.
One Sky Center
    In May 2006, the One Sky Center testified on teen suicide 
prevention. As the first National Resource Center for American Indians 
and Alaska Natives dedicated to improving substance abuse and mental 
health services in Indian Country, the One Sky Center has provided 
training, technical assistance, and lent expertise on suicide 
prevention affecting American Indian and Alaska Native people and 
tribal communities.
    The One Sky Center has produced various culturally relevant 
resources for tribal communities. (See attachment). One Sky Center 
products, available online via our website, include: Motivational 
Interviewing Enhancement Curriculum for Tribal Youth with training 
guidebooks, culturally appropriate Service Learning Curriculum, a first 
of its kind A Guide to Suicide Prevention for American Indian/Alaska 
Native Communities with a community assessment tool for American Indian 
and Alaska Native youth, a Best Practices in Behavioral Health Services 
for American Indians and Alaska Natives monograph, and a Describing 
Culture-Based Interventions for Suicide, Violence, and Substance Abuse 
    In addition, the One Sky Center has been involved in two national 
initiatives, the ``Native Aspirations Project'' (NA) of Kauffman 
Associates, Inc., and the ``Indian Country Methamphetamine Initiative'' 
(ICMI) of the Association of American Indian Physicians. In these 
efforts to reduce suicide and closely related problems, the One Sky 
Center provides clinical, programmatic, and research expertise and 
assistance in the form of consultation, education, training, and 
production of guidebooks, all in a manner appropriate to the need in 
Indian Country.
    Tribes and tribal organizations with scarce financial resources 
look to the One Sky Center to learn from medical and scientific 
disciplines and from what is working in other tribal communities. It 
has been One Sky's honor to be able to assist.
    Many lists of ``Best Practices'', including suicide prevention 
programs, have been published. However, the form and success of best 
practices depends heavily on tailoring for cultural and local context. 
With financial assistance from Substance Abuse and Mental Health 
Service Administration's (SAMHSA) Center for Mental Health Services 
(CMHS), the One Sky Center reviewed evidence-based suicide prevention 
programs developed by, actually adapted to, or potentially useful in 
Indian Country, and produced a Suicide Prevention Guide to help 
disseminate this information throughout Indian Country. This document 
has passed through several phases of review and its approval by SAMHSA 
for dissemination is eagerly awaited by Indian Country.
    Similarly, the One Sky Center assisted Indian Country experts to 
develop and disseminate culturally specific interventions for suicide 
and to train others in their application. These include Native Helping 
Our People Endure (HOPE); Project Venture; and a Tulalip tribal 
adaptation for children of the Canoe Journey/Life Skills program.
    The One Sky Center has served as a source of expertise and advocacy 
in suicide prevention in Indian Country for government, public, and 
private entities. This activity spans awareness raising, coalition 
building, motivation enhancement, resource development (such as 
inventories of best practice), broad dissemination, training, and 
technical assistance.
Northwest Portland Area Indian Health Board
    To address American Indian suicide in Oregon, Washington, and 
Idaho, the Northwest Tribes, led by the Northwest Portland Area Indian 
Health Board (NPAIHB), located in Portland, Oregon, initiated an inter-
tribal action plan in January 2008 to guide program planning and 
catalyze effort. A resolution supporting the NW Tribal Suicide Action 
Plan was unanimously passed by the 43 members of the NPAIHB in January 
2009. Coordinated and concerted effort is extremely important 
particularly to suicide prevention because of the systemic nature of 
the causes of suicide in Indian Country. For more information, visit 
National Indian Child Welfare Association
    Suicide occurs most frequently among adolescents and young adults 
with the seeds of the problem sown during childhood. Children are the 
principal and strategically important target population for suicide 
prevention. The National Indian Child Welfare Association (NICWA), 
located in Portland, Oregon, provides technical assistance and training 
to tribes, state and federal agencies serving children, removes 
barriers to accessing services, increases awareness of the risk factors 
that contribute to youth suicide in this population, and develops 
policy and strategies for increasing children's services and funding 
for tribes.
    NICWA provided technical assistance to 49 SAMHSA-funded tribal 
communities under the tribal Systems of Care and Circles of Care since 
1999. NICWA assisted two tribes in accessing Garrett Lee Smith Grants 
in 2008. NICWA has also secured funding from the American Legion Child 
Welfare Foundation, Inc. to develop and disseminate the Ensuring the 
Seventh Generation: Youth Suicide Prevention Toolkit for child welfare 
and mental health programs. The toolkit educates tribal child welfare 
workers on the warning signs of suicide, risk and protective factors, 
suicide prevention and intervention methods, and when such workers 
should seek professional mental health services.
    Policy development activities include work on the reauthorization 
of the SAMHSA programming to address funding and programming in 
children's mental health for AI/AN youth, establishing a specific 
authorization for the tribal System of Care and Circle of Care grant 
programs, creating direct access for tribes under the Mental Health 
Block Grant and supporting the expansion of IHS funding under the 
Indian Health Care Improvement Act reauthorization to allow tribes to 
utilize System of Care concepts (i.e. child centered services, 
promoting systems collaboration and culturally competent) in IHS 
programs for youth. For more information, visit www.nicwa.org.
Native American Rehabilitation Association, Northwest, Incorporated
    The Native Youth Suicide Prevention project, a three year grant 
award funded by SAMHSA for the second time, is a partnership between 
Portland, Oregon-based Native American Rehabilitation Association 
(NARA) of the Northwest, the nine federally recognized Tribes of 
Oregon, and Portland State University. The project increased community 
awareness through a media campaign with a focus on risk and protective 
factor education, provided evidenced-based gatekeeper trainings at 
Tribal and community locations, conducted culturally based prevention 
and wellness activities, developed community specific resource cards to 
strengthen the referral process, formed a Native American Elders 
Council for direction and wisdom, provided technical assistance 
including conference planning, identifying resources, coordination of 
stakeholder meetings, and evaluated effectiveness and progress of the 
Portland State University Native American Community and Student Center
    Universities and colleges are strategic points of intervention as 
students are at risk as well as being in training for careers that may 
include suicide prevention services. Healing Feathers is focused on 
American Indian/Alaska Native college students enrolled in Portland 
State University. The participants in Healing Feathers developed a 
brochure and power point presentation on warning signs of suicide, 
actions that individuals can take to provide support, and resources for 
referral and support. In the future the program seeks to establish a 
summer internship program working with the Native American communities 
in Oregon, both urban and rural to promote wellness and suicide 
prevention. The project uses community collaboration as a principal 
    Suicide is a devastating event for a family, a community, and a 
nation. Although the impact is powerful and widespread, suicide is a 
very individual event, often understandable only in retrospect, if 
ever. Expert professional intervention is critical for averting suicide 
by an individual who may be approaching such an act. A large increase 
in the number of such treatment ``slots'' and the expertise of 
interveners would avert significant numbers of suicides and reduce the 
devastating consequences for survivors.
    However, important societal, community, family, and personal 
circumstances do affect an individual's propensity to suicide, and are 
reflected in the unusually high rates of suicide in some Alaska Native 
communities. (These circumstances also adversely affect other ills 
including substance abuse, crime, and failure to thrive and prosper.) 
Such circumstances can be changed. More programs to improve youth 
development; remove pathological community factors; and foster 
community self-determination, vision, and hope for the future would 
significantly reduce suicide and, further, greatly improve the well-
being and productivity of an entire generation--the youth of today, the 
adults of tomorrow.
    Carefully assessing individual interventions and community programs 
will facilitate continuing improvement of those interventions. However, 
we should not look to break-through improvements in behavioral 
technology. We already know the technology of suicide prevention pretty 
well. We just need a lot more of it, and we need to educate and train 
more personnel to deliver those interventions.
    Our understanding and efforts are weak on some points. Although we 
have lists of best practices and strategic plan documents, the 
notorious silo problem, education and training shortcomings, and other 
factors have left us with a fractured approach to suicide prevention, 
full of working at cross-purposes, duplication, and unnecessary gaps. 
We need a systemic vision and inspiring leadership in order to bring 
together a concerted, coordinated effort. An emphasis in policy and 
investment on comprehensive vision, coordinated programming, and 
monitored and enforced collaboration from the highest levels to the 
front line would be helpful.
    Following are the One Sky Center's observations on the state of 
suicide prevention in Indian Country and some more specific 

        1. Policy and Administration

           Findings: American Indian and Alaska Native (AI/AN) health 
        needs are greater than the purview of the Indian Health Service 
        or any other single federal agency. Comprehensive vision, 
        inter-agency communication, coordination, and collaboration are 
        essential. This is well known and multi-agency strategic plans, 
        initiatives, agreements, etc., do exist. Interagency task 
        forces, committees, coordination offices, and cross-agency 
        staff placements have been employed to improve this situation.
           However, comprehensive policy, communication, coordination, 
        and collaboration are lacking. Fragmentation and dysfunction 
        include, specifically, management by crisis, unnecessary gaps 
        in service, duplications, working at cross-purposes, and inter-
        organizational competition. Of course, funding and staffing 
        (``capacity'') are vastly insufficient. At the front line, the 
        impact of administrative and policy fragmentation is felt 
        acutely and reflected in less than optimal services 

           Recommendation 1.1: We recommend creation of an effective 
        task force, office, or other at the HHS level to promote, 
        monitor, and enforce comprehensive policy, communication, 
        coordination, and collaboration on the federal response to AI/
        AN health needs.

           Recommendation 1.2: We also recommend that a ``blue ribbon'' 
        committee develop a comprehensive strategic plan for Indian 
        Health care within the emerging National Health Care Reform 

        2. Community Competence

           Findings: Research has demonstrated the ``community 
        competence'' (ability to master challenges and meet the needs 
        of community members) and ownership and control of local 
        institutions and assets have a very large, measurable impact on 
        suicide rates. These interventions are currently implemented on 
        a small, pilot basis only.

           Recommendation 2.1: We recommend extending and promoting 
        programs like Native Aspirations (Kauffman and Associates, 
        Inc.,) Nation-Building (Harvard University), and One Sky Center 
        to mobilize and improve the strength of community institutions 
        and leadership in identifying and mastering challenges within 
        the community.

        3. Youth and Family

           Findings: Suicide is a chronic illness. The illness often 
        begins in childhood and develops over years as a vulnerability, 
        propensity, ability, and, finally, a determination to suicide. 
        Providing opportunities to develop life skills, commitment to 
        community service, and involvement with nurturing and shaping 
        family relationships creates resiliency and capacity to meet 
        the crises and challenges that otherwise precipitate suicide.

           Recommendation 3.1: We recommend extending and promoting 
        youth development and family strengthening programs across 
        Indian Country.

        4. Clinical Services

           Findings: When screening, gate-keeping, school counselors, 
        social workers, law enforcement/judicial authorities identify 
        individuals with high suicide potential, they attempt to refer 
        the suicidal individual to someone able to intervene. In fact, 
        there is a massive lack of such individuals. Further, the 
        capacity of staff of multiple agencies to collaborate in the 
        care of such an individual is limited by lack of policy, 
        procedure, and infrastructure support.

           Recommendation 4.1: Increase the workforce of skilled 
        clinical staff capable of providing suicide intervention 
        services. This includes funding additional staff positions as 
        well as workforce management efforts such as recruitment, 
        retention, and infrastructure support.

           Recommendation 4.2: Promote policy, procedure and 
        infrastructure support at the community level for interagency 
        coordination and collaboration in delivering services to 

           Recommendation 4.3: Institute telehealth services to support 
        community front-line clinical staff with tertiary care 
        expertise in assessment and treatment planning for suicidal 

        5. Training and education of staff

           Findings: Physicians, where available, are not always 
        skilled in suicide risk assessment and intervention. Other 
        professional staff also lack these skills and knowledge. 
        Consequently, even those suicidal individuals who do gain 
        access to professional help may not receive an effective 

           Recommendation 5.1: Establish cultural relevance in 
        professional training curricula.

           Recommendation 5.2: Increase on-the-job continuing education 
        together with certification for AI/AN health care personnel.

           Recommendation 5.3: Institute telehealth training services 
        for on-the-job continuing education by professional colleges 
        and universities.

        6. Research

           Findings: We all feel a profound ignorance in the face of so 
        shocking an event as suicide. While there is a reasonably good 
        understanding of the epidemiology and etiology of suicide and 
        we have a large body of research on preventive and treatment 
        interventions, a great deal of work is still needed. We lack a 
        good understanding of Culture-Based Interventions, a very 
        challenging area of research. We also lack universal, 
        systematic and continuous evaluation of suicide prevention and 
        treatment interventions (and, therefore, the ability to 
        continuously improve those interventions on the basis of such 

           Recommendation 6.1: We recommend innovative research on 
        Culture-Based Interventions with mandates and financial support 
        capable of progress on this challenging area of research.

           Recommendation 6.2: We recommend a strong policy commitment 
        to ongoing evaluation of all prevention and treatment services, 
        together with utilization of that evaluation in program 
        improvement. This recommendation is not new: for example, it is 
        found in many accreditation programs.

           Recommendation 6.3: We recommend that the practice of 
        program evaluation and continuous program improvement be widely 
        taught in professional schools and in continuing-education 

    We commend Senators Dorgan, Barasso, and the Senate Committee on 
Indian Affairs for holding this hearing, requesting comment on this 
most important issue, and especially to the Oregon Delegation for their 
support on these issues, namely former U.S. Senator Gordon Smith (R-
    We would also like to recognize former U.S. Senate Majority Leader 
Tom Daschle (D-SD) who consistently fought to improve Indian health, 
and along with Senator Smith, crafted the tribal provisions for the 
Garrett Lee Smith Memorial Act that is now the authorizing statute for 
suicide prevention monies through the Substance Abuse and Mental Health 
Services Administration.
    I had the good fortune recently to visit briefly with Senator Smith 
here in Washington when he was honored by the American Psychiatric 
Association and have been in contact with him since then. I informed 
him of this opportunity to testify today and although he let me know he 
wished he could be here, he passed on these words for me to share with 
you on this most important issue to both him and all of us here today:

        ``The numbers of suicides among our Native American brothers 
        and sisters, especially among the young, is a national tragedy, 
        and ought to be a concern to all Americans. The Garrett Lee 
        Smith Memorial Act is a vital tool in helping tribal 
        governments to assure that, in the future, there are no more 
        fallen feathers. The reauthorization and funding for Garrett 
        Lee Smith Memorial Act couldn't be more urgent and important. 
        It's part of keeping faith and represents a matter as grave as 
        life and death.''

    The One Sky Center stands ready to assist the Committee on this 
issue, and we will hope to exist in our committed work.
    Thank you very much. This concludes the written part of my 

    The Chairman. Dr. Walker, thank you very much. Thanks for 
your work, Dr. Walker, and I appreciate your being here once 
again before our Committee.
    Next, we will hear from Mr. Hayes Lewis, Director of the 
Center for Lifelong Education at the Institute of American 
Indian Arts in Santa Fe, New Mexico.
    Mr. Lewis, you may proceed.


    Mr. Lewis. Thank you, Mr. Chairman and members of the 
Committee. It is a pleasure to be here.
    My name is Hayes Lewis. I am the Director for the Center 
for Lifelong Education and from Zuni Pueblo.
    I would like to talk today about my experiences as a school 
superintendent in the State of New Mexico at the Zuni Pueblo 
School District and what we did to overcome the youth suicides 
in our tribal community, but also talk about the responsibility 
that all community leaders have, as well as tribal colleges, in 
assisting tribes to build the capacity and strengthen the 
capacity to deal with these kinds of public health issues in 
their communities.
    As a school superintendent, and one of the reasons why we 
created our own school district, was because of many 
dysfunctional conditions and the lack of educational 
opportunity that was evident as part of the Gallup-McKinley 
County School District. So we broke off and in 1980 created our 
own system. One of the first things that we addressed was a 
long-term condition of youth suicides in our tribal community.
    For a while there, we were averaging about two a year, and 
it was an emotional roller coaster, particularly when you have 
a tribal community where nearly everybody is related by blood 
or by clan or by society in some way. So dealing with that, we 
called in some assistance from the Indian Health Service, 
particularly from Stanford University. Teresa LaFromboise is 
one of the key people that helped us.
    By putting a focus on youth suicide and by our tribal 
council and all the tribal organizations, including the 
schools, making the commitment to enhance life and to take the 
responsibility of saying this is our problem, you know. We can 
have all of the experts come into our tribal communities, but 
unless we decide and we own the problem, then nothing happens.
    And so we went through the process of mobilizing our 
community and developed the school-based program, culturally 
based because one of our chief referrals was to tribal 
traditional healers. While that is a family responsibility, we 
did everything we could to make that a flexible option for 
them. But more importantly, the school and the school boards 
really decided that this is a priority. These are the kinds of 
systems that we are going to put in place, protocols. So our 
youth suicides ended for quite a number of years.
    But just as Zuni has, as have other tribes, slipped back 
into seeing more youth suicides in the community again, I think 
this just points to the fact that it is a very fragile 
situation and one that always have to be reinforced in a number 
of ways by tribal leaders.
    So we look forward to the day when tribal leaders, school 
leaders, can stand up and say we are going to create safe 
schools. We are going to create safe communities so that all 
children and people and members will benefit from this. And so 
it does take that kind of a commitment.
    In terms of tribal colleges, the Center for Lifelong 
Education does not receive any monies from, with the exception 
of a small $5,000 grant from the State of New Mexico Youth 
Suicide Prevention Coalition. But we work in concert and 
collaboration with the New Mexico Youth Suicide Prevention 
Coalition to provide free technical assistance, workshops. We 
use people that have extensive experience in the communities, 
to start spreading the story, spreading the news about youth 
suicide is preventable. There are certainly resources that are 
available nationally and statewide, as well as within our 
tribal communities, that can bring to bear their talents and 
expertise to deal with this crisis.
    So our focus is really in strengthening tribes, 
strengthening communities to create the capacity to deal with 
these kinds of issues and concerns from the internal, and 
strengthening those resources that they know they have within 
the community and building relationships so that they can use 
others as well.
    The recommendations I have listed for you are very 
important in my mind, but at the same time, in listening and 
thinking about what is going on in New Mexico now, we really 
need to look at developing programs at the graduate level as 
part of the education for teachers and administrators that need 
to really develop and enhance their cultural competency about 
particularly Indian situations. But more than that, that they 
are there for service to all of the children and that schools 
become safe, just as communities become safe.
    So I will end my presentation at that. You have my 
testimony. I really appreciate the time and the commitment all 
of you have made to ending youth suicide in Indian Country.
    Thank you.
    [The prepared statement of Mr. Lewis follows:]

  Prepared Statement of Hayes A. Lewis, Director, Center for Lifelong 
              Education, Institute of American Indian Arts

    The Chairman. Mr. Lewis, thank you very much.
    And finally, we will hear from Dr. Teresa LaFromboise, 
Associate Professor, Stanford University School of Education.

