    [Senate Hearing 111-365]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 111-365

     S. 1635, SEVENTH GENERATION PROMISE: INDIAN YOUTH SUICIDE PREVENTION
                                  ACT OF 2009

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

                                    HEARING

                                   before the

                          COMMITTEE ON INDIAN AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 10, 2009

                                   __________

             Printed for the use of the Committee on Indian Affairs

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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
    JON TESTER, Montana
    TOM UDALL, New Mexico
    AL FRANKEN, Minnesota
          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

                                  ----------
                                                                       Page
    Hearing held on September 10, 2009...............................     1
    Statement of Senator Barrasso....................................     5
    Statement of Senator Dorgan......................................     1
    Statement of Senator Franken.....................................     6
        Prepared statement...........................................     6
    Statement of Senator Johanns.....................................     4
    Statement of Senator Udall.......................................     6

                                   Witnesses

    BigFoot, Dolores Subia, Ph.D., Director, Indian Country Child
      Trauma Center and Project Making Medicine, University of
      Oklahoma Health Sciences Center................................    19
        Prepared statement with attachment...........................    21
    Broderick, Hon. 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........................    13
        Prepared statement...........................................    15
    Roubideaux, Hon. Yvette, M.D., M.P.H., Director, Indian Health
      Service........................................................     7
        Prepared statement...........................................     9

                                    Appendix

    Franklin, Reno Keoni, Chairman, National Indian Health Board
      (NIHB), prepared statement.....................................    35
    Keita, Gwendolyn Puryear, Ph.D., Executive Director, Public
      Interest Directorate, American Psychological Association (APA),
      prepared statement.............................................    41
    National Congress of American Indians (NCAI), prepared statement.    37
    Response to written questions submitted by the Committee from Dr.
      Ellen Gerrity..................................................    55
    Response to written questions submitted to Dolores Subia BigFoot,
      Ph.D. by:......................................................
        Hon. Byron L. Dorgan.........................................    44
        Hon. Tom Udall...............................................    51
    Written questions submitted by the Committee to:
        Hon. Eric B. Broderick, D.D.S., M.P.H........................    58
        Hon. Yvette Roubideaux, M.D., M.P.H..........................    61

                     S. 1635, SEVENTH GENERATION PROMISE:
                  INDIAN YOUTH SUICIDE PREVENTION ACT OF 2009

                                  ----------

                          THURSDAY, SEPTEMBER 10, 2009

                                           U.S. Senate,
                                   Committee on Indian Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:47 p.m. in room
    628, Dirksen Senate Office Building, Hon. Byron L. Dorgan,
    Chairman of the Committee, presiding.

              OPENING STATEMENT OF HON. BYRON L. DORGAN,
                     U.S. SENATOR FROM NORTH DAKOTA

        The Chairman. We will now call the hearing to order.
        We are pleased today to have three witnesses join us. This
    hearing is on the subject of S. 1635, the Indian Youth Suicide
    Prevention Act.
        We have the Honorable Yvette Roubideaux, who is the
    Director of the Indian Health Service, of the U.S. Department
    of Health and Human Services. We very much appreciate your
    being here.
        The Honorable Eric Broderick, who is the Acting
    Administrator of SAMHSA, the Substance Abuse and Mental Health
    Services Administration.
        And Dr. Dolores Subia BigFoot, Ph.D., Associate Professor,
    University of Oklahoma at the Health Sciences Center, who will
    testify on behalf of the American Psychological Association.
        We appreciate very much your attendance.
        Today we are going to hold this hearing to examine S. 1635,
    the Indian Youth Suicide Prevention Act. We believe this bill
    will help address the high rates of youth suicide on Native
    American communities and improve access, especially to mental
    health services. Suicide is hitting our Native youth like an
    epidemic in some areas of this Country. And it is critical, I
    believe, that we move quickly and respond aggressively.
        The rate of suicide of Native American youth is not double,
    it is three and a half times higher than the general U.S.
    population. We have a chart that shows the suicide rates by
    race and gender in this Country. You will see the rates of
    suicide of American Indians.

        Native American male and female teens have a higher rate of
    suicides than Asians, Hispanic, African American, Caucasians.
    In fact, the rate of Native American male youth is almost
    double that of the next highest racial group, which is male
    Caucasians. Chart two shows the disparity in the youth suicide
    rates in my home State. The top line shows the rate of suicide
    for Native Americans 10 to 24. The bottom line shows the rate
    for Caucasians. Even when the incidence of Native American
    suicide is the lowest, the rate is still more than double that
    of Caucasian youth.
        These charts show statistics. They fail, however, to show
    the cluster of suicides that can impact a community. The
    Standing Rock Sioux Reservation, which traverses North and
    South Dakota borders, had 53 suicide attempts this year, 10 of
    them which were completed. The members of this community are
    experiencing extreme trauma and need more resources and help.
        This past February, when we held a hearing on teen suicide,
    a young woman named Dana Lee testified before this Committee
    about the loss of her little sister, Jami Rose. Jami Rose's
    picture is here on this chart, a beautiful little 14 year old
    girl from the Spirit Lake Nation in my home State of North
    Dakota. Last year, Jami took her life. Jami's mom had noticed
    that Jami seemed troubled. She took her daughter to the doctor,
    had her evaluated by mental health professionals from the
    Indian Health Service. The doctors dismissed her mom's concern
    and diagnosed her as being a typical teenager.

        Jami did not obtain the services she needed last November,
    and Dana Lee found her younger sister hanging in her bedroom.
        Sadly, Jami's story is one we hear far too often in Indian
    Country. I have told the story often on the Floor with the
    consent of relatives of Avis Little Wind. Actually, Avis was
    from the same reservation. She laid in a bed for 90 days in a
    fetal position. Her sister had taken her life, her mother was a
    substance abuser, her father had taken his life. And this young
    lady sort of dropped out and nobody noticed for three months
    that she wasn't in school. She was lying alone in bed in a
    dysfunctional family until they found her hanging in her closet
    at age 14. Hopeless, helpless, without the ability to get the
    services that we would expect for most teenage children in
    trouble.
        We need to do much better than that, and that is the reason
    we have put together legislation to try to address these
    issues. This is all too silent an epidemic in this Country, and
    we aim to try to address it in a significant way.
        I want to, because Senator Johanns has another hearing that
    he is supposed to be at, I want to, with the courtesy of my
    colleagues, call on Senator Johanns for a statement.

                    STATEMENT OF HON. MIKE JOHANNS,
                       U.S. SENATOR FROM NEBRASKA

        Senator Johanns. Mr. Chairman, thank you very much. And to
    my colleagues, thank you for the courtesy. I appreciate it. I,
    like all Senators, am learning that the biggest challenge we
    face is being in two places at once. So I do appreciate this.
        I would like to offer a few thoughts on what we are doing
    here this afternoon. I think it is enormously important. I
    would like to address the challenges of providing mental health
    services to our Native American youth. I want to issue my
    strongest, without reservation, support of S. 1635, the Seventh
    Generation Promise: Indian Youth Suicide Prevention Act of
    2009. In my home State, the State of Nebraska, we have four
    Native American tribes. They are just the most wonderful
    people. I have enjoyed working with them as a Senator and as a
    Governor and even as a mayor.
        However, the suicide statistics in Indian Country would
    have to concern anyone. They deeply concern me. Native American
    young people have the highest suicide rate of any population
    group in the United States. The charts really do tell the
    story.
        Alarmingly, the rate of suicide amongst Indian children in
    the northern Great Plains is 10 times higher, 10 times higher
    than the national average. Ninety percent of all Indian teens
    who commit suicide have a diagnosable mental illness at the
    time of their death. Yet more than half of these young people
    have never seen a mental health professional.
        One effective way to reach these youth who are often in
    remote locations is through tele-medicine. A trained
    professional, through video conference, can do psychiatric
    assessments, complete diagnostic interviews, intervene with
    crisis counseling and provide needed mental health services. I
    could not be more pleased to be a sponsor of this important
    legislation. Key provisions of the legislation I believe will
    help transform how we deliver mental health services in this
    Country.
        It is certainly a step in the right direction. For example,
    this bill authorizes the Department of Health and Human
    Services to carry out a project for tele-mental health services
    targeted to Native American youth. The goal is to provide
    mental health services to those Indian youth who have expressed
    suicidal thoughts, have attempted suicide or who have mental
    health conditions that could increase the risk of suicide. The
    legislation would also address the barriers Indian tribes and
    tribal organizations face when applying for Substance Abuse and
    Mental Health Services Administration grants.
        The legislation would require that this process be
    streamlined and take into account the unique obstacles that
    Indian tribes experience when applying for these grants. It
    would also give priority for youth suicide prevention grants to
    those Indian tribes and tribal organizations that have high
    youth suicide rates and prevent them from being disqualified
    from the grant application process, because they may not have
    the capability to extensively collect the data or have the
    advanced infrastructure in place to put that data there.
        Finally, the bill would encourage the use of pre-doctoral
    psychology and psychiatry interns to provide mental health
    services in Indian Country where appropriate. Increasing the
    number of interns will help increase access to services, I
    believe, and serve as a valuable recruitment tool. My hope is
    that somebody who has this experience decides to stay in Indian
    Country.
        With the impressive advancement technology in tele-medicine
    and with the tools that are at our disposal, living in an
    isolated rural area, which is oftentimes the case in all of our
    States, should not prevent a young person from getting
    services. I believe, again, that this is an important step in
    the right direction.
        Mr. Chairman, I will wrap up and just say, I so appreciate
    your leadership on this, and the Ranking Member. I said at the
    first hearing I attended on Indian Affairs I thought this was
    one of our key issues to work on. I really think that if we can
    get started today, this will be a step, an important step in
    the right direction. Thank you.
        The Chairman. Senator Johanns, thank you very much, and
    thanks for your work on and your attention to this issue. It is
    very important to this Committee.
        I am going to call on others here for any statements. I am
    trying to determine, I believe we originally had a vote
    scheduled at 3:30. I am trying to determine whether that is the
    case. But let me call on Senator Barrasso, the Vice Chairman.

