[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.]

                            A P P E N D I X




                                  
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