                      STANFORD UNIVERSITY

    Ms. LaFromboise. Good morning. Thank you for the 
opportunity, Chairman Dorgan and members of the Committee, for 
me to be able to present a little of my experience in working 
in the area of Indian youth suicide. I am a Professor of 
Counseling Psychology, the mother of an enrolled member of the 
Turtle Mountain Ojibway Tribe, the developer and evaluator of 
the Indian life skills curriculum that Mr. Lewis talked about.
    I research in the area of ethnic identity and mental 
health, and I was a former elementary and secondary teacher in 
urban and reservation schools. So I am glad that there are some 
educators at the table, too.
    I believe I was asked to talk some about the progress that 
I have seen made since the hearings that were held by this 
Committee in the past to document the extent of the problem of 
Indian youth suicide. I thought that maybe I would be additive 
in that way.
    As a result of some of the funds that have been 
appropriated through the Garret Lee Smith Memorial Act, I was 
able to work directly with a few of the SAMHSA programs for 
Indian youth suicide: one with Native Aspirations in which we 
developed regional training programs. In one year, we trained 
groups of three from 30 reservations in Wolf Point, Montana; 
Rosebud, South Dakota; Pine Ridge, South Dakota; and Anchorage, 
    I also worked with the Indian Country Child Trauma Center 
at Oklahoma University, where they helped support the 
development of a middle school version of the American Indian 
Life Skills curriculum, which we field tested on the Omaha 
    And then finally, the third SAMHSA project I was able to 
work with was with the Puyallup Tribe with their Helping Hands 
Project, where we worked with the mental health technicians 
from the tribal health authority, and six grade teachers from 
Chief Leschi School, to facilitate the field testing of the 
middle school version of American Indian Life Skills.
    So all in all, of these wonderful experiences, I have met 
an incredible number of native people who are wonderful 
interventionists. I certainly have witnessed the power of 
traditional healing when it is used in conjunction with 
effective psychological practices. Traditional healing effects 
its own power, but it certainly helps accentuate what 
psychological services can be done.
    I have also encountered a lot of frustration on the part of 
tribal leaders at the slowness with which we have been able to 
get these programs out. There are a number of programs that are 
highlighted in the special report of the Institute of Medicine 
and other evaluations of Indian-specific programs for suicide 
prevention. Dr. Walker's approach is one. The Zuni Life Skills 
Program is another. And there is a wonderful program entitled 
The Western Athabaskan Natural Helpers Program where we have 
direct evidence of the effectiveness of those programs in 
reducing hopelessness and reducing suicidal ideation, and also 
strengthening the skills of youth to help their friends talk 
about their problems and get them to help. Getting them to 
someone for help is the main thing.
    But I have also really come to appreciate the fact that 
many of these programs privilege traditional ways of knowing. 
They encourage youth to be involved in their cultural 
practices. They involve tribal leaders and resilient elders in 
those practices. And that relationship shouldn't be overlooked 
because we do have research that talks about the impact of 
being embedded in one's culture, being embedded, and how that 
is very positively associated with protective factors, such as 
academic success, and negatively associated with depression. So 
in other words, it really helps overcome depression.
    Now, what I would like to add to this conversation, 
perhaps, is the fact that I have just finished working on a 
committee at the National Academy of Sciences. As you probably 
know, a report has just been shared, and there will be public 
dissemination of it very soon, entitled Preventing Mental, 
Emotional and Behavioral Disorders Among Young People.
    This report emphasizes a number of evidence-based programs 
for families, school and community interventions. We know that 
a number of the risk factors for suicide are risk factors 
common for other kinds of problems such as substance abuse, 
unsafe sex, even eating disorders. This report highlights a 
number of those.
    Unfortunately, most of the studies outlined in the report 
have been conducted in mainstream populations and mainstream 
society. Some of those interventions have been evaluated in 
primarily African American and Latino/Latina populations, but 
very few with Native Americans. There is only one with Native 
Americans that I know of.
    What I am suggesting as a recommendation, when we talk 
about advancing funding, is that there be evaluations of the 
effectiveness of these interventions in Indian communities. If 
they are found not to be generalizable, if they are not generic 
enough to be appropriate within Indian communities, then do not 
require communities receiving Federal funding to have to use 
    I am suggesting that technical assistance centers, like the 
Institute for American Indian Arts, Center for Life Long 
Learning, or the One Sky Center, or even a new one, and the 
work that has been done at Native Aspirations, could provide 
opportunities for native researchers and clinicians to work 
with noted prevention researchers around adapting these 
evidence-based interventions so that they will be culturally 
sensitive and so that they will be more widely accepted among 
communities. I think that tribes do not want the transposition 
of one intervention that works supposedly for all onto their 
    So that is my major suggestion, that among all these things 
that we have to do, that we do pay some attention to the 
relevance of evidence-based interventions for the Native 
American communities that need to be served.
    Thank you.
    [The prepared statement of Ms. LaFromboise follows:]

Prepared Statement of Teresa D. LaFromboise, Ph.D., Associate Professor 
of Counseling Psychology and Chair of Native American Studies, Stanford 
    Good morning, Honorable Chairman Dorgan and Vice-Chairman Barrasso 
and Honorable Members of the Committee. Thank you for your invitation 
to personally testify before this Committee and to present my views 
concerning progress made in the area of preventing American Indian and 
Alaska Native (AI/AN) youth suicidal behavior.
    I come before you as a professor of Counseling Psychology, a mother 
of an enrolled member of the Turtle Mountain Band of Chippewa, the 
developer and evaluator of a suicide prevention program entitled the 
American Indian Life Skills, a researcher of ethnic identity and mental 
health, and a former elementary and secondary teacher in urban and 
reservation schools. I hope that my testimony will assist the Committee 
in taking stock of the potential for evidence-based school and 
community interventions to prevent AI/AN youth suicide and promote 
positive AI/AN mental health.
    In the 21st Century, suicide continues to be a vivid manifestation 
of distress among Native people. Untimely death accounts for almost one 
in five deaths among AI/AN youth 15-19 years of age. This proportion is 
considerably higher than that of youth from other ethnic groups or the 
general population (Centers for Disease Control, 2006). Completed 
suicide is 72 percent more common among AI/AN people than the general 
population (Indian Health Service, 2001). The estimated rate of 
completed suicides among AI/AN youth ages 5-14 years is 2.1 per 
100,000, compared to 0.8 per 100,000 for all U.S. youth in the same age 
group; the rate of completed suicides among AI/AN youth ages 15-24 
years is 37.4 per 100,000, compared to 11.4 per 100,000 for all U.S. 
youth in the same age group (Indian Health Service, 2002).
    In recent years federal efforts such as the Surgeon General's Call 
to Action and the National Strategy for Suicide Prevention (U.S. 
Department of Health and Human Services, 1999, 2001) have reflected 
growing concern over youth suicide within the U.S. Hearings on Indian 
youth suicide sponsored by this Committee have provided a forum for 
citizens to advocate for greater attention and services for those AI/AN 
youth who elect not to seek help for suicidal ideation due to stigma or 
embarrassment, who seem to lack regard for the deadly consequences of 
their behavior, and whose suicidal intent goes unrecognized, 
unappreciated, and untreated.
    Funds appropriated by the Garrett Lee Smith Memorial Act have 
served as a catalyst for the mobilization of suicide prevention 
programs in many AI/AN communities at highest risk for suicide. I have 
been fortunate to work with three SAMHSA funded programs for AI/AN 
youth suicide prevention . I designed a Training of Trainers program 
with staff from Native Aspirations (JoAnn Kauffman, PI) to train 
community members from 30 reservations in regional training in Wolf 
Point, MT, Rosebud, SD, Pine Ridge, SD, and Anchorage, AK. I was also 
supported by the Indian Country Child Trauma Center (Dee BigFoot, PI) 
to develop and field test a middle school version of the American 
Indian Life Skills on the Omaha reservation. As a consultant to the 
Helping Hands Project of the Puyallup tribe (Danelle Reed Inderbitzen, 
PI), I worked with mental health workers from the tribal health 
authority who worked in tandem with 6th grade teachers at their tribal 
school to field test the middle school version of AILS. Through these 
experiences I worked with some incredible AI/AN interventionists and 
witnessed directly the power of traditional healing in conjunction with 
effective conventional psychological practices. However, I also 
observed the frustration of tribal leaders at the slowness with which 
these programs have reached AI/AN communities.
    As a psychologist, I realize that the psychological risk for 
suicidality includes co-morbidity with psychiatric and substance use 
disorders. However, as a counseling psychologist who studies learning 
and adaptation, I believe that decisions related to suicidal behavior 
among the majority of AI/AN youth may be attributed to direct learning 
or modeling influences (e.g., family, peer, extended family suicide 
attempts/deaths by suicide) in conjunction with certain contextual 
sources (e.g., perceived discrimination, historical trauma, 
acculturation stress) and individual characteristics (e.g., depression, 
PTSD). I also believe that many risk factors for suicide are similar to 
risk factors for other problematic behaviors such as alcohol and drug 
abuse or engaging in unsafe sex. When cast from this more social 
cognitive perspective, suicide and other forms of risk behavior are 
more likely to be preventable.
Suicide Prevention and Treatment for AI/AN Youth
    ``The goal of most prevention programs is to assist an individual 
in fulfilling their normative and developmentally appropriate potential 
including a positive sense of self-esteem, mastery, well-being, and 
social inclusion and to strengthen their ability to cope with 
adversity'' (National Research Council and Institute of Medicine, 2009, 
p. 74). Five programs, targeting AI/AN youth suicide, have been 
featured in noted reviews of suicide prevention (National Academy of 
Sciences, 2002; Goldston, Molock, Whitbeck, Murakami, Zayas, & Hall, 
2008). These include: The Zuni Life Skills Development Curriculum 
(LaFromboise & Howard-Pitney, 1994), the Wind River Behavioral Program 
(Tower, 1989), the Tohono O'odham Psychology Service (Kahn, Lejero, 
Antone, Francisco, & Manuel, 1988), the Western Athabaskan Natural 
Helpers Program (May, Serna, Hurt, & DeBruyn, 2005), and the Indian 
Suicide Prevention Center (Shore, Bopp, Waller, & Dawes, 1972). These 
prevention programs incorporate positive messages regarding cultural 
heritage that increase self-esteem and sense of mastery among AI/AN 
adolescents and focus on protective factors in a culturally appropriate 
context. They provide strong grounding for adolescent pro-social 
behaviors through close ties with extended family involvement and 
resilient elders. They also integrate tribal leaders in the prevention 
effort and encourage youth to use traditional ways of seeking social 
support (May, et al., 2005).
    These programs privilege AI/AN ways of knowing, behavioral 
expectations, attitudes and values and encourage youth to be embedded 
in cultural practices. For the most part, suicide prevention programs 
that incorporate cultural teachings and traditions into the 
psychological intervention have been well-received by AI/AN communities 
and some are found to have promising outcomes. Research has shown that 
enculturation is positively related to protective factors such as 
academic success and pro-social behaviors (Whitbeck, Hoyt, Stubben, & 
LaFromboise, 2001) and negatively related to depression (LaFromboise, 
Albright, & Harris, forthcoming). One of the complexities in 
implementing these interventions across tribal groups is the extent of 
major cultural differences between more than 560 different tribes. 
However, researchers who struggle with the problem of lack of 
generalizability of prevention programs are exploring efforts to 
identify common elements among tribes with closely related traditions 
that could be incorporated into prevention programs on a wide scale 
basis (See Mohatt et al., 2004; Allen et al., 2006).
Prevention Intervention in AI/AN Communities
    Within mainstream society and a few select cultural groups there 
has been considerable evidence for the positive effects of family, 
school, and community prevention interventions to increase the 
resilience of youth and reduce their risk for mental, emotional, and 
behavioral disorders. A recent report just released by the National 
Academy of Sciences (2009), entitled Preventing Mental, Emotional and 
Behavioral Disorders among Young People, highlights interventions 
designed to prevent many of the common correlates of suicidal ideation 
(e.g., depression, substance abuse, interpersonal conflict, constricted 
thinking). The recommended interventions also focus on strengthening 
families, improving social relationships, and reducing aggressive 
behavior and school-based violence. I believe that some of the 
prevention programs featured in this report could provide a mechanism 
for advancing suicide prevention efforts in Indian Country.
    I cannot give this testimony without also advocating for the 
expansion of social emotional learning in AI/AN schools. I realize that 
schools are often overloaded with other academic-related priorities. 
However, social emotional development programs in schools have been 
found to have a positive impact on academic outcomes, especially among 
elementary school-age children. Research by Durlak and colleagues 
(2007) indicated that the effects of social and emotional learning 
programs were equivalent to a 10 percent point gain in test 
performance. Students who also participated in this intervention 
research demonstrated improvements in school engagement and grades.
    Unfortunately, few of the interventions showcased in the National 
Academy report have been implemented in Indian Country. Evidence has 
been found for long-term results of a few of the interventions with 
African American and Latino-Latina youth. No doubt that given the 
unique historical context of AI/AN communities, there is resistance to 
the mere transposing of evidence based interventions onto prevention 
programs with AI/AN youth. It is essential for AI/AN researchers to 
assess whether the relevant recommended prevention interventions 
featured in this report are generic enough to be found effective with 
AI/AN youth. Furthermore, AI/AN researchers should work to culturally 
adapt evidence based interventions while maintaining the critical core 
content and dosage of the intervention.
    1. Allocate federal funds for a technical assistance center to 
provide training in the implementation and evaluation of evidence based 
prevention interventions in Indian Country. This center could assist in 
improving the cultural competence of service providers in terms of 
knowledge of the relevant risk and protective factors for suicide among 
AI/AN youth. This center would encourage the expansion of AI/AN 
community-based research collaborations.

    2. Expand social emotional development activities in AI/AN schools 
throughout the course of Kindergarten through 12th grade.

    3. Increase the number of AI/ANs in the fields of psychology, 
social work, public health, medicine, and education to further 
advancement of prevention efforts in Indian country.

    References will be provided upon request.

    The Chairman. Thank you very much.
    I am going to call on my colleagues. I will ask questions 
at the end. I did want to mention that Dana Lee Jetty is 
accompanied by her parents, who are in the room: James Dean 
Jetty, right there, Mr. Jetty, thank you; and Cora Whiteman 
Tiger. Thank you for being with us, both of you. We appreciate 
your being here.
    Senator Murkowski?

                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. And thank you 
for convening this hearing.
    To those of you who have given testimony this morning, 
thank you very much. Ms. Jetty, thank you. Your testimony is 
very heartfelt and so very important to be able to be an 
advocate in an area that is, as the Chairman has mentioned, 
very personally challenging, and the emotional side that you 
bring to this issue is heard, and certainly very heartfelt.
    I appreciate what you have just given us, Ms. LaFromboise 
and Mr. Moore, in terms of the need to tailor the programs so 
that we do have the cultural sensitivities, if you will, that 
we have programs that are not kind of a one size fits all. If 
it works in Akron, Ohio, it is going to work in Alakanuk. Well, 
we know that is not the situation. What we need is the 
flexibility within the funding that comes available to us in 
our communities, whether it is villages in Alaska or out on the 
Rosebud Reservation, to craft that so that it works for the 
population that we are dealing with.
    We have been the recipient up in the Northwest Arctic 
Borough. Amenliak has been the recipient of a Garret Lee Smith 
grant that has allowed them to really tailor what they are 
doing to adopt a more holistic approach that really follows the 
Inupiak values. That is going to be important to the success of 
the efforts that we do up there.
    Mr. Walker, I have just a technical question for you on 
your recommendation for a standing committee. I want to ask the 
question because I was just in Juneau last week with Dr. 
Broderick. SAMHSA was awarding a grant to the community of 
Juneau. We heard from a gentleman who had lost his son to 
suicide, a 16 year old boy. This was some 10 years or so ago. 
In that community, at the time, the stigma on suicide and 
talking about it, similar to what the Majority Leader spoke to.
    They wouldn't talk about it in the schools, so there was no 
reach-out in the schools to the other students. The community 
was afraid to talk about it. It was this scar, that somehow or 
other our community was not as good as it was because of this 
unexpected, absolutely out of the blue suicide of an ``ordinary 
young teenage boy.''
    Do we still have that resistance in the schools to talk 
about it? I have had, coming out of my boy's elementary school, 
I have had parents that have suggested to me that we don't want 
to have our young kids exposed to these ideas or even knowing 
that suicide is out there, because then they might think about 
it. To me, I am one who is really focused on prevention.
    But how much of a stigma, how much difficulty do we have in 
getting out to not the kids in high school, but the kids in 
elementary school, this level of awareness and, you know, talk 
to one another so that you, Dana, would have known what your 
sister was going through. What is the attitude out there right 
now? Mr. Walker?
    Dr. Walker. You bring up a very important point, because 
there is the stigma connected to, if you will, the feeling of 
failure and somehow you have let your community down and you 
don't want to talk about it. But there is also, it comes so 
often, the numbing process that I mentioned, that you really 
want to make it go away. That is kind of a natural phenomena 
that happens inside all of us, in the pain and intensity. That 
is why I think it is a disaster, that people become so numb to 
the process they really don't want to respond.
    If I could give an example. I visited a community, a tribe, 
that had a suicide cluster. It was very difficult for me to 
even document how many people had died. The data, you know, 
aren't collected. I went to the coroner system. I went to the 
medical folks. I went to the State medical examiner trying to 
collect the data.
    I came to realize that people were, indeed, that 
encouragement not to reveal or not to open that up is 
systematic. I believe, too, that first of all, it doesn't allow 
us to understand the problem. It certainly doesn't allow a 
community to work through the grieving process when the 
information is not shared.
    Now, you ask a tough question. The question has to do with 
at what age do we somehow allow these things to happen. There 
might be families here who have different views about this, but 
I think that it needs to be open. Facts are facts in 
communities, and everybody knows when people pass away, and 
everybody deals with that in their own way. I can't help but 
think that we need to have an openness process to make that 
workable and work through.
    Having said that, what do you do when the people who are 
documenting the suicide are relatives of the person, so they 
are in authority to document, but they also are relatives. That 
puts them in a very, you have to be a clinician and you have to 
be a family member at the same time. That is very difficult. 
That is why the workload and the workforce in Indian Country 
needs to be thought through in a much more deliberate way. 
There are not enough people there, and there is not enough 
training. To be able to do what you are wanting to do would 
require, wouldn't it be nice if somebody at that school had the 
ability to work with family, but when they were involved with 
the family, that someone else could back them up. We have no 
policies like that anywhere in Indian Country.
    Senator Murkowski. You wanted to join in this?
    Ms. LaFromboise. Yes, I did, because I wanted to just 
mention from a prevention perspective, with the work that we 
have done with Zuni Life Skills, American Indian Life Skills, 
it is universal intervention in that all students go through 
this curriculum, rather than just at-risk youth.
    Senator Murkowski. And regardless of age?
    Ms. LaFromboise. Well, it has been developed for high 
school students. I wanted to answer this question about age as 
well. One of the points of it is that we know that youth talk 
to their friends, more likely than some of the adults, and we 
want them to be able to get their friends to help. We have 
found that, part of the goal is to reduce the stigma by 
allowing people to have someone that they can talk to about 
    Now, with the middle school students, people ask about age. 
We have gone into communities where people say, well, we don't 
really know how active students are in terms of suicide at the 
middle school level, but we want to find out. In one of the 
schools, and it is in some of the documentation that I have 
presented, the middle school students, 19.7 percent of them had 
already attempted. Of those, middle school students on a 
reservation in the Northern Plains, 10 percent had attempted 
more than once.
    When we do this, we actually have a series of questions 
that we ask, and make clear that we are not talking about just 
thinking about it, but have you done something physical to 
yourself to end your life. We ask, would you mind telling us 
what was going on at that time, with just some lines for open-
ended comments. And the students will tell us. They will write 
it on a sheet of paper.
    Now, what I have heard in focus groups in some of the 
communities, students will talk among themselves. In that 
particular study, 97 percent of students had not sought help 
because if they seek help, then that means that they might be 
moved to a psychiatric hospital hundreds of miles away because 
in-patient help isn't there as much as it needs to be locally. 
Or there might even be one bed assigned at the hospital and the 
charge nurse at that particular time doesn't want to deal with 
it and doesn't want the person admitted so they go to the jail 
instead of the hospital. So you know how that goes, just to 
    Senator Murkowski. Mr. Chairman, thank you very much.
    Thank you.
    The Chairman. Senator Udall?