                   STATEMENT OF HON. JOHN BARRASSO,
                       U.S. SENATOR FROM WYOMING

        Senator Barrasso. Thank you very much, Mr. Chairman. These
    statistics are tragic. The personal stories compel action. It
    is inconceivable to me now that the Indian Health Service is
    reporting suicides among children as young as five years old.
        I appreciate this legislation which attempts to address the
    lack of mental health services for these children, especially,
    as Senator Johanns talks about, through the tele-health
    services. According to the Indian Health Service, currently
    over 30 IHS and tribal facilities in 8 IHS areas are augmenting
    on-site behavioral health services with tele-behavioral health
    services.
        This past spring, the previous director of the Indian
    Health Service testified before this Committee regarding the
    National Tele-Behavioral Center of Excellence. It was in the
    planning stages and was intended to provide increased access to
    video-conference-based behavioral health services. I hope, Dr.
    Roubideaux, that you can update us on the status of this Center
    of Excellence.
        I look forward to hearing from all the witnesses on how
    this legislation can help provide an accountable system for
    addressing and preventing Indian youth suicide.
        Thank you, Mr. Chairman.
        The Chairman. Senator Barrasso, thank you very much.
        Senator Udall?

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

        Senator Udall. I just wanted to briefly, Chairman Dorgan,
    say thank you again for focusing on this issue, and thank you
    for focusing our attention on youth suicide in Indian Country.
        The figures that you put up on North Dakota, those figures
    are very similar in New Mexico. We all know we have a national
    tragedy with this problem. Former Senator Gordon Smith, my
    cousin, also had a young son, Garrett. Garrett committed
    suicide while Gordon was in the Senate. Gordon used that
    tragedy to provide leadership and pass the Garrett Lee Smith
    Act, which has provided grants and momentum to bring some
    really thoughtful approaches to this particular tragedy.
        So I thank you again for bringing our attention to this and
    really look forward to our leaders here giving us the way they
    see it and what they think we need to do. Thank you, Chairman
    Dorgan.
        The Chairman. Senator Franken?

                     STATEMENT OF HON. AL FRANKEN,
                      U.S. SENATOR FROM MINNESOTA

        Senator Franken. Thank you, Mr. Chairman.
        I have an opening statement that I would like to enter into
    the record, without objection. Because I don't want to take any
    more time. I, like Senator Johanns, have to leave at a certain
    point and I apologize for that, because this is such an
    important and tragic subject. It is in Minnesota, as well.
        So I would just like to thank the witnesses for being here,
    and I want to thank Senator Johanns for introducing the bill
    and his role in that, and you, Mr. Chairman, and you, Mr. Vice
    Chairman.
        [The prepared statement of Senator Franken follows:]

       Prepared Statement of Hon. Al Franken, U.S. Senator from Minnesota
        Thank you Chairman Dorgan and Vice-Chair Barrasso for holding this
    timely and important hearing.
        Mr. Chairman, I especially want to thank you--and Senator Johanns--
    for your leadership in introducing the ``7th Generation Promise: Indian
    Suicide Prevention Act of 2009.''
        I look forward to working with both of you, and everyone on this
    Committee, to bring this legislation to the floor.
        Over the years, this Committee has held a series of hearings on the
    issue of Indian youth suicide. I was moved by Chairman Dorgan's
    recitation of Dana Lee Jetty's testimony when he introduced the bill on
    the Senate floor last month. Ms. Jetty's testimony about the loss of
    her 14-year-old sister is just one more sobering reason why this
    legislation is so badly needed.
        Across the country, American Indian teens commit suicide at a rate
    at least twice the national average. The rate is much higher in the
    Upper Midwest and Great Plains, where it is five to seven times higher
    than the national average.
        In 2004--one of the most recent years data is available--three
    teens committed suicide on the Red Lake Indian Reservation in
    Minnesota; and a shocking 69 teems attempted it.
        Even more shocking, in a survey of ninth-grade girls at Red Lake
    High school, 81 percent said they had thought about suicide at least
    once in their life; and nearly half said they attempted it.
        Sadly, this problem is not just limited to a few reservations.
        Clearly, it is a complex problem with no easy solution. I look
    forward to hearing from our panelists on how to best deal with this.

        The Chairman. Senator Franken, thank you very much.
        Dr. Roubideaux, I indicated when you took this job, and I
    was very pleased to support your nomination, that you inherited
    a pretty big task. But I appreciate your doing that, and today
    we asked you to come and talk to us about a very sensitive
    issue. It is difficult to talk about, and sensitive to talk
    about the issue of suicide, youth suicide. In some cases, some
    would perhaps sooner not have it discussed publicly. But the
    fact is, we must. We can no longer ignore this.
        So let me ask you to begin. We appreciate very much your
    being here. Your entire statement will be a part of the record,
    I would say to all three witnesses. And we would ask that you
    summarize.
        Dr. Roubideaux?

     STATEMENT OF HON. YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR,
                         INDIAN HEALTH SERVICE

        Dr. Roubideaux. Thank you, Mr. Chairman, Mr. Vice Chairman
    and members of the Committee.
        Good afternoon. My name is Dr. Yvette Roubideaux and I am
    the Director of the Indian Health Service. I appreciate the
    opportunity to testify on S. 1635.
        As you know, the Indian Health Service plays a unique role
    because it is a health care system that was established to meet
    the Federal trust responsibility to provide health care for the
    1.9 million American Indians and Alaska Natives it serves.
        We are acutely aware that many American Indian and Alaska
    Native communities are affected by high rates of suicide. The
    most recent IHS data report that American Indian and Alaska
    Native suicide rate is 1.7 times that of the U.S. all races
    rate. Suicide is the second leading cause of death for Indian
    youth age 15 to 24, and is 3.5 times higher than the national
    average. American Indian and Alaska Native young people age 15
    to 34 make up 64 percent of all suicides in Indian Country.
        The current system of services for treating mental health
    problems of American Indians and Alaska Natives is a complex
    and often-fragmented system of tribal, Federal, State, local
    and community-based services. The availability and adequacy of
    mental health programs for American Indians and Alaska Natives
    varies considerably among tribes. The Indian Health Service
    Mental Health and Social Services program is a community-
    oriented clinical and preventive mental health services program
    that provides primarily outpatient mental health and related
    services, crisis triage, case management, prevention
    programming and outreach services.
        As you know, suicide is a complicated public health
    challenge with many contributing factors and barriers to care
    in American Indian and Alaska Native communities. There are
    many reasons for the lack of access to care. Indian Country is
    predominantly rural and remote and local care may be limited.
    Rural practice is often isolating and challenging for its
    practitioners and even well-seasoned and balanced providers
    risk burnout. Many of the IHS tribal and urban mental health
    programs that provide services do not have enough staff to
    operate 24/7. Therefore, when an emergency or crisis occurs,
    the clinics and service units will often contract out such
    services to non-IHS hospitals and crisis centers.
        Tele-health based behavioral health services are a
    promising strategy to address these access to care issues. We
    know that these services work and are acceptable to many, if
    not all, of our clinic populations. As a system of care, these
    services are either being used or are in planning stages in
    over 50 Indian Health System sites. Services being delivered
    range from settings including clinics, schools, youth and
    treatment centers.
        We also have the methamphetamine and suicide prevention
    initiative, which is another coordinated program designed to
    promote the development of evidence-based and promising
    practices using culturally appropriate prevention and treatment
    to address methamphetamine abuse and suicidal behaviors in a
    community-driven context. IHS is using this funding to
    establish a national tele-behavioral health center of
    excellence to provide technical support nationally to programs
    attempting to implement such services.
        We have preliminary indications that IHS programs are
    increasingly adopting and using these technologies. IHS is
    using Recovery Act funding to improve our telecommunications
    infrastructure, to increase the reliability and availability of
    appropriate bandwidth across the Indian Health system. We are
    investing in the infrastructure expansion support and
    maintenance needed to keep pace with potential service demands
    and to plan for the long-term success of this and any new
    Indian tele-mental effort.
        We see many benefits of the use of tele-medicine for the
    treatment of youth suicide. It can connect many isolated
    programs in a web of support with a much larger array of
    services that is more cost-effective and convenient for
    patients. Such a system could potentially translate into 24/7
    access to emergency behavioral health services in any setting
    with an adequate telecommunications service.
        Such a system has other desirable consequences, such as
    filling gaps in provider coverage, allows providers with
    specialty interests to share their skills and knowledge with
    others in isolated locations, reducing provider burnout and
    professional isolation and improves recruitment for providers
    that can live and practice in urban areas rather that isolated
    locations. Families can also participate in care, even when at
    a distance from their youth.
        We believe tele-health programs can become an integrated
    part of the IHS behavioral health services, strengthen our
    clinical expertise and expand access to needed behavioral
    health care. The additional services proposed in this
    legislation could help facilitate our ability to provide needed
    services.
        In summary, we look forward to opportunities to work with
    this Committee to address the critical problem of youth suicide
    in Indian Country.
        Mr. Chairman, this concludes my statement. Thank you for
    the opportunity to testify. I will be happy to answer any
    questions you may have.
        [The prepared statement of Dr. Roubideaux follows:]

     Prepared Statement of Hon. Yvette Roubideaux, M.D., M.P.H., Director,
                             Indian Health Service
        Mr. Chairman and Members of the Committee:
        Good morning, I am Dr. Yvette Roubideaux, Director of the Indian
    Health Service (IHS). Today, I appreciate the opportunity to testify on
    S. 1635, 7th Generation Promise: Indian Youth Suicide Prevention Act of
    2009.
        As you know, the Indian Health Service plays a unique role in the
    Department of Health and Human Services because it is a health care
    system that was established to meet the federal trust responsibility to
    provide health care to American Indians and Alaska Natives. The IHS
    provides high-quality, comprehensive primary care and public health
    services through a system of IHS, Tribal, and Urban operated facilities
    and programs based on treaties, judicial determinations, and Acts of
    Congress. The IHS has the responsibility for the delivery of health
    services to an estimated 1.9 million federally-recognized American
    Indians and Alaska Natives. 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 and 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 appropriations for ``the relief of distress
    and conservation of health'' of American Indians and 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 includes 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.
    Background
        Many American Indian and Alaska Native communities are affected by
    high rates of suicide. A wide range of general risk factors contribute
    to suicide. In the case of American Indian and Alaska Native young
    people, they face, on average, a greater number of these risk factors
    individually or the risk factors are more severe in nature for them.
    Research suggests that there are factors that protect Native youth and
    young adults against suicidal behavior. These factors are their sense
    of belonging to their culture, strong tribal spiritual orientation, and
    cultural continuity.
        The soon to be published IHS ``Trends in Indian Health, 2002-2003''
    reports:

       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 the U.S. all races rate (10.8) for 2003.

       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.

       Suicide is the 6th leading cause of death overall for males
            residing in IHS service areas and ranks ahead of homicide.

       American Indian and Alaska Native young people ages 15-34
            make up 64 percent of all suicides in Indian country.

        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 to these
    services 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.
    ---------------------------------------------------------------------------
    Addressing Suicide Among American Indians
        The current system of services for treating mental health problems
    of American Indians and Alaska Natives is a complex and often
    fragmented system of tribal, federal, state, local, and community-based
    services. The availability and adequacy of mental health programs for
    American Indians and Alaska Natives 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.
    ---------------------------------------------------------------------------
        IHS and SAMHSA work closely together to formulate long term
    strategic approaches to address the issue of suicide in Indian Country
    more effectively. For example, IHS and SAMHSA are actively involved on
    the Federal Partners for Suicide Prevention Workgroup. In 2001, the
    Office of the Surgeon General coordinated the efforts of numerous
    agencies, including IHS, SAMHSA, CDC, NIMH, HRSA, and other public and
    private partners to develop the first, comprehensive, integrated,
    public health approach to reducing deaths by suicide and suicide
    attempts in the United States in the National Strategy for Suicide
    Prevention. This resulted in the formation of the ongoing Federal
    Partners for Suicide Prevention Workgroup.
        The Indian Health Service (IHS) is responsible for providing mental
    health services to the American Indian and Alaska Native population it
    serves. The IHS Mental Health/Social Service (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 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 do not have enough staff to operate 24/
    7. Therefore, when an emergency or crisis occurs, the clinic and
    service units will often contract out such services to non-IHS
    hospitals and crisis centers.
        Suicide is a complicated public health challenge with many
    contributing factors, and barriers to care in American Indian and
    Alaska Native communities. Indian Country has communities every year
    where suicide takes on a particularly ominous and seemingly contagious
    form, often referred to as suicide clusters. In these communities, the
    suicidal act becomes a regular and transmittable form of expression of
    the despair and hopelessness experienced by some Indian youth. While
    most vividly and painfully expressed in these communities, suicide and
    suicidal behavior and their consequences send shockwaves through many
    communities in Indian Country, including urban communities. The pain
    only deepens when those seeking help for their loved ones in crisis, or
    those left behind as emotional survivors of such acts, are unable to
    access adequate care.
        There are many reasons for a lack of access to care. Indian Country
    is predominantly rural and remote, and this brings with it the
    struggles of providing support in settings where appropriate local care
    may be limited. Rural practice is often isolating for its
    practitioners. The broad range of clinical conditions faced with
    limited local resources challenge even seasoned providers. Some
    providers are so overwhelmed by the continuous demand for services,
    particularly during suicide outbreaks, that even well-seasoned and
    balanced providers risk burn-out.
        For example, there are situations where the appropriate treatment
    is known, such as counseling therapy for a youth survivor of sexual
    abuse, but there are simply no appropriately trained therapists in the
    community. One of our IHS Area Behavioral Health Consultants told me
    recently that there was only one psychiatrist in her half of a large
    Western state attempting to serve both the Indian and non-Indian
    population. Despite years of effort, the IHS Area Office had been
    unsuccessful in recruiting a fulltime psychiatrist to serve the tribes
    in that region.
        Over the years, we have attempted to apply a number of remedies to
    these problems including adopting special pay incentives in order to
    make reimbursement packages more competitive, making loan repayment and
    scholarship programming available for a wide range of behavioral health
    specialties including social work, psychology, and psychiatry, along
    with active recruitment, development of the Indians into Psychology
    program, and emergency deployment of the Commissioned Corps.
    Indian Tele-health Based Behavioral Health Services
        IHS recognizes the need to support access to services and to create
    a broader range of services tied into a larger network of support and
    care. As evidenced by the Alaska experience, where there are often no
    workable options other than tele-health based behavioral health
    services, we know such services work and are acceptable to many if not
    all of our clinic populations. As another example, a Southwest tribe
    has been providing child and youth-specific tele-behavioral services
    for the past two years and has achieved a show rate of >95 percent for
    scheduled appointments. This is an outstanding rate when other clinics
    with face to face provider availability only achieve a 65-70 percent
    show rate.
        As a system of care, tele-health based behavioral health services
    are either actively being used or in planning stages for over 50 Indian
    health system sites (both tribal and federal). They include a range of
    programming, from a broad variety of mental health services, to
    specific and intermittently available services such as child psychiatry
    consultations. Services are being delivered in a range of settings
    including clinics, schools, and youth treatment centers. Only within
    the past five years has the telecommunications infrastructure, in some
    locations, become available and reliable enough to be used routinely
    for clinical care. The lack of infrastructure is a significant issue
    for most tribal communities.
        The Methamphetamine and Suicide Prevention Initiative (MSPI) is
    another coordinated program designed to provide prevention and
    intervention resources for Indian Country. This initiative promotes the
    development of evidence-based and promising practices using culturally
    appropriate prevention and treatment to address methamphetamine abuse
    and suicidal behaviors in a community-driven context. IHS is using the
    MSPI funding to promote adoption of technologies on a larger, system
    wide basis. For example, in the California and Oklahoma Areas, programs
    will benefit from MSPI grants supporting increased access through tele-
    health service delivery.
        MSPI dollars in the amount of $863,000 are also being used to
    establish a National Tele-Behavioral Health Center of Excellence. An
    intra-agency agreement was signed in early August with our Albuquerque
    Area Office, which has agreed to take the lead on establishing a
    national center to promote and develop tele-health based behavioral
    health services. They are working in partnership with a number of
    regional entities including the University of New Mexico and the
    University of Colorado. The University of New Mexico Center for Rural
    and Community Psychiatry is a leader in the use of tele-health
    technologies in rural settings. The University of Colorado Health
    Sciences Center and the VA Eastern Colorado Healthcare System are
    leaders in tele-health outreach to veterans including Indian veterans
    in the northern Plains, the State of New Mexico, and the Tribes and
    Pueblos of the region. Services are provided to a number of settings
    including school clinics, youth residential treatment centers, health
    centers, and others. They hope to leverage their ability to use federal
    service providers and provide technical and program support nationally
    to programs attempting to implement such services.
        We have been tracking visits to behavioral health clinics using
    tele-health technology, and have preliminary indications that IHS
    programs are increasingly adopting and using these technologies. Tele-
    behavioral health services require adequate and reliable bandwidth if
    they are to be sustainably implemented. Increasing bandwidth
    utilization strains the telecommunications infrastructure. IHS was
    fortunate to be recipients of ARRA funding to improve our
    telecommunications infrastructure to increase the reliability and
    availability of appropriate bandwidth across the Indian healthcare
    system. Approximately $19 million of our Health Information Technology
    ARRA funding will be spent to provide new routers, switches, and basic
    telecom infrastructure to ensure current needs are met, as well as
    improve our ability to prioritize traffic over the network. ARRA
    funding is also supporting a mass procurement of state-of-the-art
    clinical videoconferencing equipment that will be distributed to
    Tribal, Urban, and Federal care sites depending on need later this
    fall. We are working to improve access to videoconferencing and
    bandwidth capacity to strengthen our telecommunications infrastructure.
    As one of my providers who is active in telemedicine told me, ``My
    patients are very patient and are willing to tolerate surprisingly bad
    connections. But when my image freezes up with regularity I may as well
    be using the telephone.'' We are investing in the infrastructure
    expansion, support, and maintenance needed to keep pace with potential
    service demands and to plan for the long term success of this and any
    new Indian tele-mental effort.
        We see many benefits to the use of telemedicine for the treatment
    of youth suicide. This technology promises to connect widely separated
    and often isolated programs of varying sizes together in a web of
    support. Whereas small clinics would need to develop separate contracts
    for services such as child and adult psychiatric support, pooling those
    needs in a larger pool provides potential access to a much larger array
    of services, and does so more cost-effectively and more conveniently
    for patients. Such a system could potentially move some clinics that
    are available every other Friday afternoon for 4 hours to systems where
    clinic time for assessments is available whenever the patient presents.
    This could translate into 24/7 access to emergency behavioral health
    service in any setting with adequate telecommunications service and
    rudimentary clinic staffing.
        Such a system has other desirable consequences such as
    opportunities for mutual provider support. For example, currently when
    psychiatric providers take vacation,are on sick leave, or are training
    in places where they are the sole providers, there are often either no
    direct services at that clinic for that time period, or a temporary
    doctor with limited understanding of the clinic is hired to provide
    services. Sufficient services could be provided via tele-health
    connections to reduce or eliminate discontinuities in patient care and
    do so at significantly less expense. Providers with particular
    specialty interests can share those skills and knowledge across a broad
    area even if they themselves are located in an isolated location. Burn
    out due to professional isolation is also decreased as
    videoconferencing readily supports clinical supervision and case
    management conferences. Universities providing distance-based learning
    opportunities have demonstrated for years that educational activities
    can also be facilitated by this technology. Families can participate in
    care even when at a distance from their youth, promoting improved
    contact and better resolution of home environmental concerns which is
    often the key issue in a youth transitioning successfully from a
    residential program to home. Recruitment becomes less problematic
    because providers can readily live and practice out of larger urban or
    suburban areas and are thus more likely to continue in service over
    time with sites. The resulting pool of providers accessible for hiring
    could also increase because relocation to an isolated location may not
    be necessary.
        It is important to note that the proposed services would require
    behavioral health providers including psychiatrists, psychologists,
    clinical social workers, and therapists in addition to the telemental
    health technology.
        The behavioral health services discussed in my testimony today are
    available or will be available to some degree already at 50 federal and
    tribal sites, or are otherwise unavailable or irregularly available in
    the Indian health care system.
        As described in my testimony today, IHS supports and indeed is
    already funding many of the activities included in the demonstration
    grant program outlined in, S. 1635, the 7th Generation Promise. These
    activities, including the National Tele-behavioral Health Center of
    Excellence funded by the MSPI, will also help us understand how to
    effectively deliver such services, and in particular, will provide more
    focused experience in providing services to Indian youth. We believe
    tele-behavioral programs can become an integral part of the IHS
    behavioral health services, strengthen our clinical expertise in using
    tele-health services and expand access to needed behavioral healthcare.
    We are working to augment the ability of the IHS Tele-behavioral Health
    Center of Excellence to promote and support such services across the
    Indian health system. The additional services proposed in this
    legislation could help facilitate our ability to provide needed
    services.
        In summary, we look forward to opportunities to address the
    critical problem of youth suicide in Indian Country. We are committed
    to using available technologies including our growing national
    telecommunications infrastructure to help increase access to sorely
    needed behavioral health services. For Indian Health Service, our
    business is helping our communities and families achieve the highest
    level of wellness possible.
        Mr. Chairman, this concludes my statement. Thank you for the
    opportunity to testify. I will be happy to answer any questions that
    you may have.