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. Thank you very much, Mr. Chairman, and 
thanks for your leadership on this issue. I think you and your 
staff have pulled together a distinguished panel and some very, 
very moving testimony here today.
    I was impacted a lot by Senator Reid and his testimony 
earlier, where he talked about my cousin, Gordon Smith, and 
what happened with Gordon's family. I wish Senator Reid was 
here for me to just thank him for what he did for my family and 
thank him for the support when the family was really in crisis.
    Dana Lee, you have helped us by coming forward and talking 
about your sister. It is a horrible feeling and you conveyed to 
us what you have gone through and what the family has gone 
through. But by stepping forward, I think you educate all of us 
and allow us to focus on what the issue is and what we can do 
about it. So thank you very much for being here today.
    As I listen to this panel, I hear you talking about some 
very simple things in order to deal with this. I mean, one of 
them is just for a young person to be able to have somebody to 
talk to about their problems, about their feelings, what they 
are going through. Hayes, you mentioned just changing the way 
schools approach this in terms of protocols, taking 
institutions that are there and making those institutions 
reform themselves so that they deal specifically with the issue 
of youth suicide in Indian Country.
    So the question I want to ask, I guess to Teresa and Hayes 
to start with, but happy to have any of the others jump in is, 
how much of this is about resources and how much of this is 
about realigning the use of current resources? And I think 
Teresa you talked about the Garret Lee Smith funds and 
utilizing those funds. Is it about resources? Or is it about 
taking what is in place and making sure that the people that 
are either in schools or other institutions that, tribal 
leaders, tribal healers, that they are doing the kinds of 
things that you are talking about?
    Please, Hayes, go ahead.
    Mr. Lewis. Mr. Chair, Senator Udall, in many cases it is 
realigning resources that are present within the tribal 
communities, including the schools. A lot of our school 
organizations are not set up to respond to the variety of 
tribal community issues and really have not made schools a safe 
place for all children.
    By that, if you look at, and I was just in a school 
district last week. This is a high school. Kids are coming out 
of the classrooms, walking around. Other kids are coming out 
during class, walking around. Maybe they went to the rest room 
or something, or that is what they told the teacher, but they 
are harassing each other in the hallways, text-messaging each 
other negative notes and things like that. So there is a lot of 
that kind of bullying going on right under the noses of the 
school administration and the staff.
    That is not to say that they are not trying their best, but 
at the same time, I think school resources are sometimes 
stressed. But at the same time, you can look within a community 
and see what other tribal resources are available, so that you 
can start addressing prevention, strengthening children, 
providing those kinds of skills that will give them more than 
just one option.
    Just in a quick response to your question, Madam. In a 
tribal community many times we are told you can't talk about 
death because you are going to bring on more death. The dilemma 
we had was that if we don't talk about death and dying, how are 
we going to help the living? And so, it is a circular kind of a 
situation that you are involved in.
    So we decided we will talk about death and dying, but it is 
really a determinant of how you talk about death and dying, and 
how you are respectful to younger children. You talk about 
death and dying, or you talk about options like strengths, the 
cultural strengths that you have, the cultural taboos against 
taking your own life, because I think all of the tribes have 
that. You are not to take your own life for a number of 
reasons, and they vary from tribe to tribe. But at the same 
time, if you talk about the strengths of ancestors and the 
strength of character and values that we have, then you can 
lead into other areas of discussion about death and dying.
    But I believe on the resource issue, there still needs to 
be a lot of work in that area. In New Mexico, I know there is a 
specific account out of the Public Law 81-874 impact aid that 
25 percent of it is earmarked for the use for Indian children 
for cultural, emotional and academic strengthening of Indian 
children. That means programming of different kinds, and many 
of our school districts carry that amount across to the next 
year, without really investing in programs that will strengthen 
and create safe places for all children.
    Ms. LaFromboise. I would suggest that we need more 
resources. Part of the work that we have done, it seems to me, 
is just the tip of the iceberg in terms of what could be done 
in training people and working with communities to implement 
prevention work. You know, prevention is part of the mission 
statement, of IHS, but we know that there isn't much allocated 
for that activity, if at all. When we train people, we raise 
consciousness. People then try to go back into their 
communities to implement the intervention. They are sort of 
like the champions of this intervention, but there are no 
resources for it, or very little.
    In some of the training programs we have done, we have 
actually had people where, after a couple of days, I realized 
that almost everyone at the table doesn't have a job. Or we 
might serve lunch, and people literally leave and take what 
they have been given for lunch home and then come back to the 
training immediately. So I mean, there is such poverty and such 
pervasive hardship that there needs to be more resources in 
terms of mental health support and support of social-emotional 
development in schools.
    The other thing with the work in terms of restrictions, is 
the fear in terms of No Child Left Behind of having much in 
terms of social-emotional development or mental health 
programming in the schools because it might negatively impact 
test scores. We do now have research that says that there can 
be as much as a 10 point difference in terms of standardized 
test scores among students that have received this kind of 
work, this kind of training, and more involvement in school.
    So I think that it takes actually educating teachers for 
them to actually be willing to do some of this work in their 
classrooms. And it also takes, some technical assistance for 
those people who are para-professionals and community members 
who can do so much in terms of this kind of work.
    Mr. Moore. If I could also offer an answer. At Rosebud, the 
Administration for Native Americans out of HHS, and their 
immediate response to our rising and escalating suicide 
statistics there, provided resources for us to create some 
youth activities this last summer. We trained 150 kids, mostly 
young teenagers, young adults, in the community emergency 
response team, CERT, training that is offered by FEMA. It gave 
them some essential skills, emergency medical response, fire 
suppression, et cetera. It trains lay people to be the 
immediate first responders in the event of an incident, before 
the professional first responders get there. They had this 
shared collective experience.
    One of the young men who graduated from that program, that 
training, ended up protecting a car accident victim from going 
into shock until the first responders got there, by his 
training there. There were three young girls who were just a 
day away from completing their training and getting their 
certificate. They were spending the night together.
    One of the girls got up and left, and had been gone for 
some time. The other two girls went to look for her and they 
found her hanging in a closet. With the skills they had just 
learned, they revived her. They got her down in time and they 
revived her and resuscitated her. So now they have this energy 
to become doctors and nurses themselves, and want to respond to 
that in a very positive way.
    But the resource issue is that now we are without the money 
to keep this collective group of young people together in some 
way to have ongoing work with them, ongoing development with 
them. So the hot shot response provided a base for them, but we 
simply don't have the resources to keep the collective going, 
and for these kids to continue in activities together, which 
has been one of the strengths of that program during that 
    Dr. Walker. I would like to respond as well. We do need 
more sources, simply stated. I don't want to under-sell that 
issue, but I want to go back to why we are having this meeting 
today. The core question is, what has happened in the last two 
to three years. I think we need to take a serious look at what 
has happened at Standing Rock. It is one of the best examples.
    They received an emergency grant from SAMHSA. They received 
two or three other resources. What I would tell you in a 
document that I received from them is that they have more 
mental health services readily available across their 
reservation. The suicide rate has gone down. They have more 
people working within the school system and much more 
discussion consequently within the community about these 
    So a little bit of money made a difference. I think we 
would all want to say that this is a hopeless thing, because 
that feeds right in with the issue. We know that when resources 
get directed, even though they might be small, Native 
Aspirations does not put huge amounts of money into 
communities, but they help mobilize and work in the community. 
Those systems work.
    Indian Health is under-funded. I would say 40 percent 
under-funded. I have felt that way for the last 20 years. I 
think that we need to really deal with the issues.
    Now, a point of hope has to do with what can we do, if we 
go out and train these people. Remember the grants only last 
three years. I would like to see them increase to five years, 
number one. I would also like to see some kind of integration 
of grants into continued health care. That would be an 
important step.
    We can also take a look at tele-health, tele-medicine work 
to maintain training and certification of our counselors and 
health care providers across Indian Country. One of the 
problems we have is in isolated remote areas. Counselors get 
their training and certification, but they can't maintain it 
over time because they can't receive supervision in their 
immediate area.
    Now, what that means is they can't bill for Medicare and 
Medicaid services. So there are ways that we can actually take 
smaller steps in regards to how we educate and maintain the 
training of our people in the communities.
    The Chairman. Mr. Walker, the point you made that I think 
is important is we have full-scale health care rationing on 
Indian reservations. It ought to be headline news in newspapers 
because it is a scandal. Do you think if there were health care 
rationing among U.S. Senators it wouldn't be fixed in a minute? 
Health care rationing is something that is almost unbelievable 
and it goes on every single day with the most vulnerable 
population in this Country, and it is shameful.
    And you are right about the 40 percent. Forty percent of 
the health care needs of American Indians are unmet. Now, the 
President's budget was just released today. It asks $4 billion 
for the Indian Health Service. That is approximately $600 
million more than fiscal year 2008. That is a good sign, a very 
good sign. We need to meet our obligations. We ought to go read 
the treaties. We ought to go re-read the treaties, that the 
United States Government signed with Indians.
    I don't know if you used the term rationing, but it is a 
shameful thing that ought to be headline news across this 
    Now, I want to ask, and I had invited my colleagues to 
inquire first. We have also been joined by Senator Johanns. 
What I would like to do is ask a couple of questions. I will 
recognize the Senator from Nebraska if he has inquiries. Then 
we are going to go to our colleagues who have been very, very 
patient this morning. My thanks to them, Mr. McSwain and Dr. 
    Dana Lee Jetty, I told you I am sure none of us understand 
how difficult it is to come some months after losing your 
younger sister and talk about it publicly. You are going to 
school in Minnewaukan, North Dakota, is that right?
    Ms. Jetty. Yes.
    The Chairman. What year are you in school?
    Ms. Jetty. I am a sophomore.
    The Chairman. I have been to the Spirit Lake Nation many 
times. In fact, I have been there to have meetings about teen 
suicide because there have been other teen suicides there. In 
your testimony, you indicated that you knew that your mom had 
concerns about your sister before her suicide, and you say your 
mom did all the right things. She took her to the doctor, 
talked to counselors, and even had her evaluated by mental 
health professionals from Indian Health Service. They dismissed 
your mom's concerns and diagnosed your sister as being a 
typical teenager.
    Ms. Jetty. Yes.
    The Chairman. So your sister had some issues. Your mother 
recognized that, and went to seek out some assistance.
    Ms. Jetty. Yes.
    The Chairman. And the tragedy at the end of this is your 
sister took her life.
    As a young Indian teen, are you familiar with others who 
have performed, as the professionals call it, ideation, talking 
about perhaps ending their life, or those who have actually 
made an attempt to end their life?
    Ms. Jetty. Yes. I know some people have actually come up to 
me and asked me, you know, what should I do? And how can I help 
myself? So what me and my family have been doing, we have 
actually been going around to different places, to schools, to 
jails, where teenagers are, and we tell them that there is help 
that they can get out there. Some counselors, like you said, 
they just push aside the person's feelings, you know, how they 
want to, the help that they want to get. And I don't know.
    The Chairman. Dana Lee, I told you that I met with a group 
of Indian teenagers at Standing Rock. Just me and a group of 
them, no other adults present. I just asked them about their 
lives. What is going on in their lives? What do you think? I 
talked to them about the cluster of suicides, asked them to 
give me their impressions of their classmates and so on. It was 
a fascinating discussion, and in many ways, also troubling and 
in some ways hopeful.
    But one of the things that some of those students told me 
was that their acquaintances that had committed suicide, and 
some who had tried it, felt that perhaps it wasn't a desire to 
be dead, or to actually end up being dead as a result of this. 
It was a desire to cry out for help, but without thinking this 
is forever, this is final, this is death. Do you sense that 
among the young people that talk to you about these issues?
    Ms. Jetty. Yes, actually I do. Yes. Some of them, they 
think that it is the only way that they can feel better, that 
they won't feel the pain that they are feeling. It is really, I 
don't know. It is a big concern.
    The Chairman. And there is, as all of the professionals on 
the panel have described to us appropriately, not one reason 
for suicide. You know, there just isn't one reason you can say, 
here is what is triggering it. It is a series of emotional 
things that, I think in my own view, relates to circumstances 
of life and feelings that one doesn't have the same 
opportunities and things are tough, and you know, poverty and a 
whole range of things. Substance abuse can play a role 
    So it is tragic when anyone commits suicide. The person 
that I found who had committed suicide was an adult, only 40 
years old. But to have someone 14 years old take their life is, 
as you know, such a tragedy.
    So again, let me just thank you for being here. But when 
you tell me that you go to jails and schools, you and your 
family, and are doing something in your sister's name, I think 
your younger sister would be mighty proud of her older sister, 
and we appreciate your doing it.
    To those of you who have put on the public record here your 
experience and your work, I have a number of questions, but I 
think I am going to send you these questions. I am going to ask 
more specifically about some of the services and, Mr. Walker, 
how you are going to disseminate the guide throughout Indian 
Country on what your plans are.
    And Mr. Hayes, I will ask you to respond about when the 
suicide prevention program ceased in your community, when did 
you see repercussions of that. I have a number of questions, 
but I think what I would like to do is submit them to you and 
ask if you could respond for the Committee record in writing so 
that I might get the testimony of Mr. McSwain and Dr. 
    The reason I wanted them to stay was to hear something very 
valuable from your testimony, especially you professionals. It 
is very important for Indian Health Service and SAMHSA to 
understand what it is you say and what it is you do out in 
Indian Country across America.
    So let me call on my colleague from Nebraska for any 
comments or questions you might have.

                   U.S. SENATOR FROM NEBRASKA

    Senator Johanns. Well, let me start out and thank the 
Chairman for holding this hearing, a very, very important 
    Dana Lee, if I could just inquire. Thinking about your 
friends and the very sad case of your sister committing 
suicide, do you think there is sometimes a reluctance with kids 
to reach out and seek help from, I don't know who, a parent, a 
counselor, a teacher? Would that be kind of a stigma? Would 
other kids look down on them? Is that a problem? And if you see 
that as a problem, could you give us any advice on how we might 
think about how to help that situation?
    Ms. Jetty. Yes, I think they do look down on them. They see 
that other kids are doing it, and they think that is the only 
way they know how to deal with them. They really need to talk 
to somebody who knows what they are going through and who can 
really relate to them and know how to help them. And sometimes, 
kids, they go, they talk to counselors, but it is not the stuff 
they want to hear. So I think, you know, we can really get to 
them by talking to trained professionals who know what to do 
and stuff, so.
    Senator Johanns. I appreciate your honesty in answering 
that. I wonder if it would be helpful to think about an 
approach where certainly a trained professional would be 
involved, but there would also be your own peers involved. You 
know, sometimes you will share things with a friend that you 
would, my daughter or my son, would never tell me, but they 
really need somebody to talk about it. What would you think 
about that kind of idea? Do you think that would help?
    Ms. Jetty. Yes, I think that would really help, I think, 
you know, like other students. Yes.
    Senator Johanns. Okay. I really appreciate you being here. 
I think it is very, very helpful to us as we think about how to 
fashion an approach to maybe prevent this from happening in 
another family. Thank you.
    Ms. Jetty. Thank you.
    The Chairman. I am going to dismiss the panel, but as I do, 
let me again thank Dana Lee's parents, James Dean Jetty and 
Cora Whiteman Tiger. Thank you for accompanying your daughter 
today and making it possible for her to testify.
    And I want to thank especially those of you who have 
testified about your programs and the professional work that is 
being done. Dr. LaFromboise, we particularly appreciate your 
lineage from Turtle Mountain and appreciate your work at 
    Ms. LaFromboise. Thank you.
    The Chairman. And let me thank you for being here. All of 
you are welcome to stay and listen to our next two witnesses 
from the Indian Health Service and from SAMHSA. Thank you very 
    Now, Mr. McSwain and Dr. Broderick, I thank both of you for 
being so patient with us. This took a while, but I think it 
would be enormously helpful for you to hear, so we appreciate 
your being here.
    Director McSwain, thank you very much. You may proceed, 
after which we will hear from Dr. Eric Broderick.


    Mr. McSwain. Thank you, Mr. Chairman and members of the 
Committee. I, too, enjoyed to a great degree, because I learned 
a lot from the previous panel. I made copious notes, and 
certainly had a chance to talk with Dana and her experience, so 
that it was helpful to understand our system and how our system 
interfaces, the clinical system.
    You certainly have my statement. I am accompanied today by 
Dr. Richard Olson, Director of the Office of Clinical and 
Preventive Services, and Dr. Rose Weahkee, Public Health 
Adviser, Division of Behavioral Health. And certainly I 
appreciate the opportunity today to testify on youth suicide in 
Indian Country, recognizing that my predecessors appeared 
before you and this Committee before in several parts of the 
    As was mentioned, I think it is an important feature of 
this hearing is that suicides and suicide-related behaviors do 
exact a profound toll on American Indian and Alaska Native 
communities. As it was mentioned, suicides just reverberate 
through communities, small or large, and affect the survivors 
many years after the actual incident.
    I won't go through the, you have certainly the data, and I 
just want to say that we confirm the data of the suicide rates 
that were shared with you earlier. The one thing that tends to 
make the numbers a little different when you are talking to a 
large organization like SAMHSA or U.S. national numbers is that 
remember our focus is on 1.9 million Indian people living in 35 
States on or near a reservation. So our numbers are a little 
bit smaller in terms of the actual prevalence and the like. So 
that understood, there will be some differences in the final 
    You know, suicide is a very complicated public health 
challenge. As we talked about it earlier today, certainly there 
are a whole lot of factors, and as you said, Mr. Chairman, any 
one factor. And clearly, the only pursuit of a multi-targeted 
coordinated and persistent effort is acutely aware of the 
cultural context. All those issues were shared today.
    The total cultural context of suicide blends the best of 
traditional American Indian and Alaska Native healing wisdom 
and Western public health tools, and is likely to succeed not 
only on a community basis, but also on a national basis.
    Since this hearing is a follow-up, I would like to simply 
highlight some activities that have been occurring since the 
previous two hearings. First is in the area of collaboration. I 
know that there was concern about the Indian Health Service 
collaborating and partnering with the Bureau of Indian Affairs 
and what they have going. Clearly, we have had a number of 
discussions, and I can assure you that I had discussions with 
the Bureau of Indian Affairs this last year until their 
leadership changed a bit. But basically, we are still 
continuing to focus.
    I think the important is that while there may be a sort of 
lack of real coordination at a national level, I can say that 
there is a lot of activity going on out in the field in the 
service units, in the communities, with the Bureau of Indian 
Affairs. I think a case in point is that IHS continues to 
provide both medical and behavioral health-related services to 
BIA-funded youth detention centers. For example, the Chinle 
Navajo Nation Youth Detention Center in Arizona was allocated 
both a nurse practitioner and regular contacts from the local 
IHS alcohol and substance abuse coordinator. That is just one 
example of many across the Country. If I don't run out of time 
today in my opening, I will talk about some other things that 
are going on in other States.
    But IHS is fully involved since the last time in a number 
of things. We are involved in many statewide suicide prevention 
teams, coalitions. There are two Alaska Natives who were 
appointed to the Alaska statewide Suicide Prevention Council. 
One is also a member of the Suicide Prevention Committee, which 
is the IHS prevention committee. An IHS representative sits on 
the Arizona State Suicide Prevention Coalition. The Oklahoma 
area also cosponsored a suicide prevention conference with the 
State of Oklahoma in December.
    There are a lot of things happening nationally. My 
colleague to my left here, we are working very closely with 
SAMHSA, the CDC, NIMH, and the like. Suicide prevention 
programming was offered at the annual IHS-SAMHSA meeting last 
summer, and we are looking forward to another session with 
SAMHSA as we move forward, where there were between 400 and 600 
people who were actually at the conference.
    We have been working nationally with NCAI and other 
national Indian organizations. NCAI has established its Suicide 
Prevention Work Group. The Suicide Prevention Resource Center 
works collaboratively with Indian Health Service.
    On an international level, the department has a memorandum 
of understanding with the country of Canada and our 
counterpart, First Nations. We are working together for those 
common issues. What are they experiencing up there in Canada as 
well? And two learning exchange meetings have occurred and are 
scheduled to continue.
    I just want to mention to you that I know there will be a 
question about the $14 million that the Indian Health Service 
was appropriated. It was a deliberate process on my part to 
establish a national Tribal Advisory Committee where you heard 
today, the importance of tribal communities being engaged. I 
wanted tribal leaders to be engaged in how best to target the 
resources that were given. They have come forward with a series 
of recommendations, and I am prepared to deliver on those 
recommendations very soon. We are looking at upwards of 60 
grants in the committee to begin to address suicide and 
methamphetamine abuse. Then, of course, that was the first 
charge I gave to the new group as they convened, and said, 
look, I want your ideas on best how to target these limited 
    Let me close with just a few examples of IHS area-specific 
suicide prevention activities. The Aberdeen area has 
established a suicide prevention strategic plan. Again, at 
least it is on the table and they are working through it. They 
have also used the question-persuade-refer training for every 
reservation, which is actually referred to as a QPR. And of 
course, in the Alaska area, the big news in Alaska is the 
behavioral health aids that are being actually trained and 
deployed throughout the villages in Alaska. Another event 
certainly to address local needs, to go along with the others, 
are community health aids, and certainly the dental health aid 
therapists that occur in Alaska.
    Bemidji began their efforts with applied suicide 
intervention skills training, QPR, the North Dakota Project and 
American Indian Life Skills training, and they continue to work 
throughout the area. There are certainly a number of activities 
going on in the Billings area, which includes Wyoming. I am 
sorry that Senator Barrasso isn't here, but we have a number of 
activities going on in both Montana and Wyoming, and of course 
working again with SAMHSA, you will hear more from Dr. 
Broderick on some activities there.
    The Phoenix area has teamed up with the State of Nevada for 
those interested in providing training to reservations in Utah, 
Nevada and Arizona. The Portland area, in partnership with the 
Northwest Portland Area Indian Health board, has developed an 
area-wide suicide prevention plan. And the Navajo Nation has a 
strategic plan, a suicide prevention team, and is working with 
the tribe with suicide prevention activities. In fact, they 
actually have a special project that is referred to as Suicide: 
Breaking the Silence, and we have all heard about that today.
    Let me just simply say that our successes to date, and that 
is whether it has been Colville or Flathead, has been 
community-based. I mean, we have gotten into the community and 
the community has actually taken up ownership. I think our 
successes will continue where American Indian and Alaska Native 
communities take ownership and lead the effort, and then we are 
helping and supporting them as they move forward.
    Mr. Chairman, this concludes my summary statement. Thank 
you for this opportunity to discuss youth suicide in Indian 
Country, and I will be happy to answer of your questions.
    [The prepared statement of Mr. McSwain follows:]

 Prepared Statement of Hon. Robert G. McSwain, Director, Indian Health 
         Service, U.S. Department of Health and Human Services
    Mr. Chairman and Members of the Committee:
    Good morning, I am Robert McSwain, Director of the Indian Health 
Service (IHS). I am accompanied by Richard Olson, M.D., Acting 
Director, Office of Clinical and Preventive Services, and Rose Weahkee, 
Ph.D., Public Health Advisor, Division of Behavioral Health. Today, I 
appreciate the opportunity to testify on youth suicide in Indian 
    The IHS has the responsibility for the delivery of health services 
to an estimated 1.9 million Federally-recognized American Indians and 
Alaska Natives (AI/AN) through a system of IHS, Tribal, and urban (I/T/
U) operated facilities and programs based on treaties, judicial 
decisions, and statutes. The mission of the agency is to raise the 
physical, mental, social, and spiritual health of American Indians and 
Alaska Natives to the highest level, in partnership with the population 
we serve. The agency goal is to assure that comprehensive, culturally 
acceptable personal and public health services are available and 
accessible to the service population. Our duty is to uphold the Federal 
government's obligation to promote healthy American Indian and Alaska 
Native people, communities, and cultures and to honor and protect the 
inherent sovereign rights of Tribes.
    Two major pieces of legislation are at the core of the Federal 
government's responsibility for meeting the health needs of American 
Indians/Alaska Natives: The Snyder Act of 1921, P.L. 67-85, and the 
Indian Health Care Improvement Act (IHCIA), P.L. 94-437, as amended. 
The Snyder Act authorized regular appropriations for ``the relief of 
distress and conservation of health'' of American Indians/Alaska 
Natives. The IHCIA was enacted ``to implement the Federal 
responsibility for the care and education of the Indian people by 
improving the services and facilities of Federal Indian health programs 
and encouraging maximum participation of Indians in such programs.'' 
Like the Snyder Act, the IHCIA provides the authority for the provision 
of programs, services, and activities to address the health needs of 
American Indians and Alaska Natives. The IHCIA also included 
authorities for the recruitment and retention of health professionals 
serving Indian communities, health services for people, and the 
construction, replacement, and repair of healthcare facilities.
    The Department of Health and Human Services (HHS) has been 
proactive in raising the awareness of Tribal issues through the process 
of Tribal consultation. As such, HHS recognizes the authority provided 
in the Native American Programs Act of 1974, and utilizes the 
Intradepartmental Council for Native American Affairs to address cross 
cutting issues such as suicide and to seek opportunities for 
collaboration and coordination among HHS programs serving Native 
    We are here today to discuss youth suicide in Indian Country.
    Suicides and suicide-related behaviors exact a profound toll on 
American Indian and Alaska Native communities. Suicides reverberate 
through close-knit communities and continue to affect survivors many 
years after the actual incident.

   Using the latest information available, the American Indian 
        and Alaska Native suicide rate (17.9) for the three year period 
        (2002-2004) in the IHS service areas is 1.7 times that of U.S. 
        all races rate (10.8) for 2003. (This information will be 
        published in the upcoming ``Trends in Indian Health, 2002-

   Suicide is the second leading cause of death behind 
        unintentional injuries for Indian youth ages 15-24 residing in 
        IHS service areas and is 3.5 times higher than the national 
        average. (This information will be published in the upcoming 
        ``Trends in Indian Health, 2002-2003'').

   Suicide is the 6th leading cause of death overall for males 
        residing in IHS service areas and ranks ahead of homicide. 
        (This information will be published in the upcoming ``Trends in 
        Indian Health, 2002-2003'').

   American Indian and Alaska Native young people ages 15-34 
        make up 64 percent of all suicides in Indian country. (This 
        information will be published in the upcoming ``Trends in 
        Indian Health, 2002-2003'').

    On a national level, many American Indian and Alaska Native 
communities are affected by very high levels of suicide, poverty, 
unemployment, accidental death, domestic violence, alcoholism, and 
child neglect. \1\ According to the Institute of Medicine, an estimated 
90 percent of individuals who die by suicide have a mental illness, a 
substance abuse disorder, or both. \2\ According to a 2001 mental 
health supplement report of the Surgeon General, ``Mental Health: 
Culture, Race, and Ethnicity'', there are limited mental health 
services in Tribal and urban Indian communities. \3\ While the need for 
mental health care is great; services are lacking, and access can be 
difficult and costly. \4\
    \1\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the 
Mental Health Needs of American Indians and Alaska Natives. National 
Association of State Mental Health Program Directors (NASMHPD) and the 
National Technical Assistance Center for State Mental Health Planning.
    \2\ Institute of Medicine (2002). Reducing suicide: A national 
imperative. Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., Bunney, 
W. E. (Eds.) Washington, DC: National Academies Press.
    \3\ U.S. Department of Health and Human Services. (2001). Mental 
Health: Cultural, race, and ethnicity supplement to mental health: 
Report of the Surgeon General. Rockville, MD: U.S. Department of Health 
and Human Services, Substance Abuse and Mental Health Services 
Administration, Center for Mental Health Services, National Institutes 
of Health, National Institute of Mental Health.
    \4\ Manson, S.M. (2004). Cultural Diversity Series: Meeting the 
Mental Health Needs of American Indians and Alaska Natives. National 
Association of State Mental Health Program Directors (NASMHPD) and the 
National Technical Assistance Center for State Mental Health Planning.
    The system of services for treating mental health problems is a 
complex and often fragmented system of tribal, federal, state, local, 
and community-based services. The availability and adequacy of mental 
health programs varies considerably across communities. \5\ American 
Indian youth are more likely than non-Indian children to receive 
treatment through the juvenile justice system and in-patient 
facilities. \6\
    \5\ Ibid.
    \6\ Ibid.
    The Indian Health Service is most directly responsible for 
providing mental health services to American Indians and Alaska 
Natives. The purpose of the IHS Mental Health/Social Service (MH/SS) 
program is to support the unique balance, resiliency, and strength of 
our American Indian and Alaska Native (AI/AN) cultures. The MH/SS 
program is a community-oriented clinical and preventive mental health 
service program that provides primarily outpatient mental health and 
related services, crisis triage, case management, prevention 
programming, and outreach services. The MH/SS program provides general 
executive direction and recruitment of MH/SS program staff to 12 Area 
Offices (regional) that, in turn, provide resource distribution, 
program monitoring and evaluation activities, and technical support to 
163 Service Units. These Service Units consist of IHS, Tribal, and 
urban Indian programs whose MH/SS staff are responsible for the 
delivery of comprehensive mental health care to over 1.9 million 
American Indians and Alaska Natives.
    The most common MH/SS program model is an acute, crisis-oriented 
outpatient service staffed by one or more mental health professionals. 
Many of the IHS, Tribal and Urban (I/T/U) mental health programs that 
provide services in times of crises do not have enough staff to operate 
24/7. Therefore, when an emergency occurs, the clinic and service units 
will often contract out such services to non-IHS hospitals and crisis 
centers. Inpatient services are often purchased from non-IHS hospitals 
or provided by State or County mental health facilities. Medical and 
clinical social work in the MH/SS program model are usually provided by 
one or more social workers who assist with discharge planning and 
provide family intervention for child abuse, suicide, domestic 
violence, parenting skills, and marital counseling.
    The MH/SS program model also includes tele-behavioral health 
technology. Tele-behavioral health technology is increasingly adopted 
throughout the Indian health system to improve access to behavioral 
health services. Currently, over 30 IHS and Tribal facilities in 8 IHS 
Areas are augmenting on-site behavioral health services with tele-
behavioral health services. This type of system capacity building 
supports not only distance psychiatric services to remote communities 
where such services are not available now but can also be used to share 
resources more efficiently in urban and semi-urban areas. A National 
Telebehavioral Health Center of Excellence is in the planning stages 
and should provide increased access to televideoconferencing based 
behavioral health services such as telepsychiatry.
    Over the last 15 years, most of the behavioral health programs have 
transitioned from IHS to local community control via Tribal contracting 
and compacting. Over half of the Tribes have administrative control 
over the delivery of the majority of mental health and substance abuse 
programs through tribal contracts and compacts. Such local programs are 
community based and have direct knowledge of their population and what 
interventions can be effectively implemented. It is clear then that 
Tribes, not IHS, are now primarily providing services to their 
communities. IHS now seeks to support those services with programs and 
program collaborations to bring resources to the communities 
Addressing Suicide Among American Indians
    Suicide is a complicated public health challenge with a myriad of 
contributors in American Indian/Alaska Native communities. Only the 
pursuit of a multi-targeted, coordinated, and persistent effort that is 
acutely aware of the cultural context of suicide and blends the best of 
traditional AI/AN healing wisdom and western public health tools is 
likely to succeed on a national basis. The losses caused by suicide 
affect us all and so the solutions must come from all of us working 
    IHS has five targeted approaches for suicide prevention and 

   Assist I/T/Us in addressing suicide utilizing community 
        level cultural approaches.

   Identify and share information on best and promising 

   Improve access to behavioral health services.

   Strengthen and enhance IHS' epidemiological capabilities.

   Promote collaboration between Tribal and urban Indian 
        communities with Federal, State, national, and local community 