        The Chairman. Dr. Roubideaux, thank you very much for your
    statement and for being here.
        Next we will hear from the Honorable Eric Broderick. Dr.
    Broderick is the Acting Administrator of the Substance Abuse
    and Mental Health Services Administration. Dr. Broderick?

         STATEMENT OF HON. 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

        Dr. Broderick. Thank you, Mr. Chairman.
        Mr. Chairman, Mr. Vice Chairman, members of the Committee,
    good afternoon. My name is Eric Broderick. I am the Acting
    Administrator of the Substance Abuse and Mental Health Services
    Administration within the Department of Health and Human
    Services.
        Today I am honored to join Dr. Roubideaux as a witness at
    this hearing. I have known Dr. Roubideaux for a number of
    years, and I look forward to expanding our working relationship
    with the Indian Health Service under her leadership to expand
    and enhance the well-being of American Indians and Alaska
    Natives.
        Mr. Chairman, I would like to also acknowledge the
    assistance of your staff, specifically John Hart, Erin Bailey
    and Rhonda Harjo for the assistance they provided us at SAMHSA
    in addressing and engaging issues of concern to Indian Country.
    Thank you for the opportunity to testify about suicide in
    Indian Country. As you have said, it is an extremely serious
    issue. The data are very clear, and bear our close attention.
        I regret that since I last testified, as you pointed out,
    there has been a tragic cluster of suicide on the Standing Rock
    Sioux Reservation. Mr. Chairman, SAMHSA staff, accompanied by
    your staff, visited Standing Rock on the 20th of July of this
    year, met with Chairman His Horse Is Thunder, as well as
    members of the chairman's staff, other tribal leaders,
    reservation program coordinators and tribal community members.
    Based upon this visit, SAMHSA has submitted a report to this
    Committee. The report focuses on issues at Standing Rock and is
    consistent with the testimony I provided at previous hearings.
        During our visit, the director of the Boys and Girls Club
    of the Grand River area of the Standing Rock Reservation
    reported that at Standing Rock, there is an unemployment rate
    of 74 percent, 85 percent of the tribal members live in
    poverty, violent crime is six times the national average and
    the high school graduation rate is 49 percent, compared with 76
    percent nationally. These statistics provide a glimpse of the
    risk factors American Indians and Alaska Native youth face in
    their communities. We know that protective factors such as
    tribal culture, sports, recreation and academic programs can
    mitigate these risk factors. We also know that adequate mental
    health services and substance abuse services for those in need
    are extremely important.
        Unfortunately, in many communities, these protective
    factors and essential health services are not always available.
    Federal, State and tribal governments must work together to
    address this problem, and we at SAMHSA are committed to the
    effort.
        In order to create an opportunity for systematic feedback
    and guidance from elected tribal officials, we at SAMHSA
    created and staffed a tribal advisory committee comprised of
    elected tribal officials from across the Nation. The committee
    has been in place for two years and provides us with valuable
    assistance in working with tribal communities and understanding
    the issues of importance to Indian Country.
        Additionally, over the past three years, SAMHSA has co-
    hosted with the Department of Justice Office of Justice
    Programs, Office of Violence Against Women, Office of Victims
    of Crime and the COPS program, as well as the Department of
    Interior, Department of Housing and Urban Development, the
    Small Business Administration and the HHS Office of Minority
    Health and the Indian Health Service nine technical assistance
    and consultation sessions. These tribal justice, safety and
    wellness conferences were created at the request of tribal
    leadership and provide the opportunity to both consult with
    tribal leaders on issues at the nexus of public health and
    public safety that are of concern to them as well as to provide
    technical assistance aimed at raising tribal grantsmanship
    capacity. Youth suicide has been raised as a concern at every
    one of these sessions.
        I believe that this ongoing commitment to the development
    of tribal capacity is largely responsible for the doubling of
    SAMHSA grants awarded to tribes between 2006 and 2008. However,
    I also believe that much more can be done.
        It has been our experience that giving blanket priority to
    certain groups, to specific drug types or to specific mental
    illnesses in a grant application process often fails to produce
    the desired results. As an alternative, I would like to share
    with you what has proven effective for us at SAMHSA. We
    understand the value of providing tribes and tribal
    organizations additional resources to develop infrastructure
    needed to submit competitive grant applications and to
    administer grants when funds are awarded. For example, in
    evaluating the Children's Mental Health Initiative, we have
    found that many American Indian and Alaska Native tribes were
    unsuccessful in competing for our Systems of Care grants
    because they did not have the infrastructure to draft or to
    plan for such new programs.
        The Children's Mental Health Initiative provides funding to
    local communities, including American Indian and Alaska Native
    communities, to develop systems to care for children with
    serious mental illness. In response to that finding, SAMHSA
    developed the Circles of Care grants, which are three-year
    discretionary infrastructure grant programs for American Indian
    and Alaska Native tribes and tribal organizations to plan for
    and develop community-based systems of care for children with
    serious mental illness. There have been 16 tribes or tribal
    organizations who have received Circles of Care grants. Of
    those 16, 12 have been successful in becoming Systems of Care
    grantees and implementing the models they have developed as a
    result of their Circle of Care grants.
        Mr. Chairman, when we consider ways to help tribal
    communities prevent youth suicide, I would recommend that we
    consider similar strategies to expand tribal capacity.
    Currently, fully one-third of our Garrett Lee Smith grants have
    been awarded to tribes and tribal communities. Eighteen of 54
    grants now go to tribes. They have been successful and very
    competitive in that environment.
        But to build upon that tremendous success of tribes, I
    would suggest that the Circles of Care grant model, relative to
    suicide prevention, is one worthy to consider. Creation of
    planning grants for suicide prevention would build upon
    SAMHSA's Native Aspirations program, as well as to develop
    much-needed capacity to develop programming and permit tribes
    to successfully compete for grants to implement those programs.
    These planning grants should target communities that currently
    do not possess the capacity to successfully compete for Federal
    grants. Not only would this approach direct resources to
    communities of extremely high need, it would also create the
    capacity for solid administration and implementation of those
    grants.
        Thank you for the opportunity to testify, sir. I would be
    happy to answer any questions for the Committee.
        [The prepared statement of Dr. Broderick follows:]