    To address youth suicide in Indian Country appropriately requires 
public health and community interventions as much as direct, clinical 
ones. Since 2003, the IHS National Suicide Prevention Initiative has 
provided a critical framework for addressing the tragedy of suicide in 
American Indian and Alaska Native communities. The IHS National Suicide 
Prevention Initiative builds on the foundation of the HHS ``National 
Strategy for Suicide Prevention'' and the 11 goals and 68 objectives 
for the Nation to reduce suicidal behavior and its consequences, while 
ensuring we honor and respect our people's traditions and practices.
    Traditional knowledge, along with the role of Elders and spiritual 
leaders, needs to be respected and validated for the important role 
they play in healing and wellness. Understanding and decreasing suicide 
in our communities will require the best holistically and culturally 
sensitive, collaborative efforts our communities and the agencies that 
serve them can bring together. With these principles in mind, we hope 
to provide a holistic, cultural foundation to suicide prevention, 
building on the strong resilience of AI/AN communities. We will strive 
to bridge concepts between AI/AN communities, government agencies, and 
non-profit organizations in order to effectively prevent suicide.
    The Suicide Prevention Initiative is complemented by the IHS 
Behavioral Health Initiative, both of which seek to address suicide 
prevention through a holistic, community-centered approach. Two other 
focus areas that are closely linked to the Behavioral Health Initiative 
are the Chronic Disease Management and Health Promotion and Disease 
Prevention Initiatives. All of these initiatives are pertinent to 
suicide prevention efforts and seek to address the underlying causes of 
poor physical and mental health, rather than just treating the 
symptoms. They also stress the empowerment and full engagement of 
individuals, families, and communities in health care.
    Indian Health Service supports changing the paradigm of mental 
health services from being specialty and disease focused to being a 
part of primary care and the ``Medical Home''. This offers new 
opportunities for interventions that identify high risk individuals 
before their actions or behavior becomes more clinically significant. 
One primary care based behavioral health intervention is the Alcohol 
Screening Brief Intervention for patients presenting after physical 
trauma, which our agency is broadly promoting as an integral part of a 
primary care based behavioral health program. Studies suggest that this 
and similar interventions can dramatically reduce further traumatic 
injury as well as alcohol and other substance abuse more generally. The 
agency, through our Chronic Disease Collaborative and Innovations in 
Primary Care project, is also supporting efforts to integrate 
behavioral health providers directly into primary care settings as has 
been done successfully in Alaska and in other progressive primary care 
sites across the country. This presents a dramatic change from the 
usual model of distinct and separate medical and behavioral health 
service delivery and we intend to support this practice shift over the 
coming years through developing further learning communities, sharing 
implementation best practices as they develop, and re-aligning and 
supporting the development of primary care-based behavioral health 
    We have made substantial efforts over the last several years to 
improve our behavioral health data collection in the Resource and 
Patient Management System (RPMS). Behavioral health information can now 
be integrated with primary care and other clinical information 
supporting coordinated care and improved health outcomes. As increasing 
numbers of clinics adopt the integrated model, data will become 
available that may help identify opportunities for intervention in 
medical, behavioral health, and community settings. IHS has developed a 
suicide surveillance reporting tool to document incidents of suicide in 
a standardized and systematic fashion which is available to all 
providers in the RPMS health information system. The Suicide Reporting 
Database is beginning to provide a more detailed picture of who is 
committing or attempting suicide and identifies salient factors 
contributing to the events. Accurate and timely data captured at the 
point of care provides important clinical and epidemiological 
information that can be used to inform intervention and prevention 
efforts. IHS is currently developing an IHS-wide Behavioral Health 
``data mart'' to provide IHS leadership with up-to-date information on 
suicidal events including suicide completions. The application will 
include a number of available reports and will provide the ability to 
identify ``cluster'' events to assist in the mobilization and 
deployment of available resources. Finally, IHS GPRA measures now 
include screening for depression in primary care settings as best 
practice in order to assist in identifying patients at risk for 
developing suicidal ideation. Tools have been selected to assess 
depression, monitor response, track such response over time, and are 
incorporated into the IHS Electronic Health Record. IHS has 
consistently met or exceeded target goals for this GPRA depression 
screening measure. This level of monitoring is key to identifying at 
risk populations by providers and ensuring they receive timely and 
adequate care.
    The IHS Emergency Services Program is supporting AI/AN communities 
by utilizing the IHS Emergency Response to Suicide Model to assess 
communities with high incidence of suicide, coordinate a response to 
the affected community, and augment existing staff, with the goal of 
mitigating the emergency and stabilizing the community. For example, in 
FY 2008, the IHS Emergency Services staff managed on behalf of HHS the 
deployment of Public Health Service mental health clinicians through 
the Office of Force Readiness and Deployment (OFRD) to a Tribal 
community from January-May 2008 to respond to a suicide ``cluster'' in 
that community. Federal and community efforts are still ongoing in that 
community. The deployment was directly requested by that Tribal 
government, and HHS' response was coordinated through the Office of 
Intergovernmental Affairs.
    Substantial progress has been made in developing plans and 
delivering programs, but it is still only the beginning of a long term, 
concerted and coordinated effort among Federal, Tribal, State, and 
local community agencies to address the crisis. We have recognized that 
developing resources, data systems, and promising programs, as well as 
sharing information across the system, requires national coordination 
and leadership. In response to the problem, the IHS, with Federal 
partners, Tribal, and Urban Indian communities across the country, will 
expand ongoing partnerships and formulate long term strategic 
approaches to intervene in the suicide crisis and provide suicide 
prevention and early intervention activities.
    Last year, I established the National Tribal Advisory Committee 
(NTAC) on Behavioral Health made up of Tribal Leaders from each IHS 
Area. The Committee serves as an advisory body to the Indian Health 
Service, providing expertise, guidance, and recommendations on 
behavioral health issues affecting the delivery of health care for AI/
ANs. In addition, the National Behavioral Health Workgroup was 
established which is comprised of Tribal and Urban behavioral health 
service providers. The workgroup provides information to the National 
Tribal Advisory Committee on Behavioral Health on issues in Indian 
    To help guide the overall Indian health system effort, the National 
Suicide Prevention Committee, comprised of suicide prevention experts, 
was established. The Committee was tasked with identifying and defining 
the steps needed to build on the previous suicide prevention efforts to 
significantly reduce the impact of suicide and suicide-related 
behaviors on AI/AN communities. Members of the Suicide Prevention 
Committee are interdisciplinary and represent a broad geographic 
distribution within and outside the Indian health system.
    It is the responsibility of the IHS Suicide Prevention Committee to 
provide recommendations and guidance to the Indian Health Service 
regarding suicide prevention and intervention in Indian Country. This 
past year, the SPC developed an Indian Health System National Suicide 
Prevention Strategic Plan. The National Suicide Prevention Strategic 
Plan is a first step in describing and promoting the accumulated 
practice-based wisdom in AI/AN communities. At its best, the plan will 
be a living and constantly changing reflection of the collaborative and 
focused efforts of the many people throughout American Indian/Alaska 
Native communities who are working to reduce the scourge of suicide.
    The Methamphetamine and Suicide Prevention Initiative (MSPI) is a 
another coordinated program designed to provide prevention and 
intervention resources for Indian Country. This initiative promotes the 
development of evidence-based practices using culturally appropriate 
prevention and treatment to address methamphetamine abuse and suicidal 
behaviors in a community-driven context.
    The goal is to intervene effectively to prevent, reduce or delay 
the use and/or spread of methamphetamine abuse by increasing access to 
methamphetamine and suicide prevention services through culturally 
relevant services. The $14 million initiative focuses on supporting 
promising or model practices for methamphetamine and suicide reduction 
programs in Indian Country.
    So, taken all together, where are we?
    We acknowledge that the complexity of suicide and its close 
cousins, violent and accidental death and injury, remains challenging. 
At the same time, we believe suicide and suicidal behaviors are 
preventable through the engagement of the affected communities and the 
application of research-supported public health approaches. Several 
Tribal and urban Indian communities have already taken up this 
challenge and have been implementing a number of innovative and 
culturally sensitive prevention initiatives. For example, Tribal and 
urban Indian communities are implementing the Native H.O.P.E. 
curriculum, the American Indian Life Skills Development, the Sources of 
Strength model, ASIST (Applied Suicide Intervention Skills Training), 
QPR (Question, Persuade, Refer), and other promising approaches in 
several communities across Indian Country. Increasing access to 
services, improving responsiveness of services, developing school and 
community level wisdom about how to manage distressed community 
members, educating and increasing awareness, and connecting young 
people to their culture are all successful approaches in Indian Country 
that are beginning to show us the way. However, for many other 
individuals and groups, it remains challenging to determine the best 
approach to prevent suicide in their own communities.
    The initiatives and programs that I have described here are some of 
the methods and means to engage individuals and their communities. 
These efforts are not sufficient in and of themselves to significantly 
change many peoples' living conditions. However, if we can act 
together, among agencies, branches of government, Tribes, States, and 
communities, I believe that the tide can be turned and hope restored to 
those who have lost hope. To that end, I commit to work with you and 
anyone else in and out of government to bring services and resources to 
that effort.
    Mr. Chairman, this concludes my statement. Thank you for this 
opportunity to discuss youth suicide in Indian Country. I will be happy 
to answer any questions that you may have.

    The Chairman. Mr. McSwain, thank you very much.
    Next, we will hear from Dr. Eric Broderick from SAMHSA.
    Thank you very much for being here.


    Dr. Broderick. Good morning, Mr. Chairman and Committee 
members. Thank you very much. I appreciate the opportunity to 
be here today. I thank you for bringing together survivors of 
suicide, professionals from the suicide prevention field, as 
well as Mr. McSwain and other Federal partners to talk about 
this issue.
    No one person has the answer to this. No one organization. 
It must be reliant on collaboration, a collaborative effort 
that people bring from many different perspectives to address 
this very, very serious issue.
    SAMHSA has worked very hard over the last three years to 
put our resources out into the field in Indian Country to 
ultimately help increase the capacity of Indian communities to 
address the challenges that mental illness and substance abuse 
present to them.
    Suicide is a serious public health challenge, as has been 
said today, and it is only now beginning to receive the 
attention and degree of national priority that it deserves. It 
takes huge courage to do what Senator Reid did, what Ms. Jetty 
did, and what her family did, what the gentleman that Senator 
Murkowski and I heard last week did, to stand up, in spite of 
the stigma, in spite of the guilt and the anger and grief that 
a family feels, and speak out. Until that happens, the stigma 
will remain.
    I am very pleased to hear it happening more and more and 
more across this Country because that is what will actually 
deal with the stigma and deal with the many different emotions 
that families confront when confronted with this great problem.
    Suicide is a huge problem in this Country, with 32,000 
deaths a year. You heard Senator Reid state that statistic. Any 
time there is a situation where 900,000 of our youth, 900,000 a 
year, plan their own death, and 712,000 of those youth actually 
attempt it, that, I would say, qualifies as a public health 
crisis. You have very well articulated the needs of this 
Country to face this issue.
    We have heard the data, and I won't repeat them, but as 
seriousness as this condition is across this Country, the 
situation is more serious in Indian communities. I have said 
that we have made it a priority at SAMHSA to make our resources 
available in Indian Country. As we do that, it is critical that 
we engage tribes and tribal leaders to help assure that we do 
so in a respectful way as partners. I want to mention a few 
strategies that we have used to engage tribes in that way.
    We have a Tribal Advisory Committee that is comprised of 14 
tribal leaders from around the Country, to provide us advice 
and guidance. We participate in the HHS Tribal Consultation 
Sessions each year around the Country.
    We also in 2006 partnered with the Department of Justice to 
be responsive to a call from tribal leaders to improve tribal 
capacity and infrastructure through training and technical 
assistance to tribal communities. That project, now called the 
Tribal Justice Safety and Wellness Project, began with a 
meeting in California two and a half years ago where 200 people 
attended. Mr. McSwain talked about the session that we had in 
Billings last summer. The session was convened, by the 
Department of Interior, the Department of Health and Human 
Services, and the Department of Justice. Over 1,000 people came 
together who don't talk to one another including Federal 
agencies, to allow tribes the access that they have requested 
to talk to individuals from multiple locations across the 
Executive Branch of the government.
    The partnership now includes the Department of Health and 
Human Services, the Department of Justice, the Department of 
Interior, the Department of Housing and Urban Development, the 
Small Business Administration, and our newest partner, the 
Corporation for National and Community Service.
    I will tell you at every one of these opportunities, these 
venues where tribes come together with Federal staff, suicide 
is among the most frequently mentioned issues that is brought 
to us along with requests to help tribes address that.
    We are making progress. At the start of 2005, SAMHSA had 
two suicide prevention grants. Today, we have 110. You have 
heard much discussion about the Garret Lee Smith Suicide 
Prevention Act. There have been others who talked about the 
Suicide Prevention Resource Center that SAMHSA funds. It is a 
technical assistance center. What I would add to that is there 
are now two tribal affairs specialists employed by the Suicide 
Prevention Resource Center specifically there to help Indian 
communities with their requests for technical assistance around 
    You have heard some discussions about the Native 
Aspirations Project. That project focuses on the 25 communities 
with very high risk for suicide clusters. They do wonderful 
work. I would add that some of the Native Aspiration 
communities have gone on and used that technical assistance and 
gone on to become Garret Lee Smith grant awardees.
    The situation today at SAMHSA is that fully one-third of 
our Garret Lee Smith State and tribal grants go to tribes. We 
awarded 30 last year, 12 went to tribes, 18 went to States. And 
as Senator Murkowski said, we were in Alaska last week and 
presented a $1.5 million Garret Lee Smith grant to the State of 
Alaska. One of the first things that they told us was in using 
those grant dollars, they will put them in place in communities 
where the need exists. They made it very clear that native 
communities are among the communities that they will focus on. 
So it is very heartening to see resources going out in that way 
to communities in very great need.
    The last program I would like to talk about is the National 
Suicide Prevention Lifeline Network, a network of 135 crisis 
centers across the United States that receive calls from a 
national toll-free number, number 1-800-273-TALK. Every month, 
44,000 people have their calls answered by the lifeline, an 
average of 1,439 people a day. Calls are free and confidential 
and answered 24 hours a day, 7 days a week. We know this 
program saves lives.
    The National Suicide Prevention Lifeline American Indian 
Initiative has worked to promote access to suicide prevention 
hot line services in Indian Country by supporting communication 
and collaboration between tribes and local crisis centers, as 
well as providing outreach materials customized to each tribe.
    Suicide is preventable and help is available. All Americans 
have access to the National Suicide Prevention Lifeline during 
times of crisis, and we are committed to sustaining this vital 
national resource.
    These SAMHSA initiatives are an important start, but as we 
know, there is much, much more to be done to reduce the tragic 
burden of suicide in Indian Country. The problems confronting 
the American Indians and Alaska Natives are taking a toll on 
these communities now and will in the future. I lived on the 
Wind River Reservation when the incident occurred in 1985 that 
the Senator talked about a few minutes ago. I will tell you, in 
my opportunities to go back there, much has been done to remedy 
that situation, but they still live with the outcomes and the 
consequences of those 10 or so young people who killed 
themselves all those many years ago.
    Mr. Chairman, I want to thank you for the opportunity to be 
here today. I would be happy to answer any questions that you 
might have or the Committee might have. Thank you very much.
    [The prepared statement of Dr. Broderick follows:]