     Prepared Statement of Hon. 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 afternoon. I am
    Eric B. Broderick, D.D.S., M.P.H., Acting Administrator of the
    Substance Abuse And Mental Health Services Administration (SAMHSA)
    within the Department of Health and Human Services and Assistant
    Surgeon General.
        SAMHSA and the Indian Health Service (IHS) work closely together to
    formulate long-term strategic approaches to address the issue of
    suicide in Indian Country more effectively. For example, SAMHSA and IHS
    are actively involved on the Federal Partners for Suicide Prevention
    Workgroup. In 2001, the Office of the Surgeon General coordinated the
    efforts of numerous HHS agencies, including SAMHSA, IHS, the Centers
    for Disease Control and Prevention, the National Institute of Mental
    Health within the National Institutes of Health, and the Health
    Resources and Services Administration, along with other public and
    private partners to develop the first, comprehensive, integrated,
    public health approach to reducing deaths by suicide and suicide
    attempts in the United States in the National Strategy for Suicide
    Prevention. This resulted in the formation of the ongoing Federal
    Partners for Suicide Prevention Workgroup. SAMHSA also helped
    facilitate and participated in a Federal Partners Committee on
    Telemental Health.
        While I am very pleased to be here today to talk about suicide
    rates among American Indians and Alaska Natives, I regret that since I
    testified the last time, the problem has not improved. I am saddened to
    note that we have faced yet another episode of suicides among American
    Indians and Alaska Natives, this time on the Standing Rock reservation
    where there have been ten recorded suicides, primarily among the
    younger population since January of this year.
        Along with representatives of the Chairman, we visited the
    reservation on July 20 and met with Chairman Ron His Horse is Thunder
    as well as members of the Chairman's staff, tribal leaders, reservation
    program coordinators and tribal community members. Based on this visit,
    SAMHSA submitted a report to the Committee. The report repeats much of
    what I and the previous IHS Director have testified about in previous
    hearings, except due to the recent increased loss of youth to suicide,
    the report is specific to the Standing Rock Sioux Tribe July visit.
        Despite the attention that suicide among American Indians and
    Alaska Natives deserves and gets, especially from the Committee and the
    Department, we, as a nation, continue to experience very high rates of
    suicide among Native Americans and Alaska Natives. In the case of
    Standing Rock, a cluster of youth suicide completions devastated the
    reservation despite suicide specific funding from SAMHSA through the
    Garrett Lee Smith (GLS) State/Tribal Suicide Prevention Grants.
        Program staff for the GLS grant, known as Oniyape, are deeply
    dedicated to their suicide prevention program. Community members told
    us that staff supporting this grant have their hands full just trying
    to intervene with the large number of youth and families most at risk
    for suicide.
        Programs that help increase protective factors to offset the risk
    factors that exist among the tribe--such as sports, recreation,
    cultural, and academic support programs--are scarce on the Reservation.
    Where such resources do exist, inadequate financial and human resources
    limit outreach and activity level they can provide. During the recent
    crisis, the Boys and Girls Club of the Grand River Area of the Standing
    Rock Reservation served as the de facto crisis center for the
    community. It provided--and continues to provide--support, meetings
    with families, and grief counseling to the youth following the recent
    suicides. Parents and grandparents approached Club staff at work, on
    the street, and at their homes, asking if they could help their child
    or grandchild. Club staff made referrals, ensured the youth were
    involved in the Club's programs, checked in on the youth, and listened
    to and supported the adults.
        With the suicide rates so high, tribal members report that many
    individuals at risk struggle with:

       Maintaining intimate relationships
       Trusting and being trusted
       Working in teams with others
       Persevering when problems arise
       Functioning as parents
       Holding a job--if jobs exist
       Stopping harmful behaviors such as alcohol and drug abuse or
            family violence.

        These reactions only create a deeper sense of isolation,
    depression, and substance abuse which often lead to suicidal thoughts
    and actions.
        This problem requires a public health approach that works to
    decrease risk factors and increase protective factors. This may very
    well take a concerted effort by the Federal, State, and Tribal
    Governments. It will take time.
        In the meantime, we support programs such as the Garrett Lee Smith
    State/Tribal Grants and other efforts supported by the SAMHSA and the
    Indian Health Service and consider ways of intervening such as finding
    ways to support mental health and substance abuse services for American
    Indian and Alaska Native tribes and tribal organizations.
        We provide technical assistance to tribes and encourage them to
    apply for funding. All of our grants, except those that are restricted
    by statute, are open to American Indians and Alaska Natives tribes and
    tribal organizations, and we have been working hard to increase funding
    to American Indian and Alaska Native tribes or tribal organizations.
    They may apply directly for discretionary funds without going through
    the State, and we have facilitated the application process.
        As a result of this effort, the amount of funding to American
    Indian and Alaskan Native tribes and tribal organizations, especially
    with respect to suicide prevention, now totals over $60 million a year.
    Standing Rock has been very successful in competing and receiving grant
    funds from SAMHSA. Besides a Garrett Lee Smith State/Tribal grant, they
    also have a Circles of Care grant, an inter-departmental (HHS and
    Education) Safe Schools/Healthy Students grant, and a Targeted Capacity
    Grant for substance abuse treatment.
    SAMHSA's Role in Better Serving American Indian and Alaska Native
            Populations
        SAMHSA provides national leadership for suicide prevention,
    consistent with the National Strategy for Suicide Prevention. We have
    four major suicide prevention initiatives that I will highlight briefly
    today. These initiatives include the Garrett Lee Smith Youth Suicide
    Prevention Grant Program, the Native Aspirations Project, the Suicide
    Prevention Resource Center, and the Suicide Prevention Lifeline.
    Garrett Lee Smith Youth Suicide Prevention Grant Program
        As a result of the authorization provided by the Garrett Lee Smith
    Memorial Act (P.L. 108-355), SAMHSA has been working with state and
    local governments and community providers to further 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.
        Awards were again made in 2006 and 2007, during which six Tribes/
    Tribal Organizations were awarded grants. In August 2008, 12 Tribes/
    Tribal Organizations received Garrett Lee Smith grants, totaling 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 Requests
    for Application and then put forward strong, viable applications.
    Additionally, it is important to note that many of the states which
    received grant awards are partnering with and/or reaching out to
    include suicide prevention efforts in their local tribal communities.
        Among the newest cohort of grants the Tribes/Tribal Organizations
    awardees include: 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.
        Overall, 54 states, tribes, and tribal organizations, as well as
    more than 50 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.
    Through the Native Aspirations project, a total of 25 American Indian
    and Alaska Native communities determined to be the most ``at risk''
    develop or enhance a community-based prevention plan.
        After a community is selected, the first step is an initial visit
    from Native Aspirations project staff members, who share information
    and help community leaders set up an oversight committee. The second
    step is the 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
    American Indian and Alaska Native 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 event, 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 ongoing training, consultation, technical assistance, and
    budget support.
    Suicide Prevention Resource Center
        Another initiative is the Suicide Prevention Resource Center (SPRC)
    which is 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 last major initiative I will highlight today is the National
    Suicide Prevention Lifeline. The National Suicide Prevention Lifeline
    is a network of 141 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 141 crisis centers across the country. Those crisis centers
    are independently operated and funded (both publicly and privately).
    They all serve their local communities in 49 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 Idaho, the only
    state that does not currently have a participating crisis center, the
    calls are answered by a crisis center in a neighboring state.) Every
    month, nearly 52,000 people have their calls answered through the
    National Suicide Prevention Lifeline, an average of 1,852 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
    American Indian/Alaskan Native Communities and also with the Department
    of Veterans Affairs (for veterans using the Lifeline) 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.
        In addition to the four funding programs outlined above, SAMHSA has
    also provided funding for an expanded evaluation of Garrett Lee Smith-
    funded grant activities in the White Mountain Apache tribe, focusing on
    Emergency Department interventions and follow up with American Indian
    youth who have made suicide attempts. In this innovative approach,
    Apache paraprofessionals provide outreach in the community to each
    youth who has been reported to attempt suicide or to experience
    suicidal thoughts. By electronic means, these outreach workers are
    provided remote supervision by a child psychiatrist, psychologist and
    clinical team from the Johns Hopkins University Center for American
    Indian Health. In addition, last year, SAMHSA sponsored a meeting to
    examine the tragedy of suicide clusters in Indian Country.
        These SAMHSA initiatives are an important start, but we know there
    is much more to be done to reduce the tragic burden of suicide in
    Indian Country. The problems confronting American Indian and Alaska
    Natives are taking a toll on the future 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
    here.
        Next we will hear from Dr. Dolores Subia BigFoot, Director
    of the Indian Country Child Trauma Center and the Project
    Making Medicine at the University of Oklahoma Health Sciences
    Center. She is testifying on behalf of the American
    Psychological Association.
        You may proceed. Thank you for being with us.

      STATEMENT OF DOLORES SUBIA BIGFOOT, Ph.D., DIRECTOR, INDIAN
       COUNTRY CHILD TRAUMA CENTER AND PROJECT MAKING MEDICINE,
             UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER

        Dr. BigFoot. Chairman Dorgan, members of the Committee,
    this is both a personal and a professional effort. First,
    please allow me to express my appreciation for the opportunity
    to speak on behalf of the 150,000 members and affiliates of the
    American Psychological Association. My name is Dr. Dolores
    Subia BigFoot, and I bring goodwill from the Caddo Nation of
    Oklahoma in which I am enrolled, and from the Northern Cheyenne
    Tribe in Montana, in which my children are enrolled.
        I am a child counseling psychologist by training and have
    devoted 35 years to addressing health disparities in its many
    different forms within our tribal nations. Thank you for
    convening this important hearing to discuss the need to reduce,
    to eliminate and to reveal the devastation of suicide within
    our American Indian and Alaska Native youth through the
    development of Federal legislation.
        As the Director of Project Making Medicine and the Indian
    Country Child Trauma Center at the University of Oklahoma
    Health Sciences Center, I profoundly understand the need for
    safety for our youth. There are many diligent and dedicated
    people who are concerned and working to address this same need
    for safety and to provide appropriate mental health and other
    culturally-appropriate interventions that can help prevent
    suicide.
        Project Making Medicine is funded by the Office of Child
    Abuse and Neglect, the Children's Bureau and the Indian Country
    Child Trauma Center was funded from 2003 to 2007 by the
    Substance Abuse and Mental Health Services Administration as
    part of the National Child Traumatic Stress Network. We
    currently remain a very active affiliate member of this
    network, which is an important Congressional initiative that
    works to raise the standard of care for traumatized children
    and their families.
        It is also important to acknowledge the critical role of
    SAMHSA's youth suicide prevention and early intervention
    programs created under the Garrett Lee Smith Memorial Act. The
    rates of suicide among our youth has been drastically
    illustrated by the charts that were shown. They are
    disproportionately high and we must work to address these
    preventable, yes very preventable, tragedies.
        Mr. Chairman, as I am sure you know, given your steadfast
    commitment to addressing this tragic problem, high suicide
    rates have significant impact on families, siblings, peers, and
    the community as a whole. While progress has been slow in
    understanding suicide from a cultural perspective, we know that
    both historical and current traumatic stressors in Indian
    Country affect our youth. I think that by the bill earlier
    referenced, regarding violence in Indian Country, it is very
    self-evident.
        The self-harm responses that youth may exhibit are much
    like those of other individuals exposed to collective trauma,
    such as our combat veterans that are returning and their high
    rate of suicide, such as the first responders, firefighters and
    police officers, like those involved in the Oklahoma City
    bombing. I am aware of those that committed suicide after that.
    And of course, those after 9/11. Tragedy has an impact. Trauma
    has an impact.
        Despite the challenges facing our American Indian and
    Alaska Native communities, we remain optimistic and hopeful.
    Organizations such as the National Congress of American
    Indians, the National Indian Health Board, National Council of
    Urban Indian Health, along with tribes and the Indian Health
    Service, has been formulating best practices related to suicide
    prevention that will help our youth. These efforts focus on
    developing a better understanding of what would lead youth to
    consider suicide.
        While we know that suicide typically occurs as a single
    individual act, suicide cannot be understood in isolation.
    Instead, we must consider the various precipitating factors,
    including child maltreatment, family violence, mental health
    problems, trauma, loss, grief and pain that are associated with
    feelings of hopelessness and the lack of safety among our
    youth.
        Our youth are in desperate need of safe homes, safe
    families and safe communities. Chronic under-funding of tribal
    and urban programs and a lack of infrastructure and human
    resources, as described earlier, create barriers for our youth.
    We must provide appropriate resources and opportunities to
    immediately empower and support our population to build our
    capacity to address the needs of our youth.
        Currently, there are insufficient numbers of psychologists
    and other mental health providers of Indigenous heritage. Two
    vital Federal initiatives in place to help address this problem
    are the Indians Into Psychology program and the Minority
    Fellowship program, funded by the Indian Health Service and
    SAMHSA, respectively. These programs have a strong history of
    success and are critical to building the ethnic minority
    pipeline. As such, it is important that increased funding is
    provided for these initiatives.
        At the same time, while we work to build the sufficient
    professional workforce, tribal communities require immediate
    and innovative resources to meet the urgent needs of our youth
    and families. At the University of Oklahoma Health Sciences
    Center, we currently utilize a video-conferencing system
    through the internet in which we are training via real-time
    mental health providers in tribal communities. We have done
    this in the State of Washington, we have done it in California
    and Utah and Oregon and Alaska and across Oklahoma.
        The National Child Traumatic Stress Network is also
    developing a sophisticated distance learning system that can
    help providers access the specific training they need. I
    strongly recommend the continued support and expansion of the
    National Child Traumatic Stress Network as an important
    resource to ensure that we have a national infrastructure of
    child trauma experts and providers who can meet the diverse
    needs of our youth.
        We appreciate your efforts to develop the Seventh
    Generation Promise: Indian Youth Suicide Prevention Act of
    2009. How well it is that we should think seven generations
    ahead.
        This legislation aims to increase and enhance the provision
    of mental health care for American Indians and Alaska Native
    youth by decreasing disparities in access and improving quality
    of mental health care. We look forward to working with
    Congress, the Indian Health Service, the Children's Bureau and
    SAMHSA as this proposal moves through the legislative process.
        We cannot be silent and so I will add, my own family loss,
    my beautiful, precious son of 33 years died 10 months ago
    today. His death certificate does not say suicide. However, his
    self-harm behavior created a situation in which injury resulted
    in his death. The outcome was the same. He was traumatized by
    someone outside the family that I have no knowledge about until
    he informed me as an adult. And by that time, as we tried to
    untangle all of the webs that tore at his heart, tore at his
    spirit, tore at his mind. It was very difficult.
        So his death was a result of self-harm. He chose not to
    seek medical care and knew that he would die. There are many of
    those in similar situations beyond what we see in terms of the
    statistics that are taking their own lives, and it is not
    reported as a suicide.
        Mr. Chairman, members of the Committee, I am honored. My
    family is honored and my tribe is honored by this invitation to
    join you today. But especially my son, Bryce Buffalo Man
    BigFoot is honored that his mother can voice his cry that help
    is so desperately needed. The American Psychological
    Association and the Psychology Committee looks forward to
    continuing to work with you and the tribal communities to
    ensure that our youth receive the mental and behavioral health
    care that they urgently need and deserve.
        I must also acknowledge and honor the warrior woman that
    sits here and her diligence in bringing so much to this table
    and to our communities. So I honor you.
        I am willing and open and eager to answer any questions you
    have.
        [The prepared statement of Dr. BigFoot follows:]