    Prepared Statement of Eric B. Broderick, D.D.S., M.P.H., Acting 
       Administrator, Substance Abuse and Mental Health Services 
      Administration, U.S. Department of Health and Human Services
    Mr. Chairman and Members of the Committee, good morning. I am Dr. 
Eric Broderick, Acting Administrator of the Substance Abuse And Mental 
Health Services Administration (SAMHSA) within the Department of Health 
and Human Services (HHS) and Assistant Surgeon General. I am pleased to 
have this time to share with you a few highlights of SAMHSA's efforts 
and the Agency's important role in improving behavioral health 
throughout American Indian/Alaska Native (AI/AN) communities.
    In my prior position as SAMHSA's Deputy Administrator and twice now 
as the steward of the Agency as Acting Administrator, I have worked 
hard to raise the critical issues facing our tribal nations surrounding 
behavioral healthcare and its direct relationship to overall health to 
a priority level within SAMHSA and among our federal partners. I have 
made it a priority to take SAMHSA and its resources directly to AI/AN 
communities where much-needed training and dialogue can and has taken 
place to further the process of breaking down the barriers to quality 
assistance and services.
    By participating annually in the HHS Budget Consultation and 
Regional Consultation Sessions with Tribal leaders and representatives, 
SAMHSA hears first-hand about the top priorities in Indian Country. 
Additionally, SAMHSA requires active engagement of our Senior Leaders 
in these meetings and has made this a part of all of our performance 
    I continue to believe one of my most important responsibilities is 
to leave each site visit, training session, consultation session or 
other gathering knowing more about what needs to be done in AI/AN 
communities than when SAMHSA staff and I arrived. The need for those at 
the federal level to continue engaging tribal leaders, organizations 
and communities is clear and the response should be held at a high 
level of importance.
    In particular, over the past two years SAMHSA has gained ground on 
a number of accomplishments with our tribal partners including our 
partners within the IHS Regional Health Boards. For instance, in 2006 
the Department of Justice and SAMHSA began a collaboration to respond 
to the call of tribal leaders to improve tribal capacity and 
infrastructure through training and technical assistance to tribal 
communities. With more federal agencies committing to developing 
strategic solutions for American Indians and Alaska Natives, the 
collaboration is now a multi-agency endeavor entitled Tribal Justice, 
Safety and Wellness Government-to-Government Consultation, Training and 
Technical Assistance Sessions. In 2006 about 200 people attended the 
first session. By the seventh session, there were over 1,000 people, 
which demonstrates that a collaborative approach is working-no one 
agency can solve the problems alone.
    These Tribal Training and Technical Assistance Sessions provided 
many opportunities for tribal leaders to learn about SAMHSA's grant 
programs as well as important information regarding grants 
administration and financial management, tips for successful grant 
writing, overviews of various Federal funding sources and information 
on Tribal Drug Courts. There are many federal partners including: the 
Department of Health and Human Services through SAMHSA, the Indian 
Health Service and the Office of Minority Health; the Department of 
Justice through its Office of Justice Programs, Community Orienting 
Policing Services, Executive Office of U.S. Attorneys Native American 
Issues Subcommittee, Office of Tribal Justice, and Office on Violence 
Against Women; the Department of the Interior through its Bureau of 
Indian Affairs; the Department of Housing and Urban Development through 
its Office of Native American Programs; the Small Business 
Administration's Office of Native American Affairs; and our newest 
federal partner, the Corporation for National and Community Service.
    Many of these and other steps forward taken by SAMHSA are a result 
of the agency's dedication to improve services in Indian Country 
beginning with the revision of SAMHSA's Tribal Consultation Policy in 
2007. SAMHSA has established a Tribal Technical Advisory Committee 
comprised of Tribal Leaders who provide guidance and input on critical 
issues impacting Indian Country. As we continue to move forward and 
continue to make progress, we will stay closely involved in the 
critical issues, such as suicide, which continue to face our tribal 
    SAMHSA is working to address suicide among American Indians and 
Alaska Natives. SAMHSA's efforts correspond with the efforts identified 
in the National Strategy for Suicide Prevention (NSSP). The NSSP 
represents the combined work of advocates, clinicians, researchers and 
survivors around the nation. The NSSP provides a framework for action 
to prevent suicide and guides development of an array of services and 
programs that must be developed. It is designed to be a catalyst for 
social change with the power to transform attitudes, policies, and 
services. SAMHSA's agency-wide efforts to address and prevent suicide 
continue to be developed around the recommendations of the NSSP.
Suicide--Correlation with Substance Use and Mental Health Disorders
    SAMHSA is responsible for improving the accountability, capacity 
and effectiveness of the nation's substance abuse prevention, 
addictions treatment, and mental health service delivery systems. 
Suicide prevention is among our agency priorities.
    SAMHSA has a clear role to play in addressing and preventing 
suicide, as both substance abuse and mental health disorders can 
increase the risk of and contribute to suicidal behavior in several 
ways. Two of the leading risk factors for suicide are a history of 
depression or other mental illness and alcohol or drug abuse. For 
particular groups at risk, such as American Indians and Alaska Natives, 
depression and alcohol use and abuse are the most common risk factors 
for suicide.
Suicide--A Public Health Issue
    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 account for 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 32,000 
lives each year. When faced with the fact that the annual number of 
suicides in our country now outnumbers homicides by three to two, the 
relevance and urgency of our work becomes clear. Additionally, when we 
know, based on SAMHSA's National Survey on Drug Use and Health (NSDUH) 
in 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 proof that suicide prevention must remain a priority at 
Suicide Among American Indian and Alaska Native Youth
    Suicide is now the second-leading cause of death (behind 
unintentional injury and accidents) for American Indian and Alaska 
Native youth aged 10-34. HHS's Centers for Disease Control and 
Prevention (CDC) reports that from 1999 to 2004, the suicide rate for 
American Indians/Alaska Natives was 10.84 per 100,000, higher than the 
overall U.S. rate of 10.75. Adults aged 25-29 had the highest rate of 
suicide in the American Indian/Alaska Native population, 20.67 per 
100,000. Suicide ranked as the eighth-leading cause of death for 
American Indians/Alaska Natives of all ages.
    Of significant concern is that in the two most recent years for 
which we have data, 2004 and 2005, the suicide rate among American 
Indians/Alaska Natives increased. According to CDC's National Vital 
Statistics Report, in 2005 American Indian and Alaska Native youth aged 
15-24 had a rate of suicide twice as high as youth of that age 
nationally. We do not yet know if the 2006 data will show a 
continuation of the same tragic trend, but the stories we have heard 
lead us to have great concern. What in and of itself is a tragedy to 
report is more than one-half of all persons who die by suicide in the 
United States, and an even higher number in Tribal communities, have 
never received treatment from mental health providers.
SAMHSA's Role in Better Serving American Indian and Alaska Native 
    SAMHSA focuses attention, programs, and funding on improving the 
lives of people with or at risk for mental or substance use disorders. 
SAMHSA's vision is ``a life in the community for everyone.'' The agency 
is achieving that vision through its mission of ``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 has worked to ensure Tribal entities are eligible for 
all competitive grants for which States are eligible.
    SAMHSA's activity in suicide prevention has increased dramatically 
in recent years. For example, at the start of 2005, there were two 
competitive grant awards for suicide prevention. At the end of 2005, 
there were 46. Currently, there are over 110 suicide prevention grants 
going to states, tribes/tribal organizations, territories, and colleges 
and universities, and crisis centers across the country. SAMHSA 
supports four major suicide prevention initiatives that I will 
highlight briefly today. These initiatives are: the Garrett Lee Smith 
Youth Suicide Prevention Grant Program; SAMHSA's the Native Aspirations 
Project; the Suicide Prevention LifeLine; and the Suicide Prevention 
Resource Center.
Garrett Lee Smith Youth Suicide Prevention Grant Program
    As a result of the Garrett Lee Smith Memorial Act (P.L. 108-355), 
SAMHSA has been 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, under the Garrett Lee 
Smith Memorial Act State/Tribal Suicide Prevention program. These funds 
are available to help States/Tribes implement a State-wide/Tribe-wide 
suicide prevention network. One of those first set of grants went to 
the Native American Rehabilitation Association in Oregon. In addition, 
through an Interagency Agreement between the CDC and SAMHSA, the Native 
American Rehabilitation Association was one of three Garrett Lee Smith 
grantees awarded additional funding to enhance their evaluations to 
maximize what we can learn from these important suicide prevention 
    Awards were also made in 2006 and 2007, during which six more 
Tribes/Tribal Organizations were awarded grants. These grants are 
supporting a range of suicide prevention activities in Indian Country, 
such as training community members to recognize the warning signs of 
suicide and intervening with youth seen in Emergency Departments who 
have attempted suicide. This past August (2008), 12 Tribes/Tribal 
Organizations received Garrett Lee Smith grants in addition to the 18 
grants made to States, totaling 30 new awards.
    Garrett Lee Smith grants to Tribes and Tribal Organizations now 
total one-third of the number of grant awards. This is not only a 
direct result of outreach and technical assistance, but a true 
indication of the resolve of Tribes and Tribal Organizations to 
proactively seek RFAs and then put forward strong, viable applications. 
Additionally, it is important to note that many of the states that 
received grant awards are partnering with and/or reaching out to 
include suicide prevention efforts in their local tribal communities. 
Among the 18 States that received a grant in 2008 is Alaska. Just last 
week, I was able to travel to Juneau to present to the State of Alaska, 
with Senator Murkowski in attendance, this $500,000 per year award for 
three years, totaling $1.5 million.
    Within the newest cohort of grants, the Tribes/Tribal Organizations 
awardees are: the Gila River Behavioral Health Authority Youth Suicide 
Prevention Project, The Gila River Indian Community, Sacaton, Arizona; 
Omaha Nation Community Response Team--Project Hope, Walthill, Nebraska; 
Mescalero Apache School Youth Suicide Prevention and Early Intervention 
Initiative, Mescalero, New Mexico; Wiconi Wakan Health & Healing 
Center, Rosebud Sioux Tribe, Rosebud, South Dakota; Circle of Trust 
Youth Suicide Prevention Program, The Confederated Salish Kootenai 
Tribes of the Flathead Indian Nation, Pablo, Montana; Preserving Life: 
Nevada Tribal Youth Suicide Prevention Initiative, Inter-Tribal Council 
of Nevada, Sparks, Nevada; Youth Suicide Prevention, The Crow Creek 
Sioux Tribe, Ft. Thompson, South Dakota; Tribal Youth Suicide 
Prevention Program, Oglala Sioux Tribe, Pine Ridge, South Dakota; 
Wiconi Ohitika Project, Cankdeska Cikana Community College, Fort 
Totten, North Dakota; Sault Tribe Alive Youth (STAY) Project, Sault Ste 
Marie Tribe Chippewa Indians, Sault Ste Marie, Michigan; Bering Strait 
Suicide Prevention Program, Kawerak, Inc., Nome, Alaska; and the Native 
Youth Suicide Prevention Project, Native American Rehabilitation 
Association, Portland, Oregon, which successfully recompeted for a 
second grant.
    As of October 2, 2008, a total of 54 states, tribes, and tribal 
organizations, as well as 49 colleges and universities, will be 
receiving funding for youth suicide prevention through this program. 
Again, it is important to note that with the new tribal grantees, one-
third of all of the Garrett Lee Smith State and Tribal grants will be 
going to tribes or tribal organizations.
Native Aspirations Project
    SAMHSA funds the Native Aspirations project, which is a national 
project designed to address youth violence, bullying, and suicide 
prevention through evidence-based interventions and community efforts. 
Native Aspirations, after consultation with SAMHSA based on data from 
IHS, determines the 25 AI/AN communities that are the most ``at risk'', 
and the project then helps these communities develop or enhance a 
community-based prevention plan. After a community is selected, the 
initial step is a visit from Native Aspirations project staff members, 
who share information and help community leaders set up an oversight 
committee. The second step is a Gathering of Native Americans (GONA), a 
4-day event designed to offer hope, encouragement, and a positive 
start. GONA events are based on each community's traditional culture 
and honor AI/AN values. GONA events are a safe place to share, heal, 
and plan for action.
    Within a month of a GONA, Native Aspirations staff facilitate a 2-
day planning event. At this point, participants receive training about 
prevention plans and decide which model to follow. They outline a 
customized plan based on actions that have worked for others. As the 
community finalizes and carries out its plan, Native Aspirations 
provides training, consultation, technical assistance, and budget 
support. A number of tribes who received help through Native 
Aspirations were able to build on this to successfully compete for a 
Garrett Lee Smith Youth Suicide Prevention grant.
Suicide Prevention Resource Center
    Another initiative is the Suicide Prevention Resource Center 
(SPRC), a national resource and technical assistance center that 
advances the field by working with states, territories, tribes, and 
grantees and by developing and disseminating suicide prevention 
resources. The SPRC was established in 2002. It supports suicide 
prevention with the best of available science, skills and practice to 
advance the National Strategy for Suicide Prevention (NSSP). SPRC 
provides prevention support, training, and resource materials to 
strengthen suicide prevention networks and is the first federally 
funded center of its kind.
The Suicide Prevention Lifeline
    The National Suicide Prevention Lifeline is a network of 135 crisis 
centers across the United States that receives calls from the national, 
toll-free suicide prevention hotline number, 800-273-TALK. The network 
is administered through a grant from SAMHSA to Link2Health Solutions, 
an affiliate of the Mental Health Association of New York City. Calls 
to 800-273-TALK are automatically routed to the closest of 135 crisis 
centers across the country. Those crisis centers are independently 
operated and funded (both publicly and privately). They all serve their 
local communities in 47 states, and operate their own local suicide 
prevention hotline numbers. They agree to accept local, state, or 
regional calls from the National Suicide Prevention Lifeline and 
receive a small stipend for doing so.
    In the three states that do not currently have a participating 
crisis center (Idaho, Hawaii, and Vermont), the calls are answered by a 
crisis center in a neighboring state. Every month, more than 44,000 
people have their calls answered through the National Suicide 
Prevention Lifeline, an average of 1,439 people every day. When a 
caller dials 800-273-TALK, the call is routed to the nearest crisis 
center, based on the caller's area code. The crisis worker will listen 
to the person, assess the nature and severity of the crisis, and link 
or refer the caller to services, including Emergency Medical Services 
when necessary. If the nearest center is unable to pick up, the call 
automatically is routed to the next nearest center. All calls are free 
and confidential and are answered 24 hours a day, 7 days a week.
    By utilizing a national network of crisis centers with trained 
staff linked through a single national, toll-free suicide prevention 
number, the capacity to effectively respond to all callers, even when a 
particular crisis center is overwhelmed with calls, is maximized. This 
also provides protection in the event a crisis center's ability to 
function is adversely impacted, for example, by a natural disaster or a 
blackout. Further, by utilizing the national number 800-273-TALK, 
national public awareness campaigns and materials can supplement local 
crisis centers' efforts to help as many people as possible learn about 
and utilize the National Suicide Prevention Lifeline. In fact, SAMHSA 
has consistently found that when major national efforts are made to 
publicize the number, the volume of callers increases and this 
increased call volume is maintained over time.
    The National Suicide Prevention Lifeline's American Indian 
initiative has worked to promote access to suicide prevention hotline 
services in Indian Country by supporting communication and 
collaboration between tribes and local crisis centers as well as 
providing outreach materials customized for each tribe. We are pleased 
that we have been able to work together with the AI/AN Communities and 
also with the Department of Veterans Affairs to help deliver the 
critically important messages that suicide is preventable, and that 
help is available. All Americans have access to the National Suicide 
Prevention Lifeline during times of crisis, and we are committed to 
sustaining this vital, national resource.
SAMHSA Emergency Response Grants
    SAMHSA is also committed to assisting communities which have faced 
traumatic events through our SAMHSA Emergency Response Grant (SERG) 
Program. SAMHSA provides SERG funding in rare emergency situations in 
which State and local resources are overwhelmed and no other Federal 
resources are available. Applicants must demonstrate that the need is 
greater than existing local and State resources, and must explain why 
other Federal funding doesn't meet their needs. The SERG is a SAMHSA-
wide program. Funding can be used for emergency mental health services 
and disaster-related substance abuse treatment and prevention programs 
and can be used to address new substance abuse treatment and prevention 
concerns in response to an event or to replace services destroyed by a 
    The SERGs are available in response to those situations in which a 
presidential disaster declaration has not been made and are 
particularly helpful in cases of emergent and urgent unmet behavioral 
health needs of communities such as the Red Lake reservation community. 
The Red Lake Band of Chippewa Indians in Minnesota received a SERG in 
response to the school shooting there. The SERG assisted in the 
establishment of the Wii-doo-kaa-wii-shin (Helping Each Other) Project. 
This project provides mental health needs, specialized outreach, 
assessment, ongoing support and education, as well as treatment and 
    The Standing Rock Sioux also received a SERG in response to a 
suicide cluster. The grant assisted with the establishment of a 
behavioral health network with staffing as well as funding to augment 
their suicide prevention program, crisis hotline, healing and support, 
as well as training and technical assistance. In addition, the Crow 
Creek Sioux received a SERG to assist in their efforts to protect and 
heal their community following a suicide cluster as well.
    The SAMHSA initiatives described above are important steps to 
reduce the tragic burden of suicide in Indian Country. The problems 
confronting American Indians and Alaska Natives are taking a toll on 
the future of these communities.
    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.

    The Chairman. Dr. Broderick, thank you very much for being 
    Let me ask briefly about the response to the Rosebud 
circumstance in South Dakota. The suicide rates on the Rosebud 
Reservation reached epidemic proportions there. I wonder about 
the emergency response. What is the level of suicide? What is 
the approach you use by which the IHS would implement some sort 
of emergency response model that you have? And describe to us 
what you did at Rosebud, if you would.
    Dr. Broderick. Okay. The situation at Rosebud has been 
going on for some time. It is not something that just recently 
started. Actually, the Rosebud Sioux Reservation is one of the 
communities that is part of the Native Aspirations Project. So 
in partnership with the Indian Health Service, we increased the 
resources available to that community through Native 
Aspirations. There was a deployment of commissioned officers of 
the Public Health Service to go and assist that community.
    The Chairman. But how did that happen? What was the trigger 
that caused it?
    Dr. Broderick. The tribe asked. It is a matter of the tribe 
asking the Commission Corps. The Indian Health Service was 
intimately involved in that request, and Public Health Service 
officers from SAMHSA, and quite frankly all across the 
Department of Health and Human Services responded to go to 
Rosebud for tours of three to four weeks and rotations of 
individuals to provide mental health and substance abuse 
counseling services to that community over the course of time.
    The process continues. It is hard work, because we believe 
that the solution to the problem doesn't rest at SAMHSA or 
doesn't rest at the Indian Health Service headquarters in 
Rockville. It rests in that community. And we stand ready and 
committed to provide assistance to the community.
    The Department of Health and Human Services also convened 
in the Office of Intergovernmental Affairs a cross-agency 
collaboration of multiple departments to bring resources to 
bear to help that community.
    The Chairman. We will know we have made progress when we 
see diminished rates of teen suicides on Indian reservations. 
The question I have is, with several different initiatives out 
there that are being used by SAMHSA and the Indian Health 
Service, how are we tracking the effectiveness and the 
efficiency of the use of these funds? How do we know what we 
are getting for these funds and whether we are making a 
difference? And which programs, which initiatives make the 
biggest difference?
    Dr. Broderick. For SAMHSA, each of our grants, each of our 
grant programs, rely on evidence-based practice. We heard some 
discussion about that earlier. What can we do when the 
evidence-based practices are developed in non-native 
communities to make them available? That is a whole other 
discussion, but suffice it to say that our grantees, in order 
to be successful for a SAMHSA grant, you must demonstrate the 
use of evidence-based practice.
    We then monitor progress on those grants through the 
Government Performance and Results Act and the PART process to 
make sure that data are available and that the projects are 
    The Chairman. Mr. McSwain?
    Mr. McSwain. Thank you, Mr. Chairman. I think Indian Health 
Service certainly has two things working. One is that we have 
always been there with our clinical folks and the like, so we 
are looking at a system of care that begins to identify certain 
incidences. Maybe it is depression. We are tracking that on the 
clinical side, so we can hand them off, a soft hand-off to our 
behavioral health people, and even incorporating the behavioral 
health people in.
    We have built in the evaluation piece into these grants. 
The first $14 million that we got this last year, we will build 
it into those and actually begin to measure results as they go 
out to the communities with this very thought in mind.
    The Chairman. How short are your behavioral health dollars 
in order for the reach that you should do? We talked earlier 
about rationing. I know these programs exist. I know that both 
of you do outreach on certain reservations, they get some help 
from you. I also know that is not something that is across the 
Indian populations and available to all reservations.
    So how short are we of the resources necessary to do the 
job you think should be done?
    Mr. McSwain. You know, I don't really know. The reason why 
I don't know is that because of the fact that there are so many 
other factors involved. Health is one piece of it. Until we get 
the whole pie built, if you will, the SAMHSAs, the DOJs, and 
all the other folks who enter in to helping a community with 
suicide, when we get that all together, if we take all the 
pieces, then we would have what we would project we would need.
    The Chairman. You have heard and you know of the models 
that are out there, the work that is being done to train folks 
in our schools and so on. There must be some notion of what 
kind of additional resources should be made available so that 
we better expose all of the populations that are at risk out 
there to the kinds of services that are necessary, the kinds of 
programs that are necessary.
    Would you work to try to give us your assessment of what 
that shortage of resources is at this point?
    Mr. McSwain. I certainly would give it a big try because it 
is a fact that we work so hard on the clinical side. We can 
tell you what the numbers are there, but giving you the 
behavioral health side will take a little more work, but we can 
do that.
    The Chairman. Unfortunately, because of the vote and the 
recess we felt this would go from 10 a.m to 12 noon. It is 
12:20 p.m. The Chair had a 12 o'clock speech that I didn't give 
off the Hill, but I have to chair a luncheon in the Capitol 
    So what I would like to do for both of you is to submit a 
list of questions. I think what we have done today is hear a 
lot of information with which we can try to evaluate what is 
happening and what works, what doesn't work. We have heard from 
a young woman who described these issues in personal terms, and 
the reason that is important, especially here in Washington, 
D.C. where we describe them statistically. That is not what is 
happening in America. This isn't about statistics. It is about 
great tragedy that is occurring, not only those who take their 
lives and lose their lives, but those who are left behind as 
victims of these suicides.
    So I want to thank both of you for being willing to sit 
through the previous testimony. That is not usual, but I think 
it was for good purpose. We will submit a list of additional 
questions to you.
    I want to thank all of the others who have testified.
    Our Committee is going to continue to pay attention to 
this, even as we turn now to try to write a new Indian Health 
Care Improvement bill that we will introduce. As we do that, we 
will pay special attention to this subject, which is part of 
that issue.
    This hearing is adjourned.
    [Whereupon, at 12:20 p.m., the Committee was adjourned.]
                            A P P E N D I X

 Prepared Statement of Jacqueline S. Gray, Ph.D., Assistant Professor, 
Center for Rural Health, University of North Dakota School of Medicine 
                          and Health Sciences
    Greetings Honorable Chairman Dorgan, Vice-Chairman Barrasso, and 
Members of the Committee. Thank you for the opportunity to provide 
testimony to this committee and my perspective on the present status 
and progress toward preventing American Indian and Alaska Native (AI/
AN) youth suicidal behavior.
    I bring to you my perspectives as a Choctaw and Cherokee 
descendent, a mental health clinician with 25 years of experience 
working with American Indian clients, a faculty member from the Center 
for Rural Health at the University of North Dakota focused on rural and 
tribal mental health issues, an adjunct faculty in counseling 
psychology preparing future mental health professionals, a researcher 
of mental health and suicide prevention with American Indians, and a 
concerned mother and grandmother. I have worked in suicide prevention 
and crisis intervention for 20 years and developed a crisis 
intervention model that has been adopted across the state of Oklahoma. 
I have worked with Garrett Lee Smith campus, state, and tribal suicide 
prevention programs, Native Aspirations (which utilizes Dr. Theresa 
LaFromboise's American Indian Life Skills [LaFromboise, 1996] 
curriculum), Indian Health Service, and tribal programs focused on 
behavioral health. I walk in many worlds with regard to this issue: 
Native and Western with my bicultural identity; clinician, teacher, 
researcher, and consumer of mental health services; survivor of 
suicide; promoter of wellness, and prevention of suicide. I hope my 
testimony will assist the Committee in understanding the needs and 
potentials related to AI/AN youth suicide and promotion of positive AI/
AN mental health.
    You have received statistics from others highlighting the suicide 
rates of AI/AN youth as the highest in the nation and escalating in 
recent years (Broderick, LaFromboise, McSwain, Reid, Walker, 2009). 
Suicide in AI/AN communities is an epidemic and in need of the 
attention given a public health epidemic. A great deal has been 
addressed in recent years by the Garrett Lee Smith Memorial Act (P.L. 
108-355). I have worked with campus, state, and tribal applicants and 
awardees of these grants and know the hard work that is being done to 
address youth suicide through the funds provided. I have worked with 
the Native Aspirations program and know that they are trying to address 
suicide prevention in some of the most ``at risk'' AI/AN communities in 
the country. I have also worked with the Suicide Prevention Resource 
Center and Suicide Prevention Lifeline and the great work they are 
doing to provide resources and support for suicide prevention. But this 
is clearly not enough.
    Mental health services available through Indian Health Service 
(IHS) and tribes are already stretched beyond capacity. As more youth 
are identified as suicidal or at risk we need more local services to 
address those needs. Many times youth must be transported hundreds of 
miles from home for inpatient treatment and then lack the aftercare 
services needed to transition to outpatient, and follow-up treatment 
when returned home.
    When writing a grant a few months ago, I worked with Aberdeen Area 
IHS Behavioral Health staff to determine the ratio of mental health 
providers to AI population in the Aberdeen Area. The results were 
overwhelming: one psychiatrist per every 250,000 American Indians; one 
psychologist per every 17,000 American Indians; and one social worker 
or counselor per every 3,300 American Indians. Every county with AI 
reservations has been designated as Mental Health Professional 
Underserved Areas through the Health Resources and Services 
Administration (HRSA, 2008). The requirements for Mental Health 
Provider Shortage designations are 30,000: 1 for geographic areas or 
20,000:1 for high need areas. Core mental health providers (CMHP; 
clinical social workers, psychiatric nurse specialists, clinical 
psychologists, and marriage and family therapists) rations 9,000:1 
including psychiatrists or 6,000:1 CHMP and 20,000:1 for psychiatrists 
(HRSA, 2009). Indian Health Services behavioral health services are 
currently funded at about 25% of the actual need. Solutions to this 
problem includes passage of the Indian Health Care Improvement Act, 
increased funding for behavioral health services to AI/AN communities, 
minimal standards for providers of behavioral health services to ensure 
the protection of those receiving services, funding for training 
programs to increase the numbers of AI/AN behavioral health service 
providers, cultural competence training for providers of health, and 
behavioral health services in AI/AN communities. Resources to utilize 
American Indians into Psychology trainees and other trained, 
credentialed, AI/AN providers on an emergency basis help to assist with 
suicide emergency situations. Many of the youth involved in suicidal 
behaviors are in need of substance abuse services as well as mental 
health services. More funding for dual diagnosis services close to home 
for these youth are important in maintaining connection with families 
and receiving care for both issues at the same time.
    The need for training includes increasing the numbers of AI/AN 
licensed mental health providers and trainings on cultural awareness, 
competence, and integration into services, prevention, and programs 
provided for AI/AN youth. There are approximately 250 AI/AN clinically 
trained psychologists (0.3% of 84,883), 865 AI/AN clinically trained 
counselors (0.5% of 100,533), and 150 school psychologists (0.4% of 
37,893) in the U.S. (SAMHSA, 2004). Currently, there are American 
Indian/Alaska Native into Psychology programs at the University of 
North Dakota, Oklahoma State University, the University of Montana, and 
the University of Alaska-Fairbanks. Utah State University has an 
unfunded American Indian Support Project. While these programs increase 
the number of AI/AN psychologists, there is a great need for more. The 
inclusion of clinical, counseling and school psychology programs would 
increase numbers and fill varied roles for mental health providers who 
receive the same licensure in states. To fill the gaps in the pipeline, 
mentoring programs to support AI/AN students between undergraduate and 
graduate programs would increase their competitiveness in applying to 
graduate programs and pre-doctoral internship programs; post-doctoral 
(pre-licensure) opportunities would provide clinical experiences with 
AI/AN clients and give those graduates work opportunities, helping them 
to get through the licensure process so they can work at IHS and tribal 
    In addition to training mental health providers, cultural 
competence and awareness training needs to be a requirement for all 
health service providers in Indian Country. It is critically important 
that those providing services can relate to the cultural values of the 
people they serve to increase the likelihood of AI/AN people in need of 
services seeking out the help that is available. If culturally 
appropriate programs, media, and services are not available, the 
resources are less likely to be used by those who need them most. In 
addition, a strong cultural identity has been found to be protective 
against depression (Gray, et. al, 2008).
    While the need for services and well-trained professionals is 
evident, another area of need is the training of community members, 
first responders, and school personnel to recognize, assist, and 
support youth prior to reaching a suicidal state. Programs such as 
Question, Persuade, Refer (QPR) (Quinette, 1999) have been adapted for 
Indian Country and focus on suicidal behavior recognition and 
intervention. Mental Health First Aid is a program like a first aid 
program focused more generally on mental health issues, recognizing 
symptoms, crisis situations, intervening in a crisis, and supporting a 
person throughout any treatment or follow-up (MHFA, http://
about_the_program/mhfa_course_description). This program has shown 
increased willingness for participants to intervene in the case of a 
mental health emergency, greater feelings of confidence in their 
abilities to do something in a mental health emergency, and reduced 
stigma regarding mental health issues by those completing the training 
(http://www.mhfa.com.au). Funding for programs like this in Indian 
Country, where there are great distances to travel for services and 
need for support locally, can help to increase capacity for supporting 
those in crisis within the community.
    Although we hear a great deal about evidence-based practices, there 
is virtually no research on evidence-based treatment with AI/AN 
populations (Miranda, et. al, 2005) and only two suicide prevention 
programs being studied to establish their efficacy: American Indian 
Life Skills and Sources of Strength (LaFromboise, 1996; LoMurray, 
1998). There is very limited research on the assessments used to 
measure effectiveness of programs with AI/AN programs. These measures 
must be tested before the results of efficacy of programs that utilize 
them can be tested to provide accurate information on the use of 
programs with AI/AN populations. To give the needed attention to this 
work, funds through NIMH, NIDA, and NIAAA are needed to address levels 
of research to measure, and provide evidence-based practices in AI/AN 
populations. Interfaced data and a national registry through IHS for 
suicidal behaviors and treatment, to provide data informing continuity 
of care across systems for inpatient, outpatient, dual diagnosis, and 
other supportive services, is necessary. Establishing a mandatory 
reporting system, such as the kind used for reporting child abuse, 
could help to identify troubled youth before they actually attempt 
suicide and subsequently get them access to prevention services.
    In remote areas of Alaska and throughout Indian Country, a 
technology infrastructure is needed, from electronic health records 
(EHR) that interface across IHS, tribal, Veterans Affairs, private, and 
public health systems, to telemental health programs that allow for 
services and billing of psychiatric and mental health services across 
state lines and licensure jurisdictions. Blue ribbon panels to address 
the issues of access across service systems of EHRs, and funds to 
support the development of the interface of these systems, are needed. 
Demonstration projects in telemental health are needed to find how 
these systems can provide better care and address the issues of 
licensure and access to services across state lines. Infrastructure 
funding is needed to provide adequate technological support for the 
distance services, including video and audio connections for youth 
located in residential treatment facilities to their families at home 
who may not be able to visit them while they are in treatment. This 
helps to maintain their connection to family and loved ones during a 
stressful time in their lives.
    In summary, my recommendations to this committee cover four general 
areas: mental health services, education and training, research, and 
technology and infrastructure.
Mental Health Services
    1. Passage of the Indian Health Care Improvement Act;

    2. Increase funding to Indian Health Service to increased the 
number of credentialed mental health professionals providing services 
in Indian Country;

    3. Increase funding of Indians into Psychology and Indians into 
Medicine to increase the numbers of AI/AN providers in Indian Country;

    4. Increase funding of loan repayment programs to recruit and 
retain qualified mental health service providers in Indian Country; and

    5. Fund aftercare treatment programs and circle-of-care services 
for transition and follow-up treatment for AI/AN youth.

Education and Training
    1. Fund and require cultural competence training for service 
providers in Indian Country;

    2. Increase funding and scope of Indians into Psychology and 
Indians into Medicine programs to more locations and include clinical, 
counseling and school psychology programs as part of Indians into 

    3. Fund enrichment programs for AI/AN students between 
undergraduate and graduate programs to make them stronger applicants 
for graduate and medical school;

    4. Fund clinical placement, internship, and post-doctoral residency 
programs for AI/AN students for experiences working with clients in 
Indian Country, and jobs in transition while working toward licensure; 

    5. Provide funding for programs such as Mental Health First Aid 
that help to build community capacity and reduce stigma related to 
mental health issues and crises.

    1. Funding for research on assessment materials used to determine 
efficacy of treatment programs with AI/AN populations;

    2. Funding for research to determine evidence-based treatments for 
AI/AN populations;

    3. Promote and fund the interface of data and a national registry 
through IHS for suicidal behaviors and treatment, to provide data 
informing continuity of care across systems for inpatient, outpatient, 
dual diagnosis, and other supportive services; and

    4. Establish a mandatory reporting system to gather data, plan 
programming, and get youth needed services before they complete a 

    1. Fund interfacing of electronic health records across IHS, 
tribal, Veterans Affairs, private, and public health care systems;

    2. Establish a blue ribbon panel to address the issues of access 
across service systems, as well as technology-based services across 
state lines, and licensure issues;

    3. Fund demonstration projects in telemental health to find how 
these systems can be of greatest assistance in Indian Country; and

    4. Fund infrastructure to connect service providers, families, and 
patients for communication and treatment planning with support networks 
while in residential treatment.

               Prepared Statement of Cora Whiteman Tiger

  Prepared Statement of Jessica Hawkins, Prevention Program Manager, 
   Oklahoma Department of Mental Health and Substance Abuse Services
    To Promote Healthy Communities and Provide the Highest Quality Care 
to Enhance the Well-Being of all Oklahomans.
Oklahoma's Suicide Prevention Initiative
    In 2005, Oklahoma Department of Mental Health and Substance Abuse 
Services (ODMHSAS) was awarded $1.2 million over 3 years by the 
Substance Abuse and Mental Health Services Administration (SAMHSA)--
Center for Mental Health Services, through the Garrett Lee Smith 
Memorial Act, to implement youth suicide prevention programs across the 
state. Oklahoma proposed to utilize this grant funding to implement 
portions of the state plan on youth suicide prevention.
    The Oklahoma State Plan on Youth Suicide Prevention was developed 
at the request of the Oklahoma Legislature. House Joint Resolution No. 
1018, passed in 1999, created the Youth Suicide Prevention Task Force 
with the assignment of submitting recommendations to the Legislature on 
the prevention of youth suicide. This task force involved physicians, 
educators, survivors, mental health professionals, clergy, legislators 
and representatives from state agencies including Health, Mental Health 
and Substance Abuse Services, Education, and Juvenile Affairs. The 
Oklahoma Youth Suicide Prevention Council was formed in 2001 to 
implement the plan and also serves as the advisory body for 
implementation of the Garrett Lee Smith project.
    Oklahoma's grant-funded youth suicide prevention initiative 
allocates funds for statewide, evidence-based suicide prevention 
strategies including gatekeeper training and screening. The grant funds 
five community-based projects, including one with the Kiowa Tribe of 
Oklahoma. Kiowa Tribe is located in Southwest Oklahoma. The tribe's 
suicide prevention project includes gatekeeper training (QPR), youth 
suicide risk screening (Columbia TeenScreen) within Riverside Indian 
School, suicide prevention themed Pow-Wow events, and youth leadership 
development. Also notable is that Indian Health Service is the major 
sponsor of the state's annual Suicide Prevention Conference and serves 
as an active participant on the state's Youth Suicide Prevention 
    Notable accomplishments in Oklahoma regarding suicide prevention 

        2000: Oklahoma Legislature made suicide a reportable injury in 
        2000, leading to the current collection of hospital discharge 
        data on suicide attempts.

        2006: ODMHSAS initiated an important partnership with a large-
        scale hospital system in Central Oklahoma to train all 
        physicians, nurses, and staff in suicide prevention. This 
        effort has resulted in similar partnership with other large-
        scale hospital systems in the state.

    2006-2008: ODMHSAS trained 3,125 people as suicide prevention 
gatekeepers (number for those completing evaluation surveys; actual 
number trained is estimated to be much higher) and 62 people as 
certified gatekeeper instructors.

    2008: Oklahoma Legislature passed Senate Bill 2000 which expands 
the scope of the Oklahoma Youth Suicide Prevention Act from youth-
specific to across the lifespan. In November 2008, the Youth Suicide 
Prevention Council will become the Oklahoma Suicide Prevention Council 
and will undertake the task of revising the state plan on suicide 
prevention to address all populations.

    In Spring 2008, ODMHSAS reapplied to SAMHSA to continue the youth 
suicide prevention initiative an additional three years. The new grant 
would provide additional funding for the provision of suicide 
prevention among high risk youth populations, including those in the 
juvenile justice system, foster care, and mental health/substance abuse 
     Prepared Statement of Jo Ann Kauffman, President, Kauffman & 
                            Associates, Inc.

  Prepared Statement of Laurie Flynn, Executive Director, TeenScreen 
    National Center for Mental Health Checkups, Columbia University
    Thank you for the opportunity to submit testimony on behalf of the 
TeenScreen National Center for Mental Health Checkups at Columbia 
University (National Center) for the Senate Indian Affairs Committee's 
oversight hearing on youth suicide in Indian Country. I commend the 
committee for exploring this issue and for continuing to shine a light 
on the tragedy of youth suicide within our American Indian and Alaska 
Native (AI/AN) communities. Many opportunities exist to help our tribal 
young people, yet many challenges remain to actually reach those in 
need. The National Center stands ready to help Congress as it considers 
ways to identify those in need and improve care to help save lives.
    Across our nation, youth suicide remains a significant public 
health challenge. Each year, 30,000 Americans die by suicide, while an 
estimated 500,000 high school students make attempts. Yet, among our 
tribal communities, mental illness and suicide is an even greater 
threat. According to the Centers for Disease Control and Prevention, on 
our tribal lands suicide is the second leading cause of death for 
individuals age 10 to 34. Further, when compared with other racial and 
ethnic groups, AI/AN youth have more serious problems with mental 
health disorders related to suicide, such as anxiety, substance abuse 
and depression.
    Today's hearing provides Congress with an opportunity to take 
action to improve mental health care delivered to AI/AN populations. 
The starting point for this change should be the Indian Health Service 
(IHS). Since enactment of the Indian Health Care Improvement Act 
(IHCIA) in 1976, the IHS has not kept pace with the modernizations 
taking place in the rest of the American health care system. For 
example, mainstream American health care is moving out of hospitals and 
into people's homes; focus on prevention has been recognized as both a 
priority and a treatment; and, coordinating mental health, substance 
abuse, domestic violence and child abuse services into comprehensive 
behavioral health programs is now standard practice. There is a 
critical need for mental health promotion and disease prevention 
activities in Indian Country. The National Center strongly encourages 
Congress to incorporate coverage of mental health checkups into the 
IHS. Making this change will give providers the tools needed to 
identify adolescents at risk for mental illness or suicide and take 
steps necessary to intervene and provide care.
    The availability of mental health services also is severely limited 
by the rural, isolated location of many AI/AN communities. Adding to 
the difficultly of accessing services, IHS clinics and hospitals are 
located on reservations, yet the majority of AI/NAs no longer live 
there and only one in five American Indians reports access to IHS 
services. Furthermore, AI/AN tribes that are recognized by their state, 
but not by the Bureau of Indian Affairs (BIA), are ineligible for IHS 
funding. Moreover, there are fewer mental health providers, especially 
child and adolescent specialists, in rural communities. The National 
Center encourages Congress to take steps to expand and coordinate care 
for AI/AN populations not living on or near reservations.
    Understanding the nature and the extent to which AI/ANs utilize 
mental health services is limited by the lack of research. The 1997 
Great Smoky Mountain Study examined mental health service use among 
Cherokee and non-Indian youth living in adjacent western North Carolina 
communities. Among Cherokee youth with a diagnosable psychiatric 
disorder, one in seven received professional mental health treatment. 
This rate is similar to that for the non-Indian sample. However, 
Cherokee youth were more likely to receive this treatment through the 
juvenile justice system and inpatient facilities than were non-Indian 
youth. Similarly, in a small study of Plains Indian students in the 
North-Central United States, more than one-third of those with 
psychiatric disorders used services at some time during their lives. 
Two-thirds of those who received services were seen through school; and 
just one adolescent was treated in the specialty mental health system. 
Among those youth with a psychiatric disorder who did not receive 
services, over half were recognized as having a problem by a parent, 
teacher or employer.
    The National Center was created to advance greater access to mental 
health checkups for America's youth. Our screening program is 
evidenced-based and was highlighted in the 2003 President's New Freedom 
Commission Report. TeenScreen also is included in the Substance Abuse 
and Mental Health Services Administration's (SAMHSA) National Registry 
of Evidence-based Programs and Practices (NREPP) as a scientifically 
verified intervention in the areas of suicide prevention and early 
identification of mental illness. I am proud to say that the National 
Center is funded entirely by a private, philanthropic family foundation 
whose founders had personal experience with suicide and mental illness. 
We provide our tools, training and technical assistance at no cost, and 
there are no fees to participate in our screening program. Our goal is 
to incorporate mental health evaluations as a routine part of medical 
care for teens.
    To accomplish this goal, the National Center is exploring 
partnerships with primary care providers, mental health organizations 
and elected officials in the nation's Capitol and state capitols across 
this country. The National Center currently has collaborations with 
eight primary care entities in six states. These partnerships are 
exploring effective models of incorporating teen mental health checkups 
into wellness and other health care visits. They include:

   Cincinnati Children's Hospital Emergency Department, Ohio
   Federally Qualified Community Health Center, New York
   ValueOptions, New York and Colorado
   GHI, HIP and Emblem Health, New York
   Kaiser Permanente, Colorado
   Aurora Health Care, Wisconsin
   Nevada EPSDT, Clark County Children's Mental Health 
        Consortium and the Nevada Office of Suicide Prevention, Nevada

    The National Center also has community-based mental health 
screening programs operating in over 530 communities, 11 of which are 
focused on tribal populations. The communities focused on tribal 
populations include:

   Bena, Minnesota
   Juneau, Alaska
   Las Cruces, New Mexico (three sites)
   Ruidoso, New Mexico
   Belocourt, North Dakota (two sites)
   Fort Yates, North Dakota
   Wakpala, North Dakota
   Anadarko, Oklahoma

    As Congress considers steps needed to reform our nation's health 
care system, we urge you to incorporate much needed changes and 
improvements to the care delivered to our AI/NA populations, in 
particular the mental health services available to AI/NA youth. One 
critically important and cost-effective step Congress can take is to 
integrate mental health checkups into the annual exams and medical 
visits America's young people, and in particular AI/NA youth, receive. 
Doing so will provide the foundation from which to build other 
improvements and take the first, and most important step, toward 
reducing the rate of suicide within our tribal communities.
    Thank you for the opportunity to testify. I stand ready to help the 
members of this Committee develop policies that will improve the lives 
of AI/NA youth.
              Prepared Statement of the Oglala Sioux Tribe

  Prepared Statement of Brian Patterson, President, United South and 
                          Eastern Tribes, Inc.