         Prepared Statement of Dolores Subia BigFoot, Ph.D., Director,
        Indian Country Child Trauma Center and Project Making Medicine,
                 University of Oklahoma Health Sciences Center
        Chairman Dorgan, Ranking Member Barrasso, and members of the
    Committee, please allow me to express appreciation for the opportunity
    to speak on behalf of the 150,000 members and affiliates of the
    American Psychological Association. My name is Dr. Dolores Subia
    BigFoot and I bring good will from the Caddo Nation of Oklahoma in
    which I am enrolled and from the Northern Cheyenne Tribe in Montana in
    which my children are enrolled. I am a child psychologist by training
    and have devoted 35 years to addressing health disparities in its many
    forms within our Tribal Nations. Thank you for convening this important
    hearing to discuss the need to reduce, eliminate, and reveal the
    devastation of suicide with our American Indian and Alaska Native (AI/
    AN) youth through the development of federal legislation.
        As Director of Project Making Medicine and the Indian Country Child
    Trauma Center at the University of Oklahoma Health Sciences Center, I
    profoundly understand the need for safety among our AI/AN youth. There
    are many diligent and dedicated people who are concerned and working to
    address this same need for safety, and to provide appropriate mental
    health and other culturally appropriate interventions that can help
    prevent suicide. Project Making Medicine is funded by the Office of
    Child Abuse and Neglect, Children's Bureau, and the Indian Country
    Child Trauma Center was funded from 2003-2007 by the Substance Abuse
    and Mental Health Services Administration's (SAMHSA) National Child
    Traumatic Stress Network. We currently remain a very active affiliate
    member of this Network, which is an important congressional initiative
    that works to raise the standard of care for traumatized children and
    families. It is also important to acknowledge the critical role of
    SAMHSA's Youth Suicide Prevention and Early Intervention Programs
    created under the Garrett Lee Smith Memorial Act.
        Physical, mental, and behavioral health problems continue to affect
    the AI/AN communities at alarming rates. I am particularly concerned
    about the disproportionately high prevalence of mental and behavioral
    health problems among our nation's AI/AN population, including suicide
    and suicidal ideation. The statistics regarding suicide in the AI/AN
    communities are astonishing. Research indicates that American Indians
    account for nearly 11 percent of total suicides in the United States.
    The suicide rates among youth are also deeply tragic. Of the
    approximately five million people who are classified as AI or AN in our
    country, 1.2 million are under the age of 18, which comprises 27
    percent of this group. This is particularly significant because in
    2006, suicide was the second leading cause of death for AI/AN
    individuals between the ages of 10 and 34. Furthermore, among AI/AN
    youth attending Bureau of Indian Affairs schools in 2001, 16 percent
    had attempted suicide in the 12 months preceding the Youth Risk
    Behavior Survey.
        From 1999 to 2004, AI/AN males between the ages of 15 to 24 had the
    highest rates of suicide as compared to other age or ethnic groups,
    27.99 per 100,000. This age group accounts for 64 percent of all AI/AN
    suicides. Unfortunately, more than half of all persons who die by
    suicide in AI/AN communities were never seen by a mental health
    provider.
        Mr. Chairman, as I am sure you know given your steadfast commitment
    to addressing this tragic problem, high suicide rates have a
    significant impact on siblings, peers, family members, and communities
    as a whole.
        It is also important to acknowledge the cultural aspects associated
    with suicide in our AI/AN communities. While progress has been slow in
    understanding suicide from a cultural perspective, we know that both
    the historical and current traumatic stressors in Indian Country affect
    our youth. The self harm responses that they may exhibit are much like
    those of other individuals exposed to collective trauma, such as
    service members/veterans, prisoners of war, and first responders (e.g.,
    firefighters, police officers).
        Despite the challenges facing our AI/AN communities, we remain
    optimistic and hopeful. The National Congress of American Indians,
    along with Tribes and the Indian Health Service, has been formulating
    best practices related to suicide prevention that will help our youth.
    These efforts focus on developing a better understanding of what would
    lead youth to consider suicide. While we know that suicide typically
    occurs as a single individual act, suicide cannot be understood in
    isolation. Instead, we must consider a variety of precipitating
    factors, including child maltreatment, family violence, mental health
    problems, trauma, loss, grief, and pain that are associated with
    feelings of hopelessness and a lack of safety among our youth.
        The unfortunate and often forgotten reality is that there is an
    epidemic of violence and harm directed towards this very vulnerable
    population. AI/AN children and youth experience an increased risk of
    multiple victimizations. Their capacity to function and to regroup
    before the next emotional or physical assault diminishes with each
    missed opportunity to intervene. These youth often make the decision to
    take their own lives because they feel a lack of safety in their
    environment. Our youth are in desperate need of safe homes, safe
    families, and safe communities.
        Chronic underfunding of tribal community programs and a lack of
    infrastructure and human resources create barriers for AI/AN youth. We
    must provide appropriate resources and opportunities to immediately
    empower and support our population to build their capacity to address
    the needs of our youth. Currently, there are an insufficient number of
    psychologists and other mental health providers of Indigenous heritage.
    Two vital federal initiatives in place to help address this problem are
    the Indians Into Psychology Program and the Minority Fellowship
    Program, funded by the Indian Health Service and SAMHSA, respectively.
    These programs have a strong history of success and are critical to
    building the ethnic minority pipeline. As such, it is important that
    increased funding is provided to these initiatives to meet the current
    mental and behavioral health needs of our population. At the same time,
    while we work to build a sufficient professional workforce, tribal
    communities require immediate and innovative resources to meet the
    urgent needs of our youth and families.
        At the University of Oklahoma Health Sciences Center, we are
    currently utilizing a video conferencing system through the Internet in
    which we are training via real time mental health providers in tribal
    communities in Washington State. In the past, we have trained via
    Internet tribal providers located in Alaska, California, Utah, and
    across Oklahoma. The National Child Traumatic Stress Network is also
    developing a sophisticated distance learning system that can help
    providers access the specific training they need when working with AI/
    AN youth and families. I strongly recommend the continued support and
    expansion of the National Child Traumatic Stress Network as an
    important resource to ensure that we have a national infrastructure of
    child trauma experts and providers who can help to meet the diverse
    needs of our youth.
        This past June, we traveled to Anchorage, Alaska to provide a
    Mental Health First Aid training for individuals from the villages or
    Native corporations who were interested in developing basic skills in
    assisting those experiencing mental or behavioral health problems,
    including suicide risk. Unfortunately many village providers and other
    village helpers who expressed interest in the training were unable to
    attend given the lack of transportation resources. With telehealth
    capability, such barriers might be overcome to enable the delivery of
    critical mental health and suicide prevention education and training in
    remote or less accessible areas and to large groups of community
    members.
        We appreciate your efforts in developing the 7th Generation
    Promise: Indian Youth Suicide Prevention Act of 2009. This legislation
    aims to increase and enhance the provision of mental health care to AI/
    AN youth by decreasing disparities in access and improving quality of
    mental health care. We look forward to working with Congress, the
    Indian Health Service, the Children's Bureau, and SAMHSA as this
    proposal moves through the legislative process.
        Mr. Chairman, Ranking Member, and members of the Committee, I am
    honored, my family is honored, and my tribe is honored by this
    invitation to join you here today. The American Psychological
    Association and the psychology community look forward to continuing to
    work with you and the tribal communities to ensure that our youth
    receive the mental and behavioral health care that they urgently need
    and deserve. I would be pleased to answer any questions.
    Attachment