 Prepared Statement of Rodney Bordeaux, President, Rosebud Sioux Tribe
    On behalf of the Rosebud Sioux Tribe in South Dakota, I appreciate 
the opportunity to submit written testimony regarding the youth suicide 
crisis occurring on the Rosebud Sioux Tribe Reservation. The 877,831-
acre Rosebud Reservation is located in south-central South Dakota 
consisting of 20 communities within a four county area (Tripp, Todd, 
Mellette and Gregory counties) and borders Pine Ridge to the northwest 
corner and Nebraska to the south. Our tribal headquarters is located in 
Rosebud, SD. Approximately 19,000 members of approximately 26,000 
members are domiciled on the Rosebud Reservation.
    I, thank you for convening this important hearing on youth suicide 
in Indian Country. Sadly, the Rosebud Reservation has tragically lost 
many of our youth and young people to suicide completions. From January 
2005 through January 2009 Rosebud has had 37 suicide completions, 617 
suicide attempts, and 629 suicidal ideations. Indian Health Service 
(I.H.S.) reported 1,272 encounters with different individuals who have 
completed, attempted or had suicidal ideation. The Rosebud Sioux Tribe 
has the highest suicide rate in the nation for 10-24 year old males. 
These are alarming statistics originating from our Reservation. I look 
forward to working with you and the Senate Indian Affairs Committee in 
addressing and bringing further awareness to this crisis, which is 
devastating our communities and Indian Country.
    I need to emphasize that Rosebud is working to develop and provide 
cultural suicide prevention and youth programs. However, we have an 
overwhelming need for resources to provide these programs. We have 
developed programs to assist with basic public safety and awareness, 
substance abuse and mental health, as well as the Boys and Girls Clubs 
on the Reservation. Additionally, we are supporting our families and 
communities through our cultural and educational programs.
Wiconi Wakan Health and Healing Center
    Rosebud is located in a rural, remote area of Indian Country and 
relies heavily on funding from the I.H.S. and Bureau of Indian Affairs 
(BIA) to provide services and resources to our tribal members. Due to 
I.H.S. and BIA being consistently under-funded, we have turned to our 
Congressional delegation for assistance in procuring additional 
resources for substance abuse and mental health treatment facilities 
and equipment. Rosebud identified a need to create a culturally-based 
suicide prevention treatment program and facility specific to our 
    Rosebud has worked diligently for nine years to obtain funding, to 
build the current 20-bed treatment facility for mental health, which 
has been open for three years. It remains necessary to develop 
additional youth programs to assist in recovery and rehabilitation. 
Therefore, Rosebud is establishing the Wiconi Wakan (Sacredness of 
Life) Health and Healing Center, a place to implement the Tribal Youth 
Suicide Prevention and Early Intervention Project plan targeting 
Rosebud children and youth (ages 10-24 years old) on the Rosebud 
    Inherently our youth are sacred and a vital asset to the people of 
the Sicangu Lakota Oyate. Suicide has created a destructive ripple in 
the very structure of our Lakota Oyate. The effects of suicide will be 
felt for generations. The Wiconi Wakan Health and Healing Center will 
provide a venue for reviving the life of our people.
    The Wiconi Wakan Health and Healing Center will significantly 
contribute to the available scientific knowledge on the mental health 
status and delivery of services to children and youth on the Rosebud 
Reservation regarding Tribal Youth Suicide Prevention and Intervention 
and will provide a valuable template for replication by other Tribal 
communities throughout the country. Rosebud has developed a Suicide 
Prevention plan to advocate and coordinate a culturally comprehensive 
community-based approach to reduce suicidal behaviors and suicides in 
the Sicangu Lakota communities while facilitating wellness.
    The primary purposes of the Wiconi Wakan Health and Healing Center 
is to strengthen, implement and develop culturally and linguistically 
appropriate youth suicide prevention and early intervention services 
for Rosebud tribal members. This level of intervention will include 
screening programs, gatekeeper training for ``frontline'' adult 
caregivers and peer ``natural helpers,'' support and skill building 
groups for at-risk Rosebud youth, and enhanced accessible crisis 
services and referrals sources. To be directly informed by parents, 
youth, and providers within the Rosebud Reservation. To increase 
awareness of the signs of suicide amongst community, parents, and 
youth, working collaboratively with other agencies, providers and 
organizations sharing information and resources by promoting awareness 
that suicide is preventable.
    Rosebud will implement the public health approach to suicide 
prevention as outlined in the Institute of Medicine Report, ``Reducing 
Suicide: A National Imperative.'' This approach focuses on identifying 
broader patterns of suicide and suicidal behavior, which will be useful 
in analyzing data collected and monitoring the effectiveness of 
services provided. Rosebud will focus on methodology research on 
suicide and suicide prevention by providing consistent leadership and 
monitoring of suicide prevention activities.
Collaborative Effort
    Recognizing our overwhelming need, the Department of Health and 
Human Services (HHS) deployed officials from the I.H.S. to spend 
extended lengths of time on our Reservation and address our youth 
suicide crisis.
    Dr. Kevin McGuinness, Ph.D., MS, JD, ABPP and Dr. Rose Weahkee 
visited the Rosebud reservation for a second time from December 4th to 
December 18th 2008. During this visit they worked collaboratively with 
Victor Douville, Sinte Gleska University Instructor and Lori Walking 
Eagle, MSW, Executive Administrative Officer for the RST--President's 
office. Discussions were held regarding systemic influences from the 
micro to the macro level within the Reservation systems. The 
Consultation process focused on cultural systems of wellness, cross 
cultural sharing of knowledge regarding organizational operations and 
development of systems with the expertise of Rosebud Tribal leadership 
to integrate ``Wolakota'' as a principal intervention that will restore 
balance through the tribe and its communities to its most vulnerable 
members. The Rosebud Sioux Tribal Council will participate and attend a 
retreat which will enhance traditional knowledge.
Wiconi Wakan ``Sacredness of Life'' Suicide Prevention Summit
    On July 1-2, 2008, Rosebud hosted the, ``Wiconi Wakan Suicide 
Prevention Summit,'' in Mission SD at the Sinte Gleska University. 
While I convened the Summit that morning, our community was burying 
another youth, which further emphasized the need to discuss and address 
this crisis affecting our people and communities. Representatives from 
the South Dakota delegation, state, local, and federal government 
officials including South Dakota Governor Michael Rounds' Secretary of 
the Department of Human Service, the Director of the South Dakota 
Indian Health Care Initiative, HHS Director of Office of 
Intergovernmental Affairs, and the Substance Abuse and Mental Health 
Services Administration (SAMHSA) Administrator as well as other 
officials from the I.H.S. and HHS along with tribal leaders, members, 
and youth attended and participated, providing experiences and insight 
in preventing future youth suicide.
    As a result of the Summit, the South Dakota Secretary of the 
Department of Human Services, Jerry Hofer, committed the state to 
opening more of its SAMHSA grants and resources to Rosebud. The state 
currently receives a Garrett Lee Smith Memorial Act grant from SAMHSA, 
which is also known as the ``Suicide Awareness Partnership Project,'' 
from the State/Tribal Youth Suicide Prevention and Early Intervention 
Program. For three years, $400,000 is given annually to the state. At 
the time of the Summit, Mr. Hofer indicated that the state is in its 
2nd year of the grant. The purpose of the Suicide Awareness Partnership 
Project is to reduce suicide attempts and completions in South Dakota 
for youths aged 14-24 in 25 high schools and two universities. Mr. 
Hofer reported that the Todd Country School District and St. Francis 
Indian School, both located on the Rosebud Reservation whom serve our 
youth, are pilot schools in the project as is the Sinte Gleska 
University. Mr. Hofer reported that the state has specifically 
contracted with the Sinte Gleska University to provide awareness and 
prevention activities on the Rosebud Reservation.
    Rosebud is extremely appreciative of the state providing resources 
to our schools and youth through the SAMHSA grant. We understand that 
the grant will be nearing its three-year term and are concerned as to 
how these programs will continue to operate once the grant is 
exhausted. We have overwhelming needs in our communities including a 
need for additional resources to build upon and expand on these 
imperative programs to ensure our youth are given opportunities for 
suicide prevention. At Risk Tribes should be allowed to receive block 
grants like the states from SAMHSA.
    None of the Block Grant funding reaches the tribal government for 
program development and suicide prevention efforts. Currently, the Red 
Lake Band of Chippewa (Minnesota) are the only federally recognized 
tribe included with the States that receive Block Grant Funding. 
Regarding our current suicide crisis the Rosebud Sioux Tribe should be 
allocated and allowed to receive Block Grant Funding to eliminate 
suicides on our Reservation. Because of our Government to Government 
relationship which we enjoy with the federal government we should not 
be restricted from receiving Block Grant Funding. Due to the high rate 
of suicides in Indian Country Block Grants should be available to those 
tribes experiencing the loss of their youth to suicides.
Need for Resources to Provide Programs to our Youth
    Rosebud has several programs to provide activities and resources to 
our youth. However, in each of these areas, funding resources are 
continually problematic for the viability and expansion of the 
programs. We need a major infusion of funding to serve and support 
youth in our communities to further their skill sets and provide for 
training and increase opportunities.
    I will now outline several programs which have been proven to be 
effective for our tribal youth.

   Sicangu Nation Employment and Training Program (SNETP)

    The Sicangu Nation Employment and Training Program serves' our 
youth in the following areas: work experience, on-the-job training, and 
classroom training. The SNETP receives approximately $208,148 annually 
to serve the Rosebud Sioux Tribe and approximately 20% of the Crow 
Creek Sioux Tribe youth.
    Additionally, the SNETP has developed and implemented several 
unique programs which serve our tribal youth:

   Youth Conservation Corp--a collaborative effort with 
        Rosebud, Yankton, Standing Rock, and Cheyenne River Sioux 
        Tribes with the U.S. Forest Service--allows our youth to gain 
        experience in the forestry field while spending time in our 
        sacred Black Hills area;

   Straw Bale Home Initiative--teaches our youth how to build a 
        straw bale home from start to finish in collaboration with the 
        SNETP and Sicangu Wicoti Awayankapi (Housing Authority). This 
        program operates on a ``green works'' concept; serving the dual 
        purpose of providing for less-expensive homes, and meeting 
        Reservation housing shortage needs.

   Habitat for Humanities--teaches our youth to build a 
        standard home earning a one-year building credit certificate at 
        our local university. Upon obtaining the one-year certificate, 
        our youth are offered full-time employment with the housing 

   Penn Foster Online High School Diploma Program--allows our 
        youth (18 to 21 years old) to obtain their high school diploma 

   Solar Heat Panel Training and Installation--a collaborative 
        effort by the SNETP and Sicangu Wicoti Awayankapi teaches youth 
        a ``green works'' concept that conserves our natural resources 
        while utilizing solar energy to heat homes.

    During the summer of 2008, the SNETP received 689 summer youth 
applications only 200 youths could be served due to funding 
constraints. Over two-thirds of interested students reaching out for 
assistance had to be turned away. Increased funding for the SNETP's 
youth employment program could have a major, positive impact on our 
tribal youth, especially with the high number of suicides that our 
community has experienced in the past few years. Increased funding will 
provide for additional resources to extend to the overwhelming number 
of youth we have been unable to serve. We strive to keep our youth 
occupied by increasing services in the form of employment, incentives 
for accomplishments, and supportive services in their endeavors to 
overcome barriers.

   Community Emergency Response Team (CERT) Training Sessions

    Rosebud received funding in 2008 for CERT Training Sessions for our 
youth, which were extremely effective in training, providing knowledge 
and skill sets regarding emergency medical response and preparedness. 
Rosebud held two sessions of CERT training, which trained over 100 
youth in our communities. The tribal youth that were trained under this 
program developed important set of skills which led to aiding tribal 
members in emergency medical situations and prevention. Rosebud has a 
major need to continue providing this vital training opportunity for 
our tribal youth. The CERT Training prepares our youth for emergencies 
and events for when our Emergency Medical Services arrive on the scene. 
The training empowers our tribal youth to seek medical positions. 
Having trained tribal youth in our communities provides increased 
medical and public safety, especially in light of our expansive rural 
Reservation. Rosebud greatly supports this program and seeks to receive 
additional funding to serve more of our tribal youth.

   Boys and Girls Clubs

    To be completely effective in helping prevent youth suicide we need 
Boys and Girls Club centers in all 20 of our communities. Rosebud has 
20 communities on the Reservation, but there are only three small Boys 
and Girls Clubs. Despite this fact, the Rosebud Sioux Tribe Boys and 
Girls Club plays' an important role in providing activities and a 
central place for our youth to gather. To fully reach all of our tribal 
youth on the Reservation, we need funding to provide additional 
recreational facilities, activities and programs for all of our 
    Rosebud understands and has intimately experienced the devastation 
youth suicide has on our families, communities, and Tribe. With 37 
suicide completions in less than five years, Rosebud is deeply 
concerned and focused on preventing suicides on our Reservation. 
Although we are working to develop and expand our programs by 
incorporating culturally-based components and curriculums, funding and 
resources remain a major obstacle. The federal government has a trust 
responsibility to Tribes, and Rosebud greatly appreciates the 
collaborative efforts among the state and federal government. However, 
we still have major needs and funding deficiencies that must be 
addressed. To increase the number of highly-trained individuals 
specialized in suicide prevention for each of our communities would be 
monumental in addressing our crisis.
    We need additional resources and flexibility in the use of funding 
to provide, create, and maintain programs that incorporate culturally-
based components that connect and are tailored for our youth. Tribes 
need access to resources, trained health care professionals, and 
prevention programs to adequately address this crisis that continues to 
plague our Reservation.
    Thank you, for holding this very important hearing for Indian 
Country, giving us the opportunity to express our views and concerns 
regarding tribal youth suicide.
  Prepared Statement of Leroy M. Not Afraid, Member, Great Crow Nation
    My name is Leroy M. Not Afraid! I am a teenage suicide survivor! I 
am enrolled member to the Great Crow Nation in Montana! I am also the 
Justice of the Peace for Big Horn County, Montana.
    The signs of teenage suicide are not always obvious. Often we may 
make the mistake that a young person has to be into drugs, gangs, or 
other negative behavior's concerning the prerequisites of teen suicide. 
My story will give you a different point of view;
    In 1989, I was a teenager that was looking for attention in the 
realm of education and athletics! I became the ideal student-athlete. 
What the public did not see or know behind the show I presented was 
hurt, pain, and fear. I was using the glamour of being an outstanding 
citizen to hide the anguish I felt as a young person! I did not want 
the world to see who I really was. I acquired A's and B's, became 
Student Body President, and became the captain of both the basketball 
and cross country teams to hide who I really was. A young man with no 
other alternative's! I thought being the best in everything would bring 
me serenity and hope for the future. It did not, as I would look in the 
mirror on a daily basis, ``I was ashamed of who I was and where I came 
from!'' I wanted to die!
    Then one evening, I was home alone in my bed room. I loaded my 6mm 
hunting rifle, put it under my chin and I wanted to pull the trigger! I 
thought of my childhood being born and raised on the Crow Indian 
reservation. I asked the question(s), ``Why didn't my own parents raise 
me? Why did my grandparents raise me? Why are my natural parent's 
alcoholics? Why did my natural mother run from me when I tried to take 
her home while she lived the on the streets of Skid row? Why does not 
my father visit me when he says he is?'' These very same questions are 
being asked by today's youth. ``I know'' I visit with them in the 
courtroom on a daily basis. I meet with them as I go on the road 
throughout Indian country as a motivational speaker on suicide issues.
    I understand the loneliness, depression, oppression, and anguish 
the young people feel in Indian Country! I am one of them. The signs 
are deep and real. We must work together in unity to fight this 
horrible situation. Suicide after all is a permanent solution for a 
temporary problem.
    Today, I look back! By the grace of the Creator I did not pull the 
trigger. I got the help I needed! I got into counseling and very 
involved in my native spiritual ways! That's what saved my life.
    So many young lives have been cut short! Potential lost forever! 
The young ones never live their dreams. Leroy Not Afraid has gone on to 
become the First Native American elected as Justice of the Peace in 
Montana's History! Thank God, ``I did not pull the trigger!''
    Thanks for listening! I would love to share my story with members 
of congress! AHO!
  Prepared Statement of Hayes A. Lewis, Director, Center for Lifelong 
              Education, Institute of American Indian Arts

Prepared Statement of James Gallanos, LCSW Project Coordinator, Office 
 of Prevention and Early Intervention Services, Division of Behavioral 
Suicide Rates in Alaska
    Alaska has recently adopted the Alaska Violent Death Reporting 
System (AK VDRS) which is continuing developing itself as a more 
reliable system of reporting suicide information. We have three years 
of data from 2003-2005 and will continue this grant for at least two 
more years. I attached some preliminary reports/PowerPoint slides 
above. We also conducted a study, the Alaska Suicide Follow Back Study 
between 2003-2006 as well as rates for Alaska Native youth over past 
sixteen years (page 13) up to 79 per 100,000 and higher based on other 
reports that combine region with race and age. In general . . . Alaska 
Natives account for about 16 percent of the state population but 
account for 39 percent of all suicides. More recent Vital Statistics 
data show a 5 year running balance (srrates 97-06) and seeing a slight 
decrease in the Northwest region which is typically highest in the 
State. See project below in this region.
    Project Life in Kotzebue. GLSMA SAMHSA youth grant (See description 

   Lisa Wexler research on acculturation and Inupiat youth 

    Suicide Prevention Training

   Gatekeeper Suicide Prevention Training (statewide training 
        and train the trainer model)

   Youth/children residential treatment training protocols

          --Division of Juvenile Justice, trainer, Lindsey Hayes 
        (PowerPoint) *

    * The information referred to has been retained in Committee files 
and can be found at www.ncdjjdp.org/resources/policy_manual/
          --Office of Children's Services/Alaska Children's Services 
        training of residential programs.

    Native Aspirations Project

   Kaufman and Associates (see testimony) no other information 
        on outcomes of this independent project.

   American Indian Life Skills training (Theresa LaFramboise)

    Comprehensive Prevention and Early Intervention Grants (statewide 
DHSS program)


    The Statewide Suicide Prevention Council (2008 annual report 
attached [last slide Ak Native and US incorrectly placed]).


    GLSMA SAMHSA youth suicide prevention State proposal for FY09

   See attached abstract.

   Prepared Statement of Emilio Rios, Member, Three Affiliated Tribes

  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                   Eric B. Broderick, D.D.S., M.P.H.

   Response to Written Questions Submitted by Hon. John Barrasso to 
                   Eric B. Broderick, D.D.S., M.P.H.

   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                   Eric B. Broderick, D.D.S., M.P.H.

  Response to Written Questions Submitted by Hon. Byron L. Dorgan to 
                         Hon. Robert G. McSwain

   Response to Written Questions Submitted by Hon. John Barrasso to 
                         Hon. Robert G. McSwain

   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                         Hon. Robert G. McSwain

     Response to Written Questions Submitted by Hon. Tom Coburn to 
                         Hon. Robert G. McSwain

**Response to the following written questions was not available at the 
        time this 
        hearing went to press**
            Written Questions Submitted to Hon. Robert Moore

          Written Questions Submitted to R. Dale Walker, M.D.

             Written Questions Submitted to Hayes A. Lewis 

      Written Questions Submitted to Teresa D. LaFromboise, Ph.D.