        The Chairman. Dr. BigFoot, thank you very much for being
    with us and for your testimony. I know that the spirit of your
    son would be very proud of his mother today for being with us.
        I think this issue is so difficult, it is especially more
    difficult when it requires a discussion of a loved one. I have,
    well, first of all, I have some experience, having walked into
    a room and found a friend who had taken his own life. So I know
    something about the shock and the trauma of walking into a room
    and seeing a friend who has taken his life, something that you
    never, ever, ever forget.
        It is especially tragic when it is a child, because that is
    someone whose life is in front of them and extinguished because
    of feelings of helplessness and hopelessness. So what we are
    trying to think through is, what causes all of this? We
    understand that part of the roots reflect the difficulties of
    living in third world conditions. You don't have to go to a
    third world country to see third world conditions. It too often
    exists here in America on Indian reservations. I have gone to a
    reservation where there was a cluster of teen suicides and just
    sat around a large table with a group of teenagers, no other
    adults present. And I said, just tell me about your lives. Many
    of you knew the young kids that took their own lives. Tell me
    about them, tell me about what you think.
        It is an extraordinary lesson to learn from the mouths and
    the minds of young people, to hear about their existence and
    their concerns. So there are a number of things, I think, that
    play a role here. One of the things that I think is a bright
    spot are the youth clubs and the youth centers and so on that
    are doing unbelievable work with very little funding and very
    little accolades for what they do.
        We are trying today to think through, what is it we can do.
    Let me just tell you one more story, then I will ask you some
    questions. I held a hearing once in Bismarck, North Dakota. It
    was on the subject, again, an extraordinarily difficult,
    sensitive subject, and that was child sexual abuse. A young
    woman testified from one of our reservations. She was in her
    mid-twenties. And she had been hired on that reservation to
    work on these issues.
        And she was the recipient, then, of the complaints. She
    began to testify at this hearing. She described that on her
    desk was a pile of complaints of child sexual abuse that had
    not been investigated by law enforcement. And she began to
    describe that just taking one of those complaints and talking
    to one of those children and finding a need to take one of
    those children to a professional somewhere in a medical
    facility, that in order to do that, she had to try to find a
    way to beg or borrow a car in order to have the transportation
    to get this person to a professional.
        At that point in the discussion she just began to sob and
    weep, I am talking about the woman on the, in this case, the
    Spirit Lake Nation. She just couldn't continue, thinking about
    the impossibility of her job. She quit her job several months
    later.
        But the point is, somewhere stacked in those files was, I
    am certain, tragedy occurring with a young child, not even
    investigated. So when we ask the question, what leads to this
    feeling of hopelessness and helplessness, what leads to
    suicide, there are many causes, but not the least of which, in
    my judgment, is just the lack of basic resources that exist
    routinely and are expected to exist routinely by parents in
    most other areas in our society. When someone is missing from
    school 90 days, somebody, somebody is going to track them down,
    some professional in that school district. But when there are
    not enough people around to do that job, kids get lost. That is
    what happened to 14-year-old Avis Little Wind.
        Dr. Broderick, you indicated that the time previously, when
    you testified before this Committee related to fast-forwarding
    to this point, there has not been any improvement on the
    subject of Indian teen suicide. Can you expand on that and if
    that is the case, obviously the question is why?
        Dr. Broderick. Mr. Chairman, as you know, it is an
    extremely complex topic that requires, I mean, it has taken a
    long, long time and much tragedy, much trauma to get there.
    Standing Rock is an excellent example. We have worked, we at
    SAMHSA and I know the Indian Health Service as well, have
    worked closely with the community. They currently have a
    Garrett Lee Smith suicide prevention grant and yet they still
    experience a suicide cluster, in spite of the investment of
    resources. And it tells me that what is needed is a holistic
    approach that cuts across both public safety and public health
    programs to address the fundamental needs and the fundamental
    causes that Dr. BigFoot so eloquently described.
        We know that people who have experienced trauma, be it
    inter-generational trauma or trauma as children are at
    extremely high risk. Unfortunately, children in Indian
    communities are oftentimes subjected to such trauma. So I
    believe that if we use Standing Rock as a case study, in spite
    of the investment of some resources and establishment of close
    working relationships with that community, those children still
    remain at risk. It speaks to the need for a dedicated effort to
    address the multiple causations and the multiple risk factors
    that go to contribute to the high rates of suicide that we see.
        So I think it calls for not only a redoubling of our
    effort, but the need to look at all the causes and all the
    complexities that exist in those communities that have existed
    there for a long, long time to actually break that cycle.
        The Chairman. Dr. Roubideaux, thank you for your testimony.
    You are relatively recently nominated and confirmed to your
    post. But tell me, do you think the issue is substantially
    additional resources? Condense for me your testimony, if you
    would, to a couple of paragraphs. What do you think, if you had
    your choice today and could make that choice, would be the
    couple of things you think would most affect our ability to
    reduce the rate of teen suicide on Indian reservations?
        Dr. Roubideaux. I think that the first thing that we need
    to do is to make sure that we are not all working in isolation
    on this problem. We have great partnership with SAMHSA, we have
    a great partnership with our tribes. And working with the local
    schools, the local justice systems, the local community
    programs, I really believe that that is going to be one of the
    major ways to address this problem. We can't solve the problem
    alone. We have to have partners in this effort.
        I am really excited about our new meth and suicide
    prevention initiative. Now we have 129 new meth and suicide
    prevention initiatives across the Country that involve work
    with tribes and the local IHS and other community partners to
    try to address this problem.
        The other major thing we need is just increased access to
    services. Many of our behavioral health programs are staffed
    with one clinical psychologist. Many of them have vacancies.
    And we really do need to find a way to get more access.
        I am pleased that the legislation includes the tele-
    behavioral health and the tele-mental health. Because that is a
    way that we can increase access to psychiatric and
    psychological care through a network of resources using
    technology, so that we could potentially provide 24/7 crisis
    care if needed. So I think this is an enormously heartbreaking
    and complex problem. But I think there are things that we can
    do, if we all put our resources together.
        The Chairman. Are you fighting inside the institution for
    better funding? I mean, you are part of a process by which you
    send recommendations up to OMB and then it goes to the White
    House and then they decide what you are going to have and then
    you have to come here to this table and say, I support this
    number, despite the fact it may not be your number at all. You
    may strongly, profoundly disagree, but you come to support it.
    That is the way the budget process works. But the first side of
    that is to be very aggressive, to say, here is what we need to
    address these issues, one of them being, for example, teen
    suicide, here is the money, the funding we need for these
    programs to address teen suicide. You are new to this process,
    but I assume you fully understand the early role that you will
    play in this budget process?
        Dr. Roubideaux. Absolutely. I understand the stakes are
    high and that we play an important role in trying to help
    understand what resources are needed to adequately and
    effectively meet the health needs of this population. I am
    proud to say that for the new budget process, we started by
    looking at our tribal recommendations for our budget. And I am
    really pleased with the support that I am seeing in the new
    Administration and in the Department, as people are trying to
    understand what our budget needs are. Again, I am also pleased
    with the support of the President, with his proposed Fiscal
    Year 2010 budget, a 13 percent increase, which is the highest
    in over 20 years.
        So I am doing my best to be an advocate for the people we
    serve.
        The Chairman. I should say, Dr. Broderick, thank you for
    sending the resources you did down to the Standing Rock
    Reservation, along with the staff of this Committee. That was
    very, very helpful. We are continuing, and I know with you,
    continuing to monitor what is happening there.
        Dr. Broderick. I think, if not today then very shortly,
    Standing Rock will sign an agreement with the Native
    Aspirations program to become one of the communities that are
    involved in Native Aspirations. That is a direct result of your
    intervention and our trip there. So we are seeing the
    dedication of additional resources to that community.
        The Chairman. Dr. BigFoot, describe for me, if you would,
    the child trauma center that you are directing.
        Dr. BigFoot. The child trauma center is hope. What we have
    done is we have taken evidence-based practices and culturally
    adapted them for the treatment of trauma. We have culturally
    adapted Trauma Focus, Cognitive Behavioral Therapy to Honoring
    Children, Mending the Circle. We have culturally adapted
    Parent-Child Interaction Therapy to Honoring Children, Making
    Relatives. The treatment of Children with Sexual Behavior
    Problems, we have culturally adapted it to Honoring Children,
    Respectful Ways, which has two components. One is a treatment
    component, one is a prevention component.
        And then we have taken the American Indian Life Skills
    Development, in conjunction with Terese LaFramboise, to revise
    it for lower grades. Because we also discovered that children
    very, very young, in middle school and younger, were having
    thoughts of suicide. So we wanted to be able to implement a
    curriculum that was for younger ages. Then as part of that, we
    have the Honoring Children, Honoring the Future, which is a
    suicide intervention and prevention efforts that we have
    undertaken through the Indian Country Child Trauma Center,
    which includes consultation to tribes and training. It includes
    the accessing of resources.
        For example, yesterday I was in the State of Washington
    where they were having an incredible conference with State and
    tribal agreements as part of the innovation center that is
    funded by SAMHSA. So I had a presentation on suicide, and one
    of the things that I did as part of that presentation was bring
    up the Indian Health Service suicide prevention website, and
    looked at all the resources that were on there. I had a room
    full of tribal members from all different tribes in Washington
    State, and they had no idea of the numerous resources that were
    available to them, even the simple screening that was on that
    website that you can access and get training in.
        So being able to help tribes look at what the resources
    are, and I think we have numerous kinds of resources, we have
    the American Indian Life Skills, we have the different programs
    like Native Aspirations, we have multiple different programs.
    But a lot of times, tribal communities are not aware.
        The other thing that we do is to assist tribal communities
    in that healing process so that they can become more proactive.
    So we help with healing camps, talking circles, different kinds
    of culturally-based interventions that are directed to the
    general population. Because one of the things that we need to
    recognize is that our tribal communities have always had
    healing ways.
        And even though I am a trained professional, I still am
    highly respectful of the fact that our tribal communities have
    ceremonies that are still viable to help to renew and
    regenerate and heal some of the loss and grief and some of the
    trauma that individuals and tribes have been faced with. And
    part of this, in terms of the project Making Medicine funded by
    the Office of Child Abuse and Neglect of the Children's Bureau
    is to take these evidence-based practices into tribal
    communities.
        So the culturally-adapted treatment programs were developed
    under the Indian Country Child Trauma Center funded by SAMHSA.
    But now we have made a wonderful link to be able to deliver
    those training interventions to licensed professionals. The
    problem we have is that we can train about 20 participants a
    year, and we have to do booster training and we need to do
    other kinds of things to support. If we only do 20 a year, we
    are not doing it very sufficiently. But we really try to help
    tribal communities to build their capacity.
        The Chairman. Thank you very much. It sounds like a really
    important program that is affecting and improving the lives of
    a lot of people. Thank you for your work.
        I just received a note that a vote is going to start in one
    minute on the Floor of the Senate. So it worked out pretty well
    that I could have an opportunity to hear all of the testimony
    and have all of you be here. We will continue. As you know,
    Senator Johanns, Senator Barrasso, myself, Senator Tester and
    many others are very concerned about this issue. We wanted to
    have an initial discussion today. We intend to proceed with
    these discussions on the issue of youth suicide. We will
    continue to work with all of you. We would like to get our
    legislation enacted this year and try to move forward to make
    some significant improvements.
        So we thank you for testifying. We will hold the record
    open for any additional submissions for two weeks. This hearing
    is adjourned.
        [Whereupon, at 3:40 p.m., the Committee was adjourned.]